Haglund deformity

WHAT IS A HAGLUND DEFORMITY?

A Haglund deformity is an abnormal bony enlargement on the posterior superior aspect of the calcaneus. Haglund deformity is often associated with retrocalcaneal bursitis and insertional Achilles tendinopathy, forming a characteristic triad known as Haglund syndrome.
Haglund syndrome is a condition that is commonly seen in women aged 20 to 30 years but can occur in both sexes and at any age [Schroeder, 2002; Thomas et al, 2010].
Haglund syndrome is one of the most common causes of retrocalcaneal pain addressed by
foot and ankle surgeons and is estimated to affect 25% of patients who
present with insertional Achilles tendinopathy.^48,61,75

WHAT ARE THE SYMPTOMS OF HAGLUND SYNDROME?

A Haglund deformity is an abnormally enlargement of the heel bone (calcaneus) and does not always cause symptoms.
While the bony bump of a Haglund’s deformity predisposes patients to Haglund’s syndrome, this bony bump is not always painful.
Haglund's syndrome is due to chronic friction and pressure on the insertional Achilles tendon and retrocalcaneal bursa, and patient with symptoms often have pain due to an inflamed retrocalcaneal bursitis and/or insertional Achilles tendinitis [Fauzi, 2022; Tu, 2018; Martin et al, 2017].
The typical symptoms of Haglund syndrome include:
- Heel pain that is typically triggered by initiation to walk after a period of rest [Vaishya et al, 2016].
- The pain is mostly elicited during heel strike and maximum dorsiflexion. Exercise, climbing stairs, and running or walking on uneven surfaces can aggravate the pain [Fauzi, 2022].
- Pain could also be provoked by shoe wear, especially tight-on-heel models because it puts higher mechanical pressure on the Achilles tendon and retrocalcaneal bursa. When the area of enlarged bone rubs against that back of a shoe the soft tissue becomes irritated and can cause pain in the bursa as it is pressed between the Achilles tendon and the Haglund bump or the Achilles tendon. In contrast, it would be relieved by wearing open-heel shoes or even bare-walking because there is no pressure on the calcaneus [Thomas et al, 2010; Grambart et al, 2021].
- There is also limited plantar flexion of the foot associated with limping [Xu et al, 2020; Vaishya et al, 2016].
- In chronic cases of a Haglund syndrome, the inflammatory signs would be diminished [Oesman et al, 2018].

HOW IS A HAGLUND DEFORMITY DIAGNOSED?

Diagnosis is based on detailed history, physical examination, and imaging.
On physical examination, the location of the pain and swelling are used to help differentiate between Achilles insertion tendinitis and retrocalcaneal bursitis [Choo et al, 2020; Tu, 2018].
Imaging can play a important role in diagnosing Haglund syndrome:
- Radiographs (x-rays): Lateral ankle radiographs can reveal the prominent posterosuperior calcaneal tuberosity, which is characteristic of Haglund deformity and whether calcifications are present within the Achilles tendon. However, radiographs cannot adequately show the Bursa or Achilles tendon [Shah & Wong, 2016].
- Ultrasound (US): Ultrasound can assess the adjacent soft tissue for abnormalities and . detect thickening of the Achilles tendon, inflammation of the retrocalcaneal bursa, and the presence of bony prominences. Ultrasound is particularly useful for dynamic assessment and can provide real-time evaluation of the bony abnormality impinging on the tendon and bursa [Wiell et al, 2013; Balint & Sturrock, 2000].
- Magnetic Resonance Imaging (MRI): MRI can demonstrate the retrocalcaneal bursa, and thickening of the Achilles tendon. It can also show prominence of the posterior calcaneus tuberosity and any reactive bone marrow edema in the calcaneus, which are consistent findings in Haglund syndrome. MRI is particularly useful in equivocal cases and can help differentiate between various causes of heel pain [Shah et al, 2016; Lawrence te al, 2013; Debus et al, 2019; Bullock et al, 2017].

TREATMENT

Conservative Management

Conservative management for Haglund’s syndrome includes altering shoe wear, orthotics, physical therapy and anti-inflammatory drugs. Overall, conservative management can be effective in many cases, but some patients may require surgical intervention if symptoms persist despite these measures.
Conservative therapy can fail in almost half of patients with Haglund syndrome, especially those with retrocalcaneal bursitis and/or Achilles insertional tendinopathy [Shah & Wong, 2016; Ricci et al, 2020].
- Conservative therapy is considered failed if patients are unresponsive after six months of non-surgical treatments. Surgical management is the following line of treatment [Tourne et al, 2022].

Orthobiologic Procedures:

Orthobiologic procedures will not remove the Haglund deformity, but has been reported to treat associated insertional Achilles tendinopathy. Learn more about insertional Achilles tendinopathy here.
- PRP Injections: PRP involves injecting a concentration of a patient's own platelets to promote healing. The evidence for PRP in treating insertional Achilles tendinopathy is mixed. Some studies show moderate effectiveness in reducing pain and improving function, but the overall evidence remains inconclusive [Irby et al, 2020; Boesen et al, 2017].
- BMAC Injections: BMAC involves aspirating bone marrow, concentrating it, and injecting it into the affected area. BMAC has a high concentration of growth factors and mesenchymal stem cells. A study by Thueakthong et al. demonstrated significant pain reduction and functional improvement in patients with recalcitrant Achilles tendinopathy, including insertional cases, with no reported complications [Thueakthong et al, 2021].

