Haglung's deformity symptoms and treatment

What is it?

Haglund’s deformity was described for the first time in 1928. It refers to the mechanical irritation between the posterior section of the calcaneus (heel bone) and the Achilles tendon. A bony lump, call a Haglund’s deformity, causes a conflict by entering into direct contact with the tendon. The rear pressure when putting on shoes complicates the condition and causes a mechanical irritation of the retrocalcaneal bursa (cushion between the bone and tendon). Irritation of the retroachilles bursa (located between the tendon and skin) is also observed.

Fig. 1

Haglund’s deformity with irritation of the retrocalcaneal and retroachilles bursas

Clinical presentation

The main complaint is at the level of the posterior part of the heel. There is usually a bump at this level, accompanied by pain when putting on shoes. With chronic inflammation of the Achilles tendon, pain may also be present at rest or during sustained activity.

When should you consult a specialist?

When putting on shoes is difficult or when the pain becomes incapacitating. The development of skin lesions at the rear bump is also a sign of severity requiring a specialised consultation.

The diagnosis is made by clinical examination, but also by a radiological assessment that highlights the conflict. In some cases, an MRI may be proposed to detect chronic Achilles tendon lesions that require specific care.

Non-surgical treatment

The first line of treatment is to change the footwear. The recommendation is to wear soft and comfortable shoes. Anti-inflammatory drugs can offer one-off help or can be of assistance when doing sport. Finally, physiotherapy sessions can be proposed in cases of chronic inflammation at the insertion of the Achilles tendon. Repeated infiltrations of steroid (cortisone) should be avoided as although they can offer temporary relief they may, in the long run, cause significant injury to the tendon.

Unfortunately, conservative options often give disappointing results and the treatment is primarily surgical.
Surgical treatment

Two main techniques can be proposed, depending on the specific architecture of the affected foot, the quality of the Achilles tendon and the functional demand of the patient.

The first, and the most common one, is simply to re-sect the bony postero-superior edge of the calcaneus. This technique also allows an exploration of the insertion of the Achilles tendon and direct action to be taken on the latter, if necessary. The procedure can be carried out by traditional open surgery or using an arthroscopic technique, to limit the surgical aggression and therefore, in theory, offer a more straightforward outcome.

Simple excision of the postero-superior corner of the calcaneus.

In cases of vertical calcaneus, flatfoot or failure after a simple excision, Zadek’s osteotomy can be performed. The procedure consists of removing a triangle of bone in the volume of the calcaneus. By closing this cut, the part in conflict and the insertion of Achilles tendon are displaced upwards and deeper, which significantly reduces the bone-tendon contact. The calcaneus is also shortened, which seems to change the biomechanics of the hindfoot and the lever arm at the level of the Achilles tendon, which also contributes to reducing local constraints.

Zadek’s osteotomy. Note the displacement and rotation of the posterior part of the calcaneus.
Post-surgical follow up

When only the bone malformation is removed, the after-care is relatively straightforward. The patient is allowed to walk immediately, depending on the pain.

When the surgery includes a procedure involving the Achilles tendon, the foot will be protected by a resin splint for six weeks. Rehabilitation by a physiotherapist is very important in order to work actively towards the recovery of the muscle/tendon function.

Finally, in the case of osteotomy of the calcaneus, the limb is protected by a resin splint and non-weight bearing walking is permitted. The resumption of weight-bearing walking will depend on the clinical and radiography checks carried out six weeks after surgery.

Driving a vehicle is permitted after two weeks following a simple excision, and 6-10 weeks after more extensive surgery.

Sick leave of 3 to 12 weeks will be required, depending on the surgical technique and the patient’s profession.

Sport can be resumed gradually three weeks after the excision. In case of osteotomy or surgery on the Achilles tendon, sport can sometimes only resume after a period of up to six months for contact sports or sports requiring intensive swivelling movements.
Risks and complications
Besides the possible complications after any type of surgery (thrombosis, infection <3%, algodystrophy <3%), it is recognised that the following complications may occur after surgery on the insertion area of the Achilles tendon:
- Rupture or a disinsertion of the Achilles tendon (very rare).
- The sural nerve, whose pathway passes close to the surgical area, can sometimes be affected. It is primarily a sensory nerve whose injury is generally regressive.
- The skin, in this region, is fragile and subject to considerable stresses. Healing problems have been reported when the patient returns to work too early or when there is bruising.
- Although the correction is stable, surgery is sometimes unable to remove the conflict entirely, especially during simple resections. This is usually painless and temporary; however, the revision may require a more complex surgical procedure (Zadek’s osteotomy, etc.).