Haglund's deformity
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Haglund's deformity is an excessive prominence of the posterosuperior part of the calcaneus, located adjacent to the insertion of the Achilles tendon and the retrocalcaneal bursa. The bony structure itself can remain asymptomatic for many years. Symptoms usually develop when repetitive pressure from footwear and mechanical stress lead to irritation of the bursa, the Achilles tendon insertion, and the superficial tissues of the heel. This set of changes is referred to as Haglund's syndrome. Typical symptoms include pain in the back of the heel, swelling, redness, and a palpable bump, which intensify during walking, running, and wearing footwear with a rigid heel counter. Diagnosis is based on an orthopedic examination and diagnostic imaging, and treatment usually begins with load modification, footwear changes, and an individually planned physical therapy.
Haglund's deformity - why a bump forms on the heel
The bump in Haglund's deformity is a bony prominence of the posterosuperior border of the calcaneus. Its presence is associated with the individual shape of the heel and the spatial alignment of the calcaneus relative to the ankle joint and the Achilles tendon. The development of symptoms is influenced by the interaction of anatomy, lower limb biomechanics, and repetitive pressure.
Contributing factors include:
- a high longitudinal arch of the foot, which can alter the alignment of the calcaneus and increase pressure on its posterior part;
- limited ankle dorsiflexion, among others due to increased stiffness of the gastrocnemius muscle and the musculotendinous complex;
- unfavorable load distribution during walking or running;
- increased volume of running training, walking, or exercises involving jumping;
- repetitive irritation of the heel by the heel counter;
- an individual or familial predisposition to a specific shape of the calcaneus.
Both the size of the prominence and its relationship with the surrounding tissues are of importance. During dorsiflexion of the foot, the retrocalcaneal bursa and the anterior surface of the Achilles tendon may become compressed between the calcaneus and the tendon. Repetitive compression promotes bursitis, tendon thickening, and degenerative changes within its insertion.
Haglund's deformity must be distinguished from an enthesophyte, which is a bony spur that develops directly at the insertion of the Achilles tendon. Both conditions may occur simultaneously, but they have different anatomical locations.
Haglund's deformity - what it looks like
Haglund's deformity presents as a hard, bony prominence in the posterosuperior aspect of the heel. The bump may be visible on one or both sides of the body. The size of the lesion visualized on a radiograph shows a limited correlation with the intensity of pain. A small prominence can cause significant symptoms when accompanied by bursitis or insertional Achilles tendinopathy.
The clinical picture may include:
- a hard prominence located above the posterior part of the sole;
- tenderness on the sides of the Achilles tendon;
- swelling and warmth of the tissues;
- redness or thickening of the skin at the point of contact with footwear;
- pain during the first steps after rest;
- worsening of pain when walking uphill, running, and climbing stairs;
- limited dorsiflexion of the foot;
- thickening of the insertional part of the Achilles tendon.
The primary imaging examination is a weight-bearing lateral radiograph of the foot or ankle. It allows assessment of the calcaneal profile, enthesophytes, and calcifications within the tendon. Applied measurements, such as the Fowler-Philip angle or parallel pitch lines, support the assessment of the anatomy, but a single radiological parameter has limited diagnostic value.
Ultrasound examination shows the condition of the bursa, the thickness and structure of the tendon, and its vascularity. Magnetic resonance imaging is used in cases of an ambiguous clinical picture and during surgical planning. Differential diagnosis includes, among others, insertional Achilles tendinopathy, superficial bursitis, partial tendon tear, calcaneal stress fracture, gout, inflammatory rheumatic diseases, and pain of neurological origin.
Haglund's deformity - what footwear worsens the problem
The greatest irritation is caused by footwear whose design concentrates pressure on the back of the heel. This particularly applies to models equipped with a high, narrow, or very stiff heel counter. During walking, repetitive movement of the heel against the edge of the shoe causes tissue compression and skin friction.
