What is Haglund’s deformity?
This is a bony enlargement of the back of the heel. It can lead to a painful swelling of the fluid-filled sac (bursa) that sits between the heel bone and the achilles tendon.
What causes a Haglund’s deformity?
It is not entirely known what causes a Haglund’s deformity but it has been linked to several things:
- A tight Achilles tendon leads to pressure on the bone
- A prominent heel bone that slopes outwards makes the heel more likely to rub on the back of shoes
- Feet that are more supinated or have a high arch can lead to increased rubbing during walking
What are the symptoms?
Patients generally get symptoms of pain over the heel when walking especially when wearing shoes or boots with rigid backs that rub over the area. There is normally an obvious bump over the heel and this can swell after activity and become aggravated and red. Occasionally blisters and callosities will form over the bump.
How is it diagnosed?
The diagnosis is based on the clinical examination and the history of the symptoms as well as special tests like X-rays and MRI scans. X-rays will show the bony appearance of the Haglund’s deformity and occasionally calcification or spur within the achilles tendon insertion. An MRI scan will identify swelling of the fluid-filled sac (bursitis) over the Haglund’s as well as any problems with the Achilles tendon.
What treatments are available?
The first step in management should be to look at shoe wear and avoid rigid shoes and boots which rub over the heel. A simple heel lift may lift the bump out of the way reducing rubbing and reducing the tension of the Achilles tendon. Socks with gel pads over the bump can reduce the friction and pain caused by shoe wear. Anti-inflammatory medicine can reduce the inflammation from bursitis. Physiotherapy stretching the Achilles tendon can also help.
What is the surgical treatment?
If all non-operative management fails then surgery to remove the bump and the bursa can help. Occasionally this can be done through keyhole surgery but more commonly involves detaching the Achilles tendon to remove the bump and the bursa. After the bump has been removed the Achilles tendon is reattached using specifically designed orthopaedic bone suture anchors. The subsequent rehab allows the Achilles tendon time to heal back down to the bone.
What are the risks of surgery?
General—General anaesthetic problems, scar irritation, infection or wound healing problems, deep venous thrombosis (DVT) and pulmonary embolism (PE)
Specific—Nerve injury and chronic pain. Recurrent bursitis or boney growth
Haglund’s surgery rehabilitation
Time frame
Activity
0–2 weeks
- Posterior slab/splint in mild plantarflexion
- Complete straight leg raise exercises and elevate limb when sitting
- Intrinsic toe exercises
2–4 weeks
- *† Walking boot, non-weight-bearing
- Active platarflexion and dorsiflexion to neutral
- Inversion/eversion below neutral
- Intrinsic foot exercises
- Modalities to control swelling
- Incision mobilisation modalities
- Knee/hip exercises with no ankle involvement
- Non weight-bearing fitness/cardiovascular exercise e.g static bicycling with one leg, deep water running
4–6 weeks
- *† Weightbearing as tolerated in walking boot
- Continue 2–4 week protocol
6–8 weeks
- Weaning from boot into normal shoes with 1cm heel raise
- Slow dorsiflexion stretching
- Graduated resistance exercises ( open and closed kinetic chain as well as functional activities)
- Proprioceptive and gait retraining
- Incision mobilisation
- Fitness/cardiovascular exercises to include weight bearing as tolerated e.g bicycling, walking, elliptical machine
8–12 weeks
- Continue to progress range of motion, strength, proprioception
- Retrain strength, power and endurance
- Increase dynamic weight-bearing exercise, include plyometric training and sport specific retraining
* Patients were required to wear the boot while sleeping.
† Patients could remove the boot for bathing, dressing and physio but are required to adhere to the weight-bearing restrictions according to the rehabilitation protocol.
When can I return to work?
This is always dependent on the type of work you do and the recovery period can be extremely varied for individuals.
2 weeks
- Desk work
6–8 weeks
- Standing work
10–12 weeks
- Heavy lifting work
When can I drive?
Some postoperative pain medicines can affect your concentration, mood, coordination and reactions thereby reducing your ability to drive safely. You mustn’t return to driving whilst still taking any of these medications. Please check this link for further information https://www.vicroads.vic.gov.au/safety-and-road-rules/driver-safety/drugs-and-alcohol/medicines-and-road-safety
You can not return to driving when any foot involved in driving the car is restricted by an orthotic (post-op shoe, walking boot or plaster cast).
Car type
Operated foot
Automatic
Right—6 weeks. When you are fully weight-bearing in normal shoes
Left—Restrictions related to post anaesthetic and pain medications
Manual
Right/Left—6 weeks. When you are fully weight-bearing in normal shoes
When can I return to sport?
This depends on the sport but it may take 6–9 months to get back to some activities and again this would be guided by your physiotherapist and your ability to build up your level of running and match fitness.
When can I run?
This is extremely variable and you should be guided by your physiotherapist. You should have 90% calf strength and proprioception in order to return to light jogging. Often when you can carry out 20 or more single leg calf raises or can hop on the spot then you are in a position to return to running. It would also be a staged return, starting with a light jog for a minute or two then gradually building up distance and speed over time.