Haglund's deformity: Difference between revisions

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A contribution by Nick Despeghel, Jonathan Hooft, Gertjan Pauwels and Wout Lippens


<u>'''Contents &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;'''</u>  
==Definition ==
Haglund’s deformity is defined as an abnormality of the bone and soft tissues in the foot where an enlargement of the bony section of the heel where the [[Achilles Tendon|Achilles tendon]]  inserts is triggered. <ref name=":5">Vaishya R, Agarwal AK, Azizi AT, Vijay V. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5101401/#:~:text=Haglund's%20deformity%20is%20an%20abnormality,lump%20rubs%20against%20rigid%20shoes. Haglund’s syndrome: a commonly seen mysterious condition]. Cureus. 2016 Oct 7;8(10).</ref>


• Definition/Description<br>• Clinically Relevant Anatomy<br>• Epidemiology /Etiology<br>• Characteristics/Clinical Presentation<br>• Medical Management<br>• Physical Therapy Management<br>• Key Evidence<br>• References
==Description ==
Haglund’s deformity is a symptomatic osseous prominence of the posterolateral corner of the calcaneus resulting in posterior heel pain and swelling around the insertion of the [[Achilles Tendon]].<ref name=":2">Alfredson H, Cook J, Silbernagel K, Karlsson J. Pain in the Achilles region. In: Brukner P, Bahr R, Blair S, Cook J, Crossley K, McConnell J, McCrory P, Noakes T, Khan K. Clinical Sports Medicine: 4th edition. Sydney: McGraw-Hill. p.795-797.</ref><ref>Jung H, Carag JA, Park J, Bae E, Lim S, Kim H. [https://www.sciencedirect.com/science/article/abs/pii/S126877311000113X Osteochondroma of the calcaneus presenting as Haglund’s deformity.] Foot and Ankle Surgery 2010;17:20–22.</ref> It is associated with [[Retrocalcaneal Bursitis|retrocalcaneal bursitis]].<ref name=":0">Stephens MM. [https://europepmc.org/abstract/med/8290230 Haglund's deformity and retrocalcaneal bursitis.] The Orthopedic clinics of North America 1994;25(1):41-6.</ref> Cavo varus deformities exacerbate this problem.


<u>'''Definition/Description &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;'''</u><br>Haglund’s deformity is a symtomatic osseous prominence of the posterosuperior corner of the calcaneus creating posterior heel pain and swelling around the insertion of the Achilles tendon (Hong-Geun Jung et al. 2010). It is associated with retrocalcaneal bursitis (Stephens M.M. 1994). Cavo varus deformities exacerbate this problem.
<br>It was first described by Patrick Haglund as early as 1928<ref>Haglund P. Beitrag zur uliwik der Achilesse have. Z Orthop Chir 1928;49.</ref>. Prior to that other descriptions were used, such as “pump bump” (because the rigid backs of pump-style shoes can create pressure that aggravates the posterior heel pain and swelling), and "winter heel".<ref name=":0" />
{{#ev:youtube|C3dagSnyosE|200}}
==Clinically relevant anatomy==
[[File:Achilles tendon.jpg|thumb|339x339px]]
The [[Achilles Tendon]] originates from the aponeurosis of the [[gastrocnemius]] and [[soleus]] muscles. It inserts into the middle third of the posterior surface of the calcaneus.<ref>Myerson MS, Mandelbaum B. Disorders of the Achilles tendon and the retrocalcaneal region. Foot and ankle disorders. Philadelphia: WB Saunders. 2000:1382-98.</ref> There are two bursae near the [[Achilles Tendon]] - the deep retrocaneal bursa, and the superficial bursa. These can be the sites of inflammation and can develop [[bursitis]].  <ref name=":1">Lesic A, Bumbasirevic M. [https://www.sciencedirect.com/science/article/abs/pii/S0268089003001506 Disorders of the Achilles tendon]. Current Orthopaedics 2004;18(1):63-75.</ref>


