HAGLUND DEFORMITY - RETROCALCANEAL BURSITIS

Haglund syndrome involves painful swelling of the soft tissues of the posterior heel just anterior and superior to the Achilles tendon insertion, associated with lateral calcaneal bursitis and Achilles tendinitis.


Posterior heel edema due to retrocalcaneal bursitis and Haglund deformity

CAUSES
To some extent, heredity plays a role in Haglund’s deformity. People can inherit a type of foot structure that makes them prone to developing this condition.

For example, high arches can contribute to Haglund’s deformity. The Achilles tendon attaches to the back of the heel bone, and in a person with high arches, the heel bone is tilted backward into the Achilles tendon. This causes the uppermost portion of the back of the heel bone to rub against the tendon. Eventually, due to this constant irritation, a bony protrusion develops and the bursa becomes inflamed. It is the inflamed bursa that produces the redness and swelling associated with Haglund’s deformity.

A tight Achilles tendon can also play a role in Haglund’s deformity, causing pain by compressing the tender and inflamed bursa. In contrast, a tendon that is more flexible results in less pressure against the painful bursa.

SYMPTOMS
Haglund’s deformity can occur in one or both feet. The signs and symptoms include:

  • A noticeable bump on the back of 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.

EXAMINATIONS

Clinical examination

Noticeable change of normal anatomy back heel with edema - swelling and redness.
Palpation:
Patient present with deep posterior heel pain, fullness and tenderness with palpation medial and lateral to the Achilles tendon, and increased pain during dorsiflexion.

Radiographs

Lateral foot radiographs will demonstrate Haglund deformity.
MRI and ultrasonography can be helpful to determine extent of Achilles tendon degeneration. 

 

CONSERVATIVE TREATMENT
THERAPY: 

The goal of conservative treatment is to address the existence of local inflammation of the Achilles tendon and bursa. Conservative treatment should be noted that it can not address the cause of the creation of inflammation, ie can not be shrunk the back bony prominence - spur of the heel.

Conservative treatment includes:

  • Antiinflammatory oral medications which are aimed at reduce inflammation. Some people benefit from the use of topical anti-inflammatory agents such as ointments or drops.
  • Ice. The ice applied during the period of intense inflammation, ie when behind the heel there is swelling and redness. Applications should not exceed 6-8 minutes at a time and this can be repeated several times in 24 hours.


The ice relief the patients symptoms

  • Exercises. Stretching exercises help relieve tension from the Achilles tendon. These exercises are especially important for the patient who has a tight heel cord.


Stretching exercises of the Achilles tendon

  • Heel lifts. Patients with high arches may find that heel lifts placed inside the shoe decrease the pressure on the heel. Heel pads. Placing pads inside the shoe cushions the heel and may help reduce irritation when walking. 
  • Orthotic devices. These custom arch supports are helpful because they control the motion in the foot, which can aggravate symptoms.
  • Steroids injections - cortisone-, should be avoided due to inherent risk of Achilles rupture.
  • Physical therapy. A physical therapist can help identify biomechanical abnormalities that may be contributing to inflammation and recommend appropriate strengthening and stretching exercises to help decrease discomfort and prevent the need for surgery.
  • Immobilization. In some cases, casting may be necessary to reduce symptoms.
OPERATIVE TREATMENT
THERAPY: 

Surgical treatment applied when prolonged conservative treatment did not address the patient's symptoms.

Its aims to remove the inflamed bursa that lies between the Achilles tendon and heel and removal of hypertrophic bone protrusion of the posterior apophysis of the calcaneus.

The surgery can be done with open surgical procedure or by arthroscopic method is certainly the minimally invasive method.


Swelling of the posterior surface of the heel due to hypertrophy of the posterior calcaneal tuberosity thereof and inflamed local bursa


Skin incision (open method)


Identification of hypertrophic bone protrusion preparation removal with osteotome


Haglund spur remonal with osteotome


Preparing for arthroscopic removal of bone hypertrophy and bursa


Arthroscopic removal of posterior heel spur (Haglund deformity)