Haglunds Deformity

Haglund’s deformity is the term used to describe an enlargement of the posterior/lateral heel. Haglund’s deformity also goes by the name of Haglund’s disease and pump bump. Haglund’s deformity occurs in patients ranging from the late teens until the 5^th or 6^th decade of life. Most clinicians agree that Haglund’s deformity is formed by rolling of the heel into the heel counter, or rim of the shoe. As a result of the constant pressure of the shoe, reactive bone forms. Haglund’s deformity is common in individuals who wear shoes that have a rigid heel counter such as ice skates or pump heels.

In addition to reactive enlargement of the heel bone, chronic pressure to the posterior/lateral heel often results in bursitis of the heel. This particular bursal sac forms between the heel and skin. Inflammation of the bursal sac, called bursitis, can be quite painful and limit and individual’s ability to wear shoes.

Treatment of Haglund’s deformity

Conservative care of Haglund’s deformity focuses on avoiding direct pressure on the back of the heel. Shoes that have a rigid heel counter should be avoided. Open back shoes like clogs and flip-flops can help by simply decreasing direct pressure to the posterior heel. When closed heel shoes are required, a heel lift can be used to raise the heel above the heel counter.

Use of oral anti-inflammatories and cortisone are not particularly effective if direct pressure to the posterior heel continues. Although anti-inflammatories may help to ease pain, the primary cause of Haglund’s deformity is mechanical due to direct pressure from the shoe.

Pre-op evaluation of a Haglund's deformity includes assessment of the heel with a lateral x-ray of the foot. The reactive bone deposit on the posterior heel in a Haglund's deformity can be visualized. As a result, the heel which is normally round in the back becomes square like the head of a tomahawk. This increase in bone on the back of the heel is measured by an angle called the Phillip-Fowler angle. An increase in the Phillip-Fowler angle suggests hypertrophy of the posterior heel

Surgical care of Haglund’s deformity focuses on resection of the posterior/lateral bump of the heel. Most cases of Haglund’s deformity can be corrected without displacement of the Achilles tendon from the back of the heel. The advantage of keeping the Achilles tendon intact is that patients are able to ambulate immediately post-op. If the Achilles tendon does need to be moved or is weakened during the surgery, patients are placed in a below the knee cast for 6-8 weeks to allow for adequate healing of the tendon.

In severe cases of Haglund’s deformity, a Keck and Kelly procedure may be performed. A Keck and Kelly procedure is a wedge resection of the calcaneus that results in the shortening of the calcaneus. A Keck and Kelly procedure would be performed in conjunction with a partial resection of the posterior heel.

Surgical resection of a Haglund’s deformity (without a Keck and Kelly procedure) is performed on an out-patient basis using either a general anesthetic or local anesthesia with sedation. The procedure takes approximately and hour to complete. This procedure is typically performed in the prone position. Healing from this surgery does vary, but most patients are back into a regular shoe at 4-6 weeks following surgery.

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The Achilles tendon descends from the calf to insert onto the posterior aspect of the calcaneus (heel bone).  The Achilles tendon has a natural spiral rotating from posterior to medial as it descends the leg.  The insertion of the Achilles is on the posterior heel as seen in the labeled x-ray to the left.

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The symptoms of Haglund's deformity include a burning pain of the posterior/lateral heel with enclosed shoes.  No significant pain is present with this condition while barefoot.  If pain is present while barefoot, Achilles tendonitis should be ruled out.

Achilles tendonitis

Achilles tendon rupture (partial)

Calcaneal stress fracture

Gout

Retrocalcaneal bursitis

• Achilles Tendonitis

• Plantar Fasciitis

• Calcaneal Fractures

• Cracked Heel

• Heel Spur Syndrome

This article was written by Jeffrey A. Oster, DPM and last edited on 2/8/13. No additional references are available for this topic.