<br>It was first described by Patrick Haglund as early as 1928 (Haglund P. 1928), and until that time numerous other descriptions were used, such as: “pump bump”, because the rigid backs of pump-style shoes can create pressure that aggravates the posterior heel pain and swelling, and winter heel (Stephens M.M. 1994).  
== Epidemiology ==
Hugland's Deformity are most common in the female population between the ages of 15 and 35, especially in woman who regularly wear heels. It is also common in runners.<ref name=":1" />


<br>The occurrence of Haglund deformity is more characteristic of younger patients, aged 15 – 30. Symptoms of the accompanying bursitis, such as: a noticeable bump on the back of the heel; pain in the area where the Achilles tendon attaches to the heel; swelling in the back of the heel; redness near the inflamed tissue, are intensified by wearing footwear with hard heel edges, which impinge on the bursa and the Achilles tendon on the calcaneal bone (Lesic &amp; Bumbasirevic 2004).  
== Etiology ==
'''Predisposing factors:'''<ref name=":1" />
* It is mostly an idiopathic condition
* Genetics (hereditary):  Patients can have a bone structure that makes them prone to developing Haglund’s deformity.
*High foot arches:  With high arches, the heel is tilted backward into the [[Achilles Tendon]] (due to the insertion on the calcaneus). Therefore a bony protrusion develops and the bursa becomes inflamed due to the constant irritation of the back of the heel bone as it rubs against the tendon.
* Tight [[Achilles Tendon]]: Pain is caused by compressing the tender and the inflamed bursa.
* Tendency to walk on the outside of the heel''':'''  This produces wear on the outer edge of the sole of the shoe which rotates the heel inward. This  results in a grinding of the calcaneus against the tendon; a bursa will form, which will eventually becomes inflamed and tender.


<br><u>'''Clinically Relevant Anatomy&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;'''</u><br>The Achilles tendon originates from the aponeurosis of both gastrocnemius and soleus muscles. It inserts into the middle third of the posterior surface of the calcaneus (Mayerson &amp; Mandelbaum 2000). Near the Achilles tendon insertion, there are two bursae. One bursae is located deeply – the retrocaneal bursae, and the other one is superficial below the skin. These can be the sites of inflammation processes or can develop non-inflammatory, inflammatory suppurative or calcified retrocalcaneal bursitis (Lesic &amp; Bumbasirevic 2004).
* Increase in weight
* Injury
* Improper/tight shoes:  Does not counter the bump but causes symptoms which maybe lead to [[bursitis]].
* Over-practice in runners.
* Tight or poorly fitting shoes.
* Altered biomechanics of foot joints because of the dealigned subtalar joint.
* A high-arched foot
* A tight Achilles tendon


<br><u>'''Epidimiology/Ethiology &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;'''</u><br>In some cases heredity can play a role in this deformity. You can inherit the bone structure that makes them prone to developing Haglund’s Deformity.
== Signs and symptoms ==
* A noticeable bump or an enlarged bony prominence on the back of the heel.
* Heel pain.
* Constant sharp feet pain
* Swelling and pain in the [[Achilles Tendon|Achilles tendon]]
* Mild cases usually involve episodic pain after long periods of inactivity.
* Severely restricted ankle joint mobility.
* Redness and swelling.
* The friction between the soft tissue at the back of the heel and the shoe, can cause the bursae can become inflamed. Symptoms are aggravated by wearing footwear with hard heel edges, as this impinge on the bursa and the [[Achilles Tendon]] on the calcaneas.<ref name=":1" />
== Differential diagnosis ==
* [[Achilles Tendinopathy|Achilles tendinitis]]<ref name=":1" />
* [[Retrocalcaneal Bursitis|Retrocalcaneal bursitis]]<ref name=":2" />
* Calcaneal bursitis
* Planter fasciitis
* Avulsion of calcaneal tendon<ref name=":5" />


<br>The major factor of Haglund’s Deformity are high arches. When you have high arches, the heel is tilted backward into the Achilles tendon because the Achilles tendon is attached to the back of the heel bone. A bony protrusion develops and the bursa becomes inflamed due to the constant irritation of the back of the heel bone to rub against the tendon.
== Diagnostic procedures ==
* [[X-Rays|X-rays]]:  To identify bony protrusion
* [[Ultrasound Scans|Ultrasound]]:  Assess pathology of bursa and Achilles tendon
* [[MRI Scans|MRI]]:  Assess pathology of bursa and Achilles tendon
<ref name=":2" />