Shockwave Therapy

Shockwave therapy will not remove the Haglund deformity, but has been reported to treat associated insertional Achilles tendinopathy. Shockwave uses shock waves to stimulate healing and has been shown to be effective in reducing pain and improving function in patients with insertional Achilles tendinopathy.. Learn more about insertional Achilles tendinopathy here.
- Rompe et al. found that ESWT was superior to eccentric loading exercises, with significant improvements in pain and function at four months and sustained benefits at one year [Rompe et al, 2008].
- Another study by Mansur et al. confirmed the effectiveness of ESWT when combined with eccentric exercises, although it did not show additional benefits over eccentric exercises alone [Mansur et al, 2021].

Surgical Intervention

The goal of surgery for Haglund deformity is to remove the exostosis/bone prominence on the posterosuperior calcaneus and relieve the pressure against its surrounding tissue.
In a study by Sundararajan et al, there is a 25% chance of having insertional Achilles tendinopathy, with or without retrocalcaneal bursitis (Haglund syndrome) [Sundrarajan & Wilde, 2014]. In case with associated Achilles tendinopathy or bursitis, addressing the associated degenerative Achilles tendon and/or retrocalcaneal bursa have been shown to result in better outcomes [Tu, 2018].
Surgery options for Haglund deformity include [Thomas et al, 2010]:
- Open resection of the exostosis: An open resection has more than one approach, but thew most common is a mid-line approach where the Achilles tendon is split and detached, a calcaneal osteotomy removes the enlarged bony bump and then the Achilles tendon is then later reattached. Although this procedure is considered an effective, multiple complications have been described, including impaired wound healing, sural nerve injury, wound tenderness, shoe wear irritation, infection, pain, prolonged recovery time, and skin sensitivity [Hall et al, 2024].
- Calcaneal osteotomy: The Zadek osteotomy involves removing a wedge-shaped piece of bone in the back and top part of the heel bone. By removing this wedge, the surgeon can change the shape and position of the heel bone, which helps to reduce the pressure and irritation on the Achilles tendon and the inflamed bursa
- Endoscopic calcaneoplasty: In an endoscopic calcaneoplasty two incisions are made on either side of the heel and a small camera (endoscope) and surgical instruments are inserted through these incisions. The camera provides a view of the area, and the instruments are used shave down or remove the bony enlargement on the heel bone and any inflamed bursal tissue. An endoscopic calcaneoplasty can be effective in
  improving pain and function in patients with Haglund syndrome, with high
  patient satisfaction and low complication rates [Alessio-Mazzola et al, 2021; Jerosch & Sokkar, 2007; Cardone et al, 2024]. Possible complications of the endoscopic approach include sural nerve entrapment caused by scar formation in the incision site (lateral incision approach), wound dehiscence, ankle stiffness, and Achilles tendon avulsion [Vaishya et al, 2016; Grambart et al, 2021].
- Ultrasound-guided calcaneoplasty: Ultrasound guided osteotomy procedures involve making a small incision and guiding an instrument adjacent to the heel bone to precisely resect the bony prominence and any inflamed bursal tissue, reducing pressure and
  irritation on the Achilles tendon [Madarevic et al, 2014; Rakovac et al, 2012; Chimenti et al, 2019; Sung et al, 2023]. The effectiveness and outcomes of ultrasound-guided calcaneoplasty have been evaluated in several studies.
  - Wang et al. reported that patients who underwent an ultrasound-guided osteotomy procedure experienced shorter surgical times, reduced hospital stays, and faster recovery compared to those who had traditional open surgery, with additional
    benefits including less wound pain, minimal blood loss, and quicker
    return to activity [Wang et al, 2019].
  - Madarevic et al. also demonstrated that ultrasound-assisted calcaneoplasty
    resulted in significant improvements functional scores, with rapid to recovery and high patient satisfaction. The study reported only one minor complication, a superficial infection, indicating a favorable safety profile [Madarevic et al, 2014].
  - Chimenti et al. presented a retrospective chart review describing long-term outcomes with a satisfaction rate of 70% and minimal complications after a minimally-invasive ultrasound guided procedure for insertional Achilles tendinopathy. In this study, if compressive pathology was appreciated and association with a Haglund deformity, the Tenex device was advanced to this location and a further limited debridement performed [Chimenti et al, 2019].
  - Sung et al. described a long-distance runner who underwent an ultrasound-guided calcaneoplasty using the Tenex bone device under local anesthsia, a single incision using a transtendinous approach, and a rapid return to running. At a 2-year follow up there were no recurrent symptoms [Sung et al, 2023].

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Haglund deformity

TREATMENT

Other Foot/Ankle Conditions