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Haglunds Deformity
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Contents
Other Names
- Haglund’s Syndrome
- Retrocalcaneal exostosis
- Mulholland deformity
- Pump bump
Background
- This page refers to 'retrocalcaneal exostosis', more commonly termed Haglund's Deformity
History
- First described by Patrick Haglund in 1927[1]
Epidemiology
Pathophysiology
- General
- Typically affects middle aged females[2]
- Often bilateral
- Diagnosis is a combination of clinical and radiographic assessment
- Haglund's Deformity
- Defined as a bony enlargement of the posterosuperior part of the Calcaneus at the attachment site of the Achilles Tendon[3]
- Haglund's Syndrome
- Posterior heel pain, characterized by a painful soft tissue swelling at the level of the Achilles tendon insertion
- Pump Bump
- Visible and palpable thickening of the soft tissues at the Achilles Tendon insertion
Etiology
- Pathophysiology is poorly understood
- Generally considered to be an idiopathic condition
Mechanism
- General
- Achilles tendon attaches to the back of the heel bone
- The uppermost portion of the back of the heel bone can rub against the tendon[4]
- Soft tissues can get irritated when the posterior calcaneus rubs against the shoe
- This can lead to retrocalcaneal bursitis, achilles tendonitis and subsequent thickening of the tendon
Associated Conditions
Risk Factors
- Runners
- Tight or poorly fitting shoes
- Altered biomechanics
- Tight Achilles Tendon or Posterior chain
- Walking on outside of heels
Differential Diagnosis
- Fractures & Dislocations
- Muscle and Tendon Injuries
- Ligament Injuries
- Bursopathies
- Nerve Injuries
- Arthropathies
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Other
Clinical Features
Clinical example of Haglund's Deformity[5]
- History
- Characterized by retrocalcaneal heel or ankle pain
- Limping swelling may be present
- Pain worse at the initiation of walking or unning
- Physical Exam: Physical Exam Ankle
- Prominent swelling and bump is noted over the back of both heels
- Warmth, redness, and tenderness may be present over the posterior heel
- Plantarflexion should be intact
- Special Tests
- Thompson Test: should be normal
Evaluation
Radiographs
- Standard Radiographs Ankle
- Sufficient to make the diagnosis
- Potential Findings
- Haglund's lesion: prominent calcaneal projection at posterosuperior part of the calcaneal tuberosity
- Calcaneal bursal swelling
- Increased density in pre-Achilles bursae
- Heterotopic bone formation at the insertion of or within the Achilles tendon
- Fowler's Angle: needs update
MRI
- Not routinely required
- Can be obtained in equivocal cases
- Potential findings
- Posterosuperior calcaneal spurring with impingement on the Achilles tendon
- Synovial thickening and collection in the retrocalcaneal bursa
- Thickening and high signal in the insertional fibers of Achilles tendon and
- Edema in the adjoining retro-Achilles fat pad
Classification
- Not applicable
Management
Nonoperative
- Indications
- Vast majority of patients
- Goal
- Reduce symptoms, treat soft tissue swelling and pain
- This approach will not shrink the bony protrusion
- Shoe inserts
- Altering heel height in shoe wear can offload the achilles
- Consider heel pads, lifts or wedges
- Open heel shoes
- Wearing shoes that are backless or have soft backs will avoid or minimize irritation
- Orthosis
- Physical Therapy
- Stretching of posterior chain
- NSAIDS
- Topical Analgesics
- Ice therapy
- Corticosteroid Injection
- In select cases with ultrasound guidance to avoid injecting in Achilles Tendon
- Additional therapies to consider (note: no current evidence to support)
Operative
- Indications
- Failure of conservative management
- Technique
- Retrocalcaneal decompression
- Calcaneal ostectomy or osteotomy
- Calcaneoplasty
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play/ Work
- Needs to be updated
Complications and Prognosis
Prognosis
- Needs to be updated
Complications
- Recurrence of symptoms
- Can be seen as a complication of surgery with inadequate bone resection
See Also
- Internal
- External
- Sports Medicine Review Ankle Pain: https://www.sportsmedreview.com/by-joint/ankle/
References
- ↑ Haglund P. Beitrag zur Klinik der Achilles tendon. Zeitschr Orthop Chir. 1928; 49: 49-58.
- ↑ Dündar Ü. Pusak H. Kavuncu V. A Rare Cause of Heel Pain: Haglund’s Syndrome. Turk J Phys Med Rehab. 2008; 54: 33-35.
- ↑ Vega MR. Cavolo DJ. Green RM. Cohen RS. Haglund’s deformity. J Am Podiatry Assoc. 1984; 74: 129–135.
- ↑ van Dijk CN. van Sterkenburg MN. Wiegerinck JI. Karlsson J. Maffulli N Terminology for Achilles tendon related disorders. Knee Surg Sports Traumatol Arthrosc. 2011; 19: 835–841.
- ↑ Vaishya, Raju, et al. "Haglund’s syndrome: a commonly seen mysterious condition." Cureus 8.10 (2016).