<br>Another cause of Haglund’s Deformity can be a tight Achilles tendon, it causes pain by compressing the tender and the inflamed bursa.  
== Physical examination ==
* History
* Evaluation of bursa, tendon and calcaneus
* Functional tests to elicit pain: Tensile (hopping on toes) vs compressive (jumping lunge) vs combination
* A visible bump  seen on the posterior of the heel
* Signs of inflammation like swelling, warmth, redness, and tenderness may be present over the posterior heel.
<ref name=":2" />


<br>Or a tendency to walk on the outside of the heel. it produces wear on the outer edge of the sole of the shoe which will rotate the heel inward. That will result in a grinding of the heel bone against the tendon. There will be formed a bursa, which eventually becomes inflamed and tender.
==Treatment==


<br>Haglund’s Deformity can also be caused by an increase in weight, injury, improper shoes, or tight shoes who will not counter the bump but cause symptoms and which maybe lead to a bursitis.  
==== Conservative management ====
Conservative management of Hugland's deformity is used to relieve the associated symptoms, but it cannot  resolve the problem. Anti-inflammatory medication are recommended for pain relief, but corticosteroid injections are avoided, as it can lead to [[Achilles Rupture|rupture of the Achilles tendon]].


<br>
In some cases casting can help with pain reduction.


<u>'''Characteristics/Clinical Presentation &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;'''</u><br>The main symptom of Haglund’s Deformity is the enlargement of the bone on the back of the heel. There is a bump visible in the area where the Achilles tendon attaches to the heel. This bump can be very painful when it’s pressed or when the person wears tight shoes. It often becomes swollen and red and also the bursae can become inflamed, due to the soft tissue in the back of the heel that rubs against the shoe. Offcours persons with Haglund’s Deformity feel pain in the back of the heel. Most patients who suffer from Haglund’s syndrome are women between 15 to 35 years old, because they regularly wear high heels. Haglunds syndrome is also very common in runners and is frequently misdiagnosed as Achilles tendonitis.  
Ice/cryotherapy helps deal with swelling.


<br>
Stretching exercises, and physiotherapy help relieve tension from the calcaneal tendon.


<u>'''Medical Management &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;'''</u><br>Haglund’s deformity itself cannot be resolved by non-operative treatment. After all the calcified parts can only be removed by surgery.
==== Surgery ====
If conservative treatment is not effective then following surgical treatment options are considered
* Removal of bony protrusion: Possible complication of injury to the [[Achilles Tendon]]


<br>Surgical treatment specific for Haglund’s deformity consists either of bump removal or a closing wedge calcaneal osteotomy. A recent article is published about a closing wedge osteotomy witch is called the Keck and Kelly closing wedge osteotomy. It can be of great importance as a physiotherapist to know witch operative treatment the patient underwent. The crucial difference between the two kinds of operation is the state of the Achilles tendon. When there is a bump removal, there is a bone resection adjacent to the Achilles tendon. The other form, which is implied in the technique of the article avoids this. The goal of the technique is that there is a limited opportunity for intraoperative or postoperative complications. In another article they talk about a partial excision ant the risk of avulsion of the tendon afterward. As conclusion we can say that depending on the kind of operative treatment, the physiotherapist can adapt his treatment taking into account whether the insertion of the Achilles tendon is intact or not or if there is a risk of avulsion of the tendon.  
* Partial removal of bony protrusion: High risk of Achilles tendon avulsion<ref>Kolodziej P, Glisson RR, Nunley JA. [https://journals.sagepub.com/doi/abs/10.1177/107110079902000707 Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendonitis and Haglund's deformity: a biomechanical study.] Foot & ankle international 1999;20(7):433-7.</ref>
* Closing wedge calcaneal osteotomy (Keck & Kelly technique)<ref>Boffeli TJ, Peterson MC. [https://www.sciencedirect.com/science/article/pii/S1067251612001044 The Keck and Kelly wedge calcaneal osteotomy for Haglund's deformity: a technique for reproducible results.] The Journal of Foot and Ankle Surgery 2012;51(3):398-401.</ref>


<br>
====Physiotherapy management====
Physiotherapists play a big role in conservative management of Hugland's Deformity, especially with the management of the [[bursitis]] associated with this deformity.


