What is it?

Haglund’s deformity, also called pump bump, winter heel, Mulholland deformity, or retrocalcaneal exostosis, is a bony enlargement of the posterosuperior heel bone, called the calcaneus, at the insertion site of the Achilles tendon. The Achilles tendon is the tendinous combination of the calf muscles, consisting of the gastrocnemius, soleus and plantaris muscles.

Haglund’s syndrome is a condition that results when Haglund’s deformity leads to inflammation and pain of the Achilles tendon, subcutaneous calcaneal bursa, and/or retrocalcaneal bursa. The subcutaneous calcaneal bursa is a fluid-filled sac located between the skin and the Achilles tendon. The retrocalcaneal bursa is a fluid-filled sac located between the Achilles tendon and the calcaneus.

 

Symptoms/Risks

Symptoms of Haglund’s deformity include:

• Posterior heel pain, typically described as a dull pain

• Pain worse with walking, after rest and when wearing shoes

• Posterior heel redness, swelling and enlargement

 

Risk factors of Haglund’s deformity include:

• Improper shoe use, such as high heels, rigid backs of shoes, or low backs of shoes

• High foot arch

• Tight Achilles tendon

• Female gender

• Obesity

• Over-training, especially in runners

 

Sports Medicine Evaluation & Treatment

A sports medicine physician will take a history of the condition and perform a physical exam. The physical exam will include close examination of all of the posterior heel structures. They will likely order X-rays of the feet and ankles and may perform a diagnostic ultrasound to evaluate for the bony enlargement at the posterosuperior calcaneus and signs of inflammation of the Achilles tendon and/or bursa.

Conservative treatment options for Haglund’s deformity include:

• Shoe wear modifications

• Use of an orthosis; such as heel lifts or heel pads

• Physical therapy, focusing on stretching and ankle/foot muscle strengthening

• Application of ice to the posterior heel

• Anti-inflammatory medications, oral or topical

If conservative treatment options fail to improve the condition, then more invasive options are available. A sports medicine physician can perform a local corticosteroid injection in the bursa to decrease pain and inflammation. Regenerative medicine interventions like Platelet-Rich Plasma (PRP) injections may be considered in some cases.

Surgical intervention is the last option and involves removal of the bony enlargement of the calcaneus, called a calcaneus osteotomy. Surgical intervention can be performed with an endoscopic (minimally invasive) technique or an open technique.

Injury Prevention

Injury prevention is similar to many of the conservative management options, including:

• Shoe wear modifications

• Adequate training progression and technique

• Stretching exercises

 

Return to Play

Return to play and return to normal shoe wear is dependent on the level of pain. If surgical intervention has been performed, then return to play and normal shoe wear is typically 3-6 months after surgery.

AMSSM Member Authors
Gerardo Miranda-Comas, MD and Fairen Walker-McCarter, MD

References
1. Bulstra GH, et al. Can We Measure the Heel Bump? Radiographic Evaluation of Haglund’s Deformity. The Journal of Foot & Ankle Surgery 54: 338 – 340, 2015. http://dx.doi.org/10.1053/j.jfas.2014.07.006
2. Netter, Frank. Atlas of Human Anatomy. 4th ed., Saunders Elsevier, 2006.
3. Pavlov H, et al. The Haglund Syndrome: Initial and Differential Diagnosis. Radiology 144 (1) : 83-88, 1982. DOI:10.1148/radiology.144.1.7089270
4. Syed TA, Perera A. A Proposed Staging Classification for Minimally Invasive Management of Haglund’s Syndrome with Percutaneous and Endoscopic Surgery. Foot and Ankle Clinics 3 (21): 641-664, 2016. http://dx.doi.org/10.1016/j.fcl.2016.04.004
5. Vaishya R, Agarwal A, Azizi A, et al. Haglund’s Syndrome: A Commonly Seen Mysterious Condition. Cureus 8 (10): e820, 2016. DOI 10.7759/cureus.820