What is Haglund’s Deformity?
Haglund’s deformity is an enlargement of the calcaneus, at the insertion point of the Achilles tendon.
Overtime, this can lead to irritation and inflammation of the surrounding soft tissues such as the Achilles tendon or the retrocalcaneal bursa.
Largely the development of this condition is determined by a person’s foot type but particular activities and footwear choices can also play a major role.
Haglund’s Deformity Symptoms
A painful Haglund’s Deformity usually starts with tenderness at the back of the heel. The pain may remain localised to the insertion point of the Achilles tendon or may radiate around the entire back of the heel.
Symptoms can vary but are often worse on the first step after rest, then they can warm up a little, and then get worse again with more loading.
But not always. Some people present with constant weight bearing pain or pain that lingers at night in their haglund’s deformity on their heels..
A visible “bump” will be apparent at the posterior heel, with or without signs of inflammation present. This can often present bilaterally or just on one side.
What To Do
To start with symptom guidance can be advised upon to manage whilst awaiting podiatry assessment and intervention. As the reason(s) for developing Haglund's Deformity are varied, not everyone will respond in the same manner.
While awaiting podiatry assessment, therapeutic advice, that is unlikely to cause harm and potentially be beneficial, is:
- Education: Pain education, reassurance, avoidance of nocebic language.
- NSAIDS topically (Voltaren Gel). If safe to proceed, oral NSAID’s can be trialled to relieve any associated pain resultant of retrocalcaneal bursitis.
- Wear shoes you feel MORE comfortable in
- Footwear without a rigid back can often decrease the level of irritation by reducing the compression of the Haglund’s deformity on surrounding soft tissues.
- Refer or see a podiatrist
For referrers we find that the following explanation works best:
What Not To Do
- Wait and delay. Usually X-rays are unlikely to be beneficial and ultrasound not required most times. If referring for imaging is going to delay expert assessment or cloud patients understanding of pathology, it’s not needed and potentially nocebic (harmful)
- Nothing. A delay in expert assessment and intervention can prolong pain and limit a patient’s daily activity.
Here's a more in-depth look at Haglund’s Deformity
What is it?
A bony enlargement of the calcaneal tuberosity. Largely this is due to heredity however the pain associated with surrounding soft tissue irritation can be contributed by particular footwear choices, training errors or loading imbalances.
The Haglund’s Deformity itself is often asymptomatic. Pain associated with this condition results from chronic irritation of the Achilles tendon or retrocalcaneal bursa with direct compression or friction of these soft tissues over the bony enlargement (Vaishya et al).
For this reason, conservative intervention is often successful at calming painful symptoms and surgical intervention is likely avoidable. This allows a patient to avoid any potential surgical complications and non-weight bearing recovery periods.
- A Haglund’s Deformity typically presents with pain at the back of the heel.
- Like a lot of fascia and tendon pathologies the pain is worse on the first few steps in the morning or after periods of rest.
- A very common pattern for pain is that it will warm up and settle with some mild activity and then deteriorate with increased loading (hours on feet at work, a long run etc.).
- Often pain will present bilaterally with signs of inflammation like swelling, redness and tenderness.
- Symptoms may be present over a palpable enlargement at the posterior heel.
- For referrers, your clients symptoms from a painful Haglund's Deformity will vary but a common thread is a sharp feeling on weight bearing and a burning sensation throughout the entire posterior heel and into the Achilles tendon when overdone it and when chronic - a burning at rest as well.
Myths, falsehoods and quarter truths
Myth 1: Wearing soft-backed or backless shoes is the best thing to do
Although this will indeed ease compression and friction on the posterior heel, it is important to recognise the foot as a whole.
Such a sudden, significant change in footwear has the potential to cause an overload in stress on other areas of the foot. Particularly for someone with a high-arched foot, taking away the ankle stability provided by a stiffer heel counter can increase the risk of a lateral ankle sprain.
It is important that a thorough, holistic foot assessment is undertaken before any footwear modifications made.
Myth 2: Say goodbye to your high heels
No. Haglund’s Deformity is largely referred to as “pump bump” due to the impact that stiff-backed high heeled shoes can have on the irritation of this condition.
This does not, however, mean that we need to rule particular footwear choices out completely.
The soft tissue irritation associated with Haglund’s Deformity is largely seen within a younger female population: significantly limiting footwear options may negatively impact their buy-in to the overall treatment plan.
Instead, it may be beneficial to discuss various modifications and offloading options, via the help of a podiatrist, so that high heeled shoes may remain a regular fashion choice.
Myth 3: Imaging is required
Why? A thorough history and clinical examination should give you a 95% certainty of diagnosis.
If you suspect something sinister like osteosarcoma then imaging is certainly warranted but otherwise, imaging referrals delay timely access to expert health professionals (Sofka et al).
Of course, if a client’s goals are imaging related “doc I really want to get a scan done on my sore heel” then person centred care could allow for a referral for imaging and to an expert at the same time.
As it is an irritation on the tissue surrounding the bony enlargement, treatment options are best focused on reducing compressional and frictional stress around the posterior heel.
It is important to recognise that these stresses are both internal and external. Therefore we need to address both aspects to optimise a patient’s care.
Externally, we do this via:
- Footwear modifications
Internally, it is most important to reduce inflammation where possible and provide intrinsic stability around the hindfoot and ankle. This is done via:
- NSAIDs - topical and oral
- Gait retraining cues
- Resistance training
Although a local cortisone injection may be beneficial in the reduction of retrocalcaneal bursitis and Achilles tendinitis, it is important to consider the increased risk of Achilles tendon rupture (Kearney et al).
Education on management of a painful Haglund’s Deformity is fundamental to effective treatment.
This education really focuses on pain education. As professionals when we take the time to talk through pain in terms of nociception, the factors that can positively and negatively influence symptoms it can empower our clients to take charge of their painful Haglund’s Deformity.
We also take the time to explain to every client the exact reason for their Haglund’s Deformity, their symptoms and allow opportunities for discussion and questions. This leads to the critical step of goal setting.
Goal setting is such an overlooked yet critical aspect of managing a painful Haglund’s Deformity, actually asking what our clients want and why.
A client suffering from Haglund’s Deformity symptoms for only a short period of time vs. those with chronic symptoms will have different goals and expectations.
Goal setting in the short, medium and long term provides a useful framework to fall back on when compliance/adherence or life gets in the way of best-made plans.
1. Injection treatment for painful Achilles tendons in adults. Cochrane Systematic Review- Intervention (2015). Kearney RS, Parsons N, Metcalfe D & Costa ML.
2. Haglund’s Syndrome: A commonly seen mysterious condition. Cureus (2016). Vaishya R, Agarwal AK, Aziz AT & Vijay V.
3. Haglund’s Syndrome: Diagnosis and Treatment Using Sonography. HSS J (2006). Sofka C, Adler K, Positano K, Pavlov H & Luchs J.