<u>'''Physical Therapy Management &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;'''</u><br>Non-operative treatment can be helpful in prevention and in curing the bursitis who is often the cause of this deformity.
===== Management of [[bursitis]]/[[Achilles Tendinopathy|tendinitis]]=====
* Management of inflammation:
** Rest
** Immobilization
** Ice
** Ultrasound


<br><u>Prevention:</u><br>As the deformity is caused by inflammation of the achilles’ tendon or of the bursa nearby prevention is based on minimizing the friction between these structures and the calcaneus. Wearing backless shoes or shoes with a soft backside is the first step. Also pads who are placed under the calcaneus can help to reduce irritation when walking. If the patient has a high arch a heel lift could be helpful to decrease pressure on the heel.  
* Eccentric [[gastrocnemius]] and [[soleus]] exercises
* Achilles stretches
<ref name=":3">American Orthopaedic Foot & Ankle Society. Haglund deformity. Available from: http://www.aofas.org/PRC/conditions/Pages/Conditions/Haglund-Deformity.aspx (accessed 06/01/2019).</ref>


<br><u>Curing Bursitis/tendinitis:</u><br>Both bursitis and tendinitis are inflammations which means the pain can be reduced with ant-inflammatory medication, rest, immobilization and ice. Corticoid injection are NOT recommended because their use can cause tendon ruptures. Excentric exercises has proven to be a good asset to the therapy in treating an inflammation of the Achilles’ tendon.
Also see the pages for [[Achilles tendinosis]] and [[Retrocalcaneal Bursitis|retrocacaneal bursitis]] for more information on the management thereof.<br>


<br>More information about how to treat [[Achilles tendonitis]] or [[Retrocalcaneal bursitis]] can be found on other physiopedia pages.  
===== Post-operative management =====
It is important to take the risks of Achilles tendon rupture and injury after removal of the bony protrusion into consideration when managing these patients post-operatively. <blockquote>Full rehabilitation after Haglund's resection can take up to one year.</blockquote>'''<u>Day 0 - 10</u>'''
* '''Oedema management:'''
** Rest - Active rest
** Ice
** Elevation - for first 10 days of recovery period
** Compression
* '''Mobilization:'''
** Patients are mostly put in moon boot or below-knee backslab
** Non-weight bearing mobilization:  3 days to 2 weeks (as per surgeon)
* '''Stretches:''' Lower leg strengthening exercises are vital
* Achilles stretches (contra-indicated if Achilles was injured or if it was detached and re-attached intra-operatively)
* Return to full activity at 6 weeks post-surgery.
<ref>Midwest bone & joint institute. Haglund's deformity of the foot. Available from: https://midwestbonejoint.com/foot/haglunds-deformity-of-the-foot/ (accessed 09/01/2019).</ref><ref>Healthline. Haglund's deformity. Available from: https://www.healthline.com/health/haglund-deformity (accessed 09/01/2019).</ref><ref name=":4">Medical College of Wisconsin. Haglund's resection. Available from: https://www.mcw.edu/-/media/MCW/Departments/Orthopaedic-Surgery/hagland.pdf?la=en (accessed 14/01/2019).</ref>


<br><u>'''Key Evidence &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;'''</u><br>We have given some evidence levels of the most important articles.<br>• Troy J. Boffeli, DPM, FACFAS, Matthew C. Peterson, DPM, The Keck and Kelly Wedge Calcaneal Osteotomy for Haglund's Deformity: A Technique for Reproducible Results, The Journal of Foot and Ankle Surgery, Available online 23 March 2012. (2C)<br>• Kolodziej P, Glisson RR, Nunley JA., Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendonitis and Haglund's deformity: a biomechanical study., juli 1999. (2C)<br>• Pradeep Alexander, MD. Haglund deformity. Orthopaedia. (http://www.orthopaedia.com/display/Main/Haglund+deformity), 2012. (2C)
'''<u>Day 10 - 6 weeks</u>'''
* '''Mobilization:'''
** ''Resection without Achilles debridement/repair:'' Moonboot with raised heel and progress from toe-touch weight bearing to partial weight bearing to assisted full weight bearing in the 4 week period
** ''Resection with Achilles debridement/repair:'' Moonboot or cast in equinis. Patient has to stay non-weight bearing 4 weeks
** Oedema management as needed
<ref name=":4" />


