HAGLUND’S DEFORMITY

Image Credit: Medical News Today 

“The human body has been designed to resist an infinite number of changes and attacks brought about by its environment. The secret of good health lies in successful adjustment to changing stresses on the body.”
– Harry J. Johnson

What Is Haglund’s Deformity?

When a large, bony protrusion develops on the back of the heel, this condition is known as Haglund’s deformity. As a bony enlargement, the condition causes the soft tissue in the surrounding area, near to the Achilles tendon to become irritated during daily activities, such as the wearing of shoes. When the heel area becomes irritated, conditions such as bursitis can develop. With a variety of treatments both non-surgical and surgical, it is possible to treat this condition, and restore normal life activities. 

Causes

With a variety of root causes for this condition, one of the most frequent causes of Haglund’s deformity is actually induced via the wearing of pump style shoes that can aggravate the tissues and the bones in the heels. It is therefore important to wear the right shoes: 

What is the right shoe? 

The right shoe provides the feet with a mixture of cushion, support and comfort. The anatomy of the foot is such that it supports the body on a hinge joint. The appropriate alignment of the feet is critical to so much, inclusive of the health of the spine. The right fit of the shoe should be such that it fits snugly, and there is at least 1-1.5 cm of space at the end of shoe. A few key characteristics of shoes that should be factored in include: 

  1. A stiff back for appropriate heel support 
  2. Flexibility to facilitate the motion of your feet
  3. Appropriate arch support – The arch of the foot is part of its engineering design that facilitates its ability to support the body appropriately. Shoes will not all be perfectly designed, so with the appropriate inserts, shoes can be customized to facilitate that additional comfort. 
  4. Heel height – Heel height is very important for the support of the feet and the body. The body was designed for an optimum height. The higher an individual is off the ground, the higher will be the center of gravity of that individual. Any object with a high center of gravity will have the tendency to fall, compared to an object with a lower center of gravity. Women are aware of the fact that with higher heels, they do feel the instability that comes with being elevated. It will be important for an individual to ensure that they match their heel height with their personal height. 

Because the wearing of shoes such as pumps can develop Haglund’s Deformity, the condition is often known as “pump bump”. The rigid backs of the heels, coupled with the already enlarged heel, will induce the generation of the growth. For those in the sporting realm, ice skates can also induce Halgund’s Deformity. From a genetic perspective, if you have the following noted characteristics:

  • A high-arched foot
  • A tight Achilles tendon
  • A tendency to walk on the outside of the heel,

you will likely develop Haglund’s Deformity. 

Symptoms

  • A noticeable bump on the back of the heel
  • Pain in the area where the Achilles tendon attaches to the heel
  • Swelling in the back of the heel
  • Redness near the inflamed tissue

Source: Reference[1] 

Diagnosis

During a consultation with your Orthopaedic surgeon, you will then be presented with a suitable course of action. There will be more than one foot condition that can lead to an enlargement of the heel area, so carefully ensure that you are thoroughly assessed. In some instances, it is highly likely that you may have a condition such as Achilles Tendonitis, instead of Haglund’s deformity. Medical tests will be the most efficient way to determine what the diagnosis of your condition will be. 

Via the utilization of equipment such as an X-ray, the internal conditions of your heel will be visible to your doctor. He can then take the time to actually determine your condition. The prominent heel bone will be visible from the lab results. Once the diagnosis is indeed Haglund’s Deformity, your doctor can also take the necessary steps to ensure that you’re taken care of. This includes the manufacture of your custom orthotic device, a foot insert, that will help to relieve your heel pain. 

