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Haglunds Deformity

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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
  • 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


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

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


References

  1. Haglund P. Beitrag zur Klinik der Achilles tendon. Zeitschr Orthop Chir. 1928; 49: 49-58.
  2. Dündar Ü. Pusak H. Kavuncu V. A Rare Cause of Heel Pain: Haglund’s Syndrome. Turk J Phys Med Rehab. 2008; 54: 33-35.
  3. Vega MR. Cavolo DJ. Green RM. Cohen RS. Haglund’s deformity. J Am Podiatry Assoc. 1984; 74: 129–135.
  4. 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.
  5. Vaishya, Raju, et al. "Haglund’s syndrome: a commonly seen mysterious condition." Cureus 8.10 (2016).
Created by:
John Kiel on 7 July 2019 08:12:28
Authors:
Last edited:
3 October 2022 23:50:16
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