<br><u>'''References &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;'''</u><br>• Stephens M.M. (1994). Haglund’s deformity and retrocalcaneal bursitis. Orthop Clin North Am. 25: 41 – 46<br>• Hong-Geun Jung M.D., Ph.D., John Alistair Carag M.D., Jae-Yong Park M.D., Eui-Jung Bae M.D., So-Dug Lim M.D., Ph.D., Han-Soo Kim M.D., Ph.D. (2010). Osteochondroma of the calcaneus presenting as Haglund’s deformity. Foot and Ankle Surgery. 17: 20 – 22<br>• Mayerson M.S &amp; Mandelbaum B. (2000). Disorders of the Achilles tendon and the retrocalcaneal region. Foot and ankle disorders. 1367 – 1398<br>• Lesic A. &amp; Bumbasirevic M. (2004). Disorders of the Achilles tendon. Current Orthopaedics. 18: 63 – 75<br>• Haglund P. (1928). Beitrag zur uliwik der Achilesse have. Z Orthop Chir. 49<br>• Neuhaus and Know, Matthew D. and Jason R.. Neuhaus foot and ankle, Geraadpleegd op 26 april 2012, http://www.neufoot.com/haglunds-deformity.html<br>• Foot Associates of central Texas ,Geraadpleegd op 26 april 2012, http://www.whymyfoothurts.com/aboutus/<br>• Haglund’s Deformity Symptoms And 4 Ways Of Treatment, geraadpleegd op 10 mei 2012, http://haglundsdeformity.net/ <br>• YourFootHealth, Haglund's Foot Deformity, geraadpleegd op 10 mei 2012, http://www.yourfoothealth.com/haglunds-deformity.html <br>• Stephens, MM. , Haglund's deformity and retrocalcaneal bursitis, Cappagh Orthopaedic Hospital, Dublin, Ireland, 1994<br>• Troy J. Boffeli, DPM, FACFAS, Matthew C. Peterson, DPM, The Keck and Kelly Wedge Calcaneal Osteotomy for Haglund's Deformity: A Technique for Reproducible Results, The Journal of Foot and Ankle Surgery, Available online 23 March 2012,<br>• Kolodziej P, Glisson RR, Nunley JA., Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendonitis and Haglund's deformity: a biomechanical study., juli 1999.<br>• Pradeep Alexander, MD. Haglund deformity. Orthopaedia. (http://www.orthopaedia.com/display/Main/Haglund+deformity), 2012.<br>&nbsp;
'''<u>6 - 12 weeks</u>'''
* '''Mobilization:'''
** ''Resection without Achilles debridement/repair:'' 
*** Wean moonboot wear
*** Full weight bearing
* ''Resection with Achilles debridement/repair: Moonboot in equinis''
** Progress to moonboot in cast was initially required
** Progress to weight bearing from toe-touch weight bearing to partial weight bearing to assisted full weight bearing over 4 weeks