Symptoms may be aggravated by:
- classic pumps and other shoes with a hard back;
- dress shoes with a narrowed heel space;
- stiff hiking, ski, and work boots;
- ice skates and roller skates tightly encasing the back of the foot;
- running shoes with a tight heel counter or ill-fitting width;
- models that cause the heel to lift and slip;
- high heels, which alter pressure distribution and, with prolonged use, can contribute to reduced flexibility of the calf-Achilles complex.
Footwear with adequate space for the back of the foot, a soft or flexible heel counter, and a stable midfoot fit is more beneficial. Open-heel models can provide temporary relief. A slight heel lift limits dorsiflexion and compression of the Achilles tendon insertion, but its height should be determined by a physiotherapist, orthopedist, or podiatrist. Heel lifts that are too high or used unilaterally alter gait biomechanics.
Orthopedic insoles are primarily justified in individuals with a diagnosed alignment disorder or load distribution issue of the foot. The presentation of Haglund's deformity alone rarely constitutes a sufficient indication for making insoles.
Haglund's deformity - how to relieve pain
Conservative management focuses on reducing compression, regulating load, and improving the Achilles tendon's ability to transfer forces. Such therapy alleviates soft tissue symptoms, although it maintains the existing bone shape.
The key elements of treatment include:
- temporary reduction of running, jumping, steep inclines, and other activities that aggravate pain;
- footwear modification and protecting the pressure area with a soft pad;
- cooling the painful area through a cloth after greater exertion;
- short-term use of analgesics or anti-inflammatory drugs after evaluating contraindications;
- graduated calf muscle and Achilles tendon training;
- exercises to improve foot control, balance, and mechanics of the entire lower limb;
- individual adjustment of the activity plan.
In insertional Achilles tendinopathy, calf raise exercises are often started on a flat surface. Lowering the heel deeply below the level of the step increases compression of the insertion against the calcaneus and can aggravate symptoms. The range, tempo, and load are selected based on the pain response and tolerance the following day.
At Ambasada Urody Clinic & Spa, services are available that can complement management following prior orthopedic diagnosis:
- physiotherapy and manual therapy, including functional assessment, work on ankle mobility, calf tension, and limb loading patterns;
- therapeutic massage, used adjunctively to work with overloaded calf muscles and soft tissues;
- sports massage, useful as an element of recovery and tension control in active individuals;
- kinesiotaping, used as temporary support for proprioception, tissue protection, or swelling control.
The offer also includes acoustic wave therapy used in body treatments. However, the treatment of insertional tendinopathy requires medical qualification, proper parameters, and equipment designed for musculoskeletal therapy. The wave can affect coexisting tendinopathy, but does not eliminate the bony prominence. Glucocorticoid injections in the vicinity of the Achilles tendon require special caution due to the risk of tendon weakening and damage.
Haglund's deformity - when is surgery needed
Surgery is considered in the case of persistent pain and activity limitation despite consistent conservative treatment, usually conducted for several months. The decision is made by an orthopedic surgeon specializing in foot and ankle surgery based on symptoms, clinical examination, imaging, and the degree of Achilles tendon damage. The mere presence of a bump on a radiograph constitutes an indication only when it corresponds to the location of the symptoms and the mechanism of impingement.
The scope of the procedure may include:
- removal of the inflamed bursa;
- resection of the posterosuperior prominence of the calcaneus, i.e., calcaneoplasty;
- debridement of damaged Achilles tendon fibers;
- partial detachment and re-anchoring of the tendon;
- calcaneal osteotomy altering its geometry;
- reconstruction using the flexor hallucis longus tendon in the case of extensive Achilles tendon damage.
Surgeries are performed using an open, endoscopic, or minimally invasive technique. The outcomes of both main treatment approaches are usually favorable, while the quality of evidence comparing the individual techniques remains limited. The choice of method depends on the bony anatomy, tendon changes, surgeon's experience, and the patient's functional needs.
Possible complications include impaired wound healing, infection, sural nerve injury, persistent pain, scarring, thrombosis, tendon weakening, and recurrence of impingement due to insufficient bone correction. Return to full weight-bearing and sports is gradual, and in the case of reconstruction of the Achilles tendon insertion, rehabilitation may take many months.