Nonsurgical Treatment

In the instance where your condition is in its early stages, you may not need surgery in order to treat your bursitis. What works well, is the utilization of various treatments and medications that will work for management of your condition. These treatments include: 

  • Medication. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce the pain and inflammation. Ice. To reduce swelling, apply an ice pack to the inflamed area, placing a thin towel between the ice and the skin. Use ice for 20 minutes and then wait at least 40 minutes before icing again.
  • Exercises. Stretching exercises help relieve tension from the Achilles tendon. These exercises are especially important for the patient who has a tight heel cord.
  • Heel lifts. Patients with high arches may find that heel lifts placed inside the shoe decrease the pressure on the heel.
  • Heel pads. Pads placed inside the shoe cushion the heel and may help reduce irritation when walking.
  • Shoe modification. Backless or soft backed shoes help avoid or minimize irritation.
  • Physical therapy. Physical therapy modalities, such as ultrasound, can help to reduce inflammation.
  • Orthotic devices. Custom arch supports control the motion in the foot.
  • Immobilization. In some cases, casting may be necessary.

Reference[1] 

When Is Surgery Needed?

Surgery is always the treatment of last resort, because it is so invasive in nature. From the list of non-surgical methods outlined above, a combination of the treatments works well in order to achieve a comfortable standard of living. In those instances where nonsurgical treatment fails to provide adequate pain relief, surgery may be needed. Your orthopaedic surgeon will then prepare an adequate plan for your to ensure that your Haglund’s Deformity protrusion is removed. At best, wear your orthotic devices and keep your feet as comfortable as possible, until your surgery is done.

Post-operative management

With all treatments, there’s a time line for recovery.  Full rehabilitation after Haglund’s resection can take up to one year. Here is a solid plan for healing[3]:

Day 0 – 10

  • Oedema management:
    • Rest – Active rest
    • Ice
    • Elevation – for first 10 days of recovery period
    • Compression
  • Mobilization:
    • Patients are mostly put in moon boot or below-knee backslab
    • Non-weight bearing mobilization: 3 days to 2 weeks (as per surgeon)
  • Lower leg strengthening exercises
  • Achilles stretches (contra-indicated if Achilles was injured or if it was detached and re-attached intra-operatively)
  • Return to full activity at 6 weeks post-surgery.

Day 10 – 6 weeks

  • Mobilization:
    • Resection without Achilles debridement/repair: Moonboot with raised heel
      • Progress from toe-touch weight bearing to partial weight bearing to assisted full weight bearing in the 4 week period
    • Resection with Achilles debridement/repair: Moonboot or cast in equinis
      • Non-weight bearing 4 weeks
  • Oedema management as needed

6 – 12 weeks

  • Mobilization:
    • Resection without Achilles debridement/repair:
      • Wean moonboot wear
      • Full weight bearing
  • Resection with Achilles debridement/repair: Moonboot in equinis
    • Progress to moonboot is cast was initially required
    • Progress weight bearing from toe-touch weight bearing to partial weight bearing to assisted full weight bearing over 4 weeks
  • Oedema management
  • Start scar management as soon as wounds are fully healed

Week 12+

  • Mobilization: Wean off moonboot and mobility assistive devices if still in use
  • Exercises:
    • Strengthening and endurance of foot and ankle muscles
  • Oedema management

References: 

  1. FootHealthFacts: https://www.foothealthfacts.org/conditions/haglund%E2%80%99s-deformity
  2. HealthLine: https://www.healthline.com/health/haglund-deformity#TOC_TITLE_HDR_1
  3. Physiopedia: https://www.physio-pedia.com/Haglund%27s_deformity

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Dr. Gordon Slater

Dr. Slater is one of the first foot and ankle surgeons in Australia to adopt minimally invasive surgical techniques. He routinely uses MIS to treat a range of conditions, including bunions.

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Dr Gordon Slater is a highly-skilled surgeon specialising in foot and ankle conditions and sports injuries. Dr Slater is one of the first foot and ankle surgeons in Australia to adopt minimally invasive surgical techniques. He routinely uses MIS to treat a range of conditions, including bunions. MIS  has many advantages including shorter operating times, reduced post-operative pain, reduced risk of infection, minimal scarring and better cosmetic outcomes.

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