* Oedema management as needed
* Start scar management as soon as wounds are fully healed
<ref name=":4" />
'''<u>Week 12+</u>'''
* Mobilization:  Wean off moonboot and mobility assistive devices if still in use
* Exercises: Strengthening and endurance of foot and ankle muscles are main focus.
* Oedema management as needed
<ref name=":4" />
== Resources ==
* [https://www.lakeviewhealth.org/upload/docs/HaglundsDeformity.pdf Information sheet]
* [https://www.mcw.edu/-/media/MCW/Departments/Orthopaedic-Surgery/hagland.pdf?la=en Haglund's resection information]
== Prevention ==
* Patient education
* Modification of aggravating factors to minimize friction between [[Achilles Tendon]] and bursa
* Ask the patient to avoid shoes with rigid back.
* If patient has a high arch or tight [[Achilles Tendon|achilles tendon]], wearing appropriate shoe inserts can help prevent the development of Haglund's Deformity.
* Referral to podiatry (for arch support or orthotic devices)
* Advice regarding weight loss (where applicable)
* For runners: Avoid hard surfaces and uphill
* Achilles stretches to prevent stiffness
<ref name=":3" /><ref>American College of Foot and Ankle Surgeons. Haglund's deformity. Available from: http://www.oregonmedicalgroup.com/wp-content/uploads/2015/07/1f43c091d17ec4f2d9902a5687e39819.pdf (accessed 09/01/2019).</ref>
== Clinical bottom line ==
Hugland's deformity is a bony protrusion on the posterolateral part of the heel. It occurs mostly in young females. Friction with incorrect foot ware or biomechanics cause bursitis, and patients will often complain of pain and swelling at the back of the heel. Conservative management includes management of the inflammation, modification of aggravating factors and an eccentric training programme. Surgical management consists of partial or full removal of the bony protrusion, but risks include injury or rupture of the Achilles tendon. A closing wedge calcaneal osteotomy can also be done.
==References==
[[Category:Primary Contact]]
[[Category:Primary Contact]]
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Latest revision as of 06:27, 8 August 2022

Original Editors - Nick Despeghel, Jonathan Hoof, Gertjan Pauwels and Wout Lippens

Top Contributors - Niha Mulla, Leana Louw, Kim Jackson, Wout Lippens, Kalyani Yajnanarayan and Claire Knott


Definition[edit | edit source]

Haglund’s deformity is defined as an abnormality of the bone and soft tissues in the foot where an enlargement of the bony section of the heel where the Achilles tendon inserts is triggered. [1]

Description[edit | edit source]

Haglund’s deformity is a symptomatic osseous prominence of the posterolateral corner of the calcaneus resulting in posterior heel pain and swelling around the insertion of the Achilles Tendon.[2][3] It is associated with retrocalcaneal bursitis.[4] Cavo varus deformities exacerbate this problem.


It was first described by Patrick Haglund as early as 1928[5]. Prior to that other descriptions were used, such as “pump bump” (because the rigid backs of pump-style shoes can create pressure that aggravates the posterior heel pain and swelling), and "winter heel".[4]

Clinically relevant anatomy[edit | edit source]

Achilles tendon.jpg

The Achilles Tendon originates from the aponeurosis of the gastrocnemius and soleus muscles. It inserts into the middle third of the posterior surface of the calcaneus.[6] There are two bursae near the Achilles Tendon - the deep retrocaneal bursa, and the superficial bursa. These can be the sites of inflammation and can develop bursitis. [7]

Epidemiology[edit | edit source]

Hugland's Deformity are most common in the female population between the ages of 15 and 35, especially in woman who regularly wear heels. It is also common in runners.[7]

Etiology[edit | edit source]

Predisposing factors:[7]

  • It is mostly an idiopathic condition
  • Genetics (hereditary): Patients can have a bone structure that makes them prone to developing Haglund’s deformity.
  • High foot arches: With high arches, the heel is tilted backward into the Achilles Tendon (due to the insertion on the calcaneus). Therefore a bony protrusion develops and the bursa becomes inflamed due to the constant irritation of the back of the heel bone as it rubs against the tendon.
  • Tight Achilles Tendon: Pain is caused by compressing the tender and the inflamed bursa.
  • Tendency to walk on the outside of the heel: This produces wear on the outer edge of the sole of the shoe which rotates the heel inward. This results in a grinding of the calcaneus against the tendon; a bursa will form, which will eventually becomes inflamed and tender.
  • Increase in weight
  • Injury
  • Improper/tight shoes: Does not counter the bump but causes symptoms which maybe lead to bursitis.
  • Over-practice in runners.
  • Tight or poorly fitting shoes.
  • Altered biomechanics of foot joints because of the dealigned subtalar joint.
  • A high-arched foot
  • A tight Achilles tendon

Signs and symptoms[edit | edit source]

