That stubborn, painful lump at the back of your heel which turns putting on shoes into sheer agony – it might be more than just a resented rub from a stiff shoe collar. The Haglunds deformity of the heel is a bony growth that develops on the superior-posterior aspect of the calcaneus a fact that is often overlooked and confused with a minor sports injury long before it is established as a structural condition in its own right.
What Is Haglunds Deformity of the Heel?
Haglunds deformity is a particular bony prominence that forms on the posterosuperior portion of the calcaneum basically, the tip-top back corner of the heel bone. It is named after Swedish surgeon, Patrik Haglund, who first detailed the condition in 1928. The protrusion can be palpated and visualised in the subcutaneous tissue.
The cause of irritation of the soft tissues of the heel as they come into contact with footwear is the relative irritation of the soft tissues that cover it leading to inflammation, soreness and often chronic pain. It is not simply an abrasion of the skin or a crush injury overlying the bony prominence, but a structural deformity of the underlying structure.
How Haglunds Deformity Develops in the Heel Bone
The calcaneus has a naturally rounded posterior edge, which in Haglunds deformity becomes prominent. The Achilles tendon attaches directly to this area and on between the Achilles and the bone lies a small fluid-filled sac known as the retrocalcaneal bursa. When the bone overhang becomes large enough to impinge on the bursa and the lowest fibers of the Achilles tendon a repetitive inflammatory process occurs which may persist indefinitely.
The bursa may become enlarged over time leading to retrocalcaneal bursitis with swelling which may be hot, puffy and tender.
Haglunds Deformity vs. Other Heel Conditions
People frequently confuse it with plantar fasciitis, which on the bottom of your heel as a lump while Achilles tendinopathy occurs at the back but results from tendon degeneration and not bony proliferation. “Pump bump” is just a lay term for Haglunds deformity, derived from the fact that tight backed footwear and high heels are a trigger. These details are relevant – as therapies for one condition do not naturally translate to beneficial outcomes in another.
Common Causes and Risk Factors
While there is a variety of proposed etiologies for the Haglunds deformity, no single cause can be found for all cases. In general, a Haglunds deformity will be a result of an interaction between inherited anatomical structures, loading mechanisms and external shoe pressures over several months or years. Many individuals will have inherited anatomical structures associated with this deformity for their entire lives without complaints, while others will experience pain relatively rapidly depending on their footwear and activity levels.
Foot Shape, Biomechanics, and Genetics
High-arched feet—Pes cavus from a pes cavus relates to Haglunds deformity more than flat feet. As the arch arches, the heel tends to invert, putting the posterosuperior border of the calcaneus in a position where it is more likely to hit the back of a shoe. This pressure is even worsened by a tight Achilles.19 The shape of the calcaneus is based on genetics; if one parent has the deformity, there is a fair chance the children of that parent will also develop it.
Footwear, Sports, and Lifestyle Triggers
Certainly the best known environmental trigger of RBP is indeed rigid backed footwear. It is not difficult to see how many different types of footwear come into contact with the prominent bony part of the heel- ice skating boots, dress shoes, higher end running shoes with large rigid heel counters. Over, and over repeatedly the bony part of the heel is pressed up against by footwear.
Runners who have high mileage and train regularly on ascents particularly steep ascents will place additional stress on the Achilles insertion- worsening inflammation. Other professions that involve long standing and walking that involve rigid footwear will gradually cause similar pressure. Shoes that are more open or sandal like can provide significant short term relief which can serve as a very good diagnostic clue.
Signs, Symptoms, and When to Seek Medical Help
Identifying Haglunds deformity as soon as possible can save you a few months of discomfort, or possible years if left unidentified. Its symptoms are pretty distinctive when you are aware of what signs to spot; however they can be a slow build up that few people recognize as coming from a deformity.
What Haglunds Deformity Feels and Looks Like
The clearest symptom is a hard lump that is identifiable at the back of the heel, usually the lump will be red or inflamed and a little swollen if it was the bursa that was inflamed. Usually people complain that they have pain most the time, especially when first putting on enclosed shoes, just after rest and after sporting activities. Some people say that it feels warm but tender to touch, although in the more chronic patellar symptoms the lump may be tender to touch even when just applying light pressure with a sock.
When Heel Pain Needs Professional Assessment
Ongoing pain over several weeks even with rest and footwear modifications should be assessed. Acute inability to push off the foot, clicking sensation around the heel or rapid progression of swelling could signify inclusion of Achilles tendon that should be examined by a professional.
Diagnosis and Medical Evaluation
The diagnosis is made by clinicians by taking a history, conducting a clinical examination, and using appropriate investigations. A correct diagnosis is really key—as the management varies considerably depending on what the doctor finds.
Physical Exam and Clinical Tests
On examination, a clinician will feel for tenderness over the posterosuperior aspect of the heel, examine the Achilles tendon and the ankle movements. The “two-finger squeeze test”, by squeezing the two sides of the heel simultaneously, will reproduce a characteristic pain pattern in retrocalcaneal bursitis. Decreased ankle dorsiflexion indicates a contracted heel cord strengthening the diagnosis.
Imaging: X-rays, Ultrasound, and MRI
Plain X-ray can confirm the bony swellings and the severity can also be determined by measuring the calcaneal pitch angle. Ultrasound can identify bursal swellings and allows assessment of the condition of the Achilles in real time. MRI demonstrates the soft tissue involvement in great detail and is most useful when surgical intervention is contemplated or the Achilles tendon is suspected to be damaged.
Treating Haglunds Deformity of the Heel
The majority of individuals with the Haglunds deformity respond to conservative (non-operative) management, particularly in the early stages of the condition. Management should aim to reduce inflammation, offload the bony prominence and alter contributory factors leading to irritation.
Non-Surgical Treatments and Self-Care
The easiest and most basic intervention is simply switching to open backed shoes or softer heel counters. Heel lifts-have small, lift inserts placed into the shoes above the heel-area can lift the heel and decrease the angle of pull on the calcaneus by the Achilles. For those with high arches, custom orthotics may help correct various, underlying biomechanics.
Ice for 15-20 minutes following activity to decrease the acute inflammatory response. Daily stretching of the calf musculature and Achilles will lengthen the structure decreasing tension at insertion. Oral NSAIDS may work in the acute phase to decrease inflammation, but will not address the structural abnormalities.
Physical therapy strengthening for the lower-limbs and stretching of the calf muscles could be helpful for long term results.
Surgical Correction and Recovery
Surgical management is initiated when conservative care has failed over time (up to several months). The classical surgical procedure is resection of the bone bump (called a calcaneal osteotomy or exostectomy) combined with retrocalcaneal bursectomy if the bursa is badly damaged. Good results can be achieved, although recovery takes three to six months.
Patients will need a period of non-weight bearing for some time before rehabilitation is gradual. Return to high impact sport is also slow.
Long-Term Prevention and Lifestyle Tips
Selecting shoes with flexible, well-cushioned heel counters minimizes long-term distension of the calcaneus. Pay close attention to training terrains and avoid doing excessive uphill work, especially at high weekly mileages. Daily stretching of the calf muscle complex (especially the gastrocnemius and soleus) can mitigate the effects of continuing Achilles over-stretch.
Must be aware of heel health if had it in the past—relapse can occur if old shoe habits are reintroduced.