  • A noticeable bump or an enlarged bony prominence on the back of the heel.
  • Heel pain.
  • Constant sharp feet pain
  • Swelling and pain in the Achilles tendon
  • Mild cases usually involve episodic pain after long periods of inactivity.
  • Severely restricted ankle joint mobility.
  • Redness and swelling.
  • The friction between the soft tissue at the back of the heel and the shoe, can cause the bursae can become inflamed. Symptoms are aggravated by wearing footwear with hard heel edges, as this impinge on the bursa and the Achilles Tendon on the calcaneas.[7]

Differential diagnosis[edit | edit source]

Diagnostic procedures[edit | edit source]

  • X-rays: To identify bony protrusion
  • Ultrasound: Assess pathology of bursa and Achilles tendon
  • MRI: Assess pathology of bursa and Achilles tendon

[2]

Physical examination[edit | edit source]

  • History
  • Evaluation of bursa, tendon and calcaneus
  • Functional tests to elicit pain: Tensile (hopping on toes) vs compressive (jumping lunge) vs combination
  • A visible bump seen on the posterior of the heel
  • Signs of inflammation like swelling, warmth, redness, and tenderness may be present over the posterior heel.

[2]

Treatment[edit | edit source]

Conservative management[edit | edit source]

Conservative management of Hugland's deformity is used to relieve the associated symptoms, but it cannot resolve the problem. Anti-inflammatory medication are recommended for pain relief, but corticosteroid injections are avoided, as it can lead to rupture of the Achilles tendon.

In some cases casting can help with pain reduction.

Ice/cryotherapy helps deal with swelling.

Stretching exercises, and physiotherapy help relieve tension from the calcaneal tendon.

Surgery[edit | edit source]

If conservative treatment is not effective then following surgical treatment options are considered

  • Removal of bony protrusion: Possible complication of injury to the Achilles Tendon
  • Partial removal of bony protrusion: High risk of Achilles tendon avulsion[8]
  • Closing wedge calcaneal osteotomy (Keck & Kelly technique)[9]

Physiotherapy management[edit | edit source]

Physiotherapists play a big role in conservative management of Hugland's Deformity, especially with the management of the bursitis associated with this deformity.

Management of bursitis/tendinitis[edit | edit source]
  • Management of inflammation:
    • Rest
    • Immobilization
    • Ice
    • Ultrasound

[10]

Also see the pages for Achilles tendinosis and retrocacaneal bursitis for more information on the management thereof.

Post-operative management[edit | edit source]

It is important to take the risks of Achilles tendon rupture and injury after removal of the bony protrusion into consideration when managing these patients post-operatively.

Full rehabilitation after Haglund's resection can take up to one year.

Day 0 - 10

  • Oedema management:
    • Rest - Active rest
    • Ice
    • Elevation - for first 10 days of recovery period
    • Compression
  • Mobilization:
    • Patients are mostly put in moon boot or below-knee backslab
    • Non-weight bearing mobilization: 3 days to 2 weeks (as per surgeon)
  • Stretches: Lower leg strengthening exercises are vital
  • Achilles stretches (contra-indicated if Achilles was injured or if it was detached and re-attached intra-operatively)
  • Return to full activity at 6 weeks post-surgery.

[11][12][13]

Day 10 - 6 weeks

  • Mobilization:
    • Resection without Achilles debridement/repair: Moonboot with raised heel and progress from toe-touch weight bearing to partial weight bearing to assisted full weight bearing in the 4 week period
    • Resection with Achilles debridement/repair: Moonboot or cast in equinis. Patient has to stay non-weight bearing 4 weeks
    • Oedema management as needed

[13]

6 - 12 weeks

  • Mobilization:
    • Resection without Achilles debridement/repair:
      • Wean moonboot wear
      • Full weight bearing
  • Resection with Achilles debridement/repair: Moonboot in equinis
    • Progress to moonboot in cast was initially required
    • Progress to weight bearing from toe-touch weight bearing to partial weight bearing to assisted full weight bearing over 4 weeks
  • Oedema management as needed
  • Start scar management as soon as wounds are fully healed

[13]

Week 12+

  • Mobilization: Wean off moonboot and mobility assistive devices if still in use
  • Exercises: Strengthening and endurance of foot and ankle muscles are main focus.
  • Oedema management as needed

[13]

Resources[edit | edit source]

Prevention[edit | edit source]

  • Patient education
  • Modification of aggravating factors to minimize friction between Achilles Tendon and bursa
  • Ask the patient to avoid shoes with rigid back.
  • If patient has a high arch or tight achilles tendon, wearing appropriate shoe inserts can help prevent the development of Haglund's Deformity.
  • Referral to podiatry (for arch support or orthotic devices)
  • Advice regarding weight loss (where applicable)
  • For runners: Avoid hard surfaces and uphill
  • Achilles stretches to prevent stiffness

[10][14]

Clinical bottom line[edit | edit source]

Hugland's deformity is a bony protrusion on the posterolateral part of the heel. It occurs mostly in young females. Friction with incorrect foot ware or biomechanics cause bursitis, and patients will often complain of pain and swelling at the back of the heel. Conservative management includes management of the inflammation, modification of aggravating factors and an eccentric training programme. Surgical management consists of partial or full removal of the bony protrusion, but risks include injury or rupture of the Achilles tendon. A closing wedge calcaneal osteotomy can also be done.

References[edit | edit source]

  1. ↑ 1.0 1.1 Vaishya R, Agarwal AK, Azizi AT, Vijay V. Haglund’s syndrome: a commonly seen mysterious condition. Cureus. 2016 Oct 7;8(10).
  2. ↑ 2.0 2.1 2.2 2.3 Alfredson H, Cook J, Silbernagel K, Karlsson J. Pain in the Achilles region. In: Brukner P, Bahr R, Blair S, Cook J, Crossley K, McConnell J, McCrory P, Noakes T, Khan K. Clinical Sports Medicine: 4th edition. Sydney: McGraw-Hill. p.795-797.
  3. ↑ Jung H, Carag JA, Park J, Bae E, Lim S, Kim H. Osteochondroma of the calcaneus presenting as Haglund’s deformity. Foot and Ankle Surgery 2010;17:20–22.
  4. ↑ 4.0 4.1 Stephens MM. Haglund's deformity and retrocalcaneal bursitis. The Orthopedic clinics of North America 1994;25(1):41-6.
  5. ↑ Haglund P. Beitrag zur uliwik der Achilesse have. Z Orthop Chir 1928;49.
  6. ↑ Myerson MS, Mandelbaum B. Disorders of the Achilles tendon and the retrocalcaneal region. Foot and ankle disorders. Philadelphia: WB Saunders. 2000:1382-98.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Lesic A, Bumbasirevic M. Disorders of the Achilles tendon. Current Orthopaedics 2004;18(1):63-75.
  8. ↑ Kolodziej P, Glisson RR, Nunley JA. Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendonitis and Haglund's deformity: a biomechanical study. Foot & ankle international 1999;20(7):433-7.
  9. ↑ Boffeli TJ, Peterson MC. The Keck and Kelly wedge calcaneal osteotomy for Haglund's deformity: a technique for reproducible results. The Journal of Foot and Ankle Surgery 2012;51(3):398-401.
  10. ↑ 10.0 10.1 American Orthopaedic Foot & Ankle Society. Haglund deformity. Available from: http://www.aofas.org/PRC/conditions/Pages/Conditions/Haglund-Deformity.aspx (accessed 06/01/2019).
  11. ↑ Midwest bone & joint institute. Haglund's deformity of the foot. Available from: https://midwestbonejoint.com/foot/haglunds-deformity-of-the-foot/ (accessed 09/01/2019).
  12. ↑ Healthline. Haglund's deformity. Available from: https://www.healthline.com/health/haglund-deformity (accessed 09/01/2019).
  13. ↑ 13.0 13.1 13.2 13.3 Medical College of Wisconsin. Haglund's resection. Available from: https://www.mcw.edu/-/media/MCW/Departments/Orthopaedic-Surgery/hagland.pdf?la=en (accessed 14/01/2019).
  14. ↑ American College of Foot and Ankle Surgeons. Haglund's deformity. Available from: http://www.oregonmedicalgroup.com/wp-content/uploads/2015/07/1f43c091d17ec4f2d9902a5687e39819.pdf (accessed 09/01/2019).
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