Haglund’s deformity

General information

Haglund’s deformity (Haglund syndrome) is a type of osteochondropathy characterized by the appearance of an osteophyte or bony outgrowth on the back of the heel bone, just above the Achilles tendon attachment site. This pathology is named after the Swedish orthopedists who first described it in the early XX century. The heel bone is the largest in the foot. It is the attachment for the powerful Achilles tendon, which provides full-fledged work of the ankle joint and plantar flexion of the foot. This tendon allows a person to stand, jump, and run on his toes.

The articular bursa above the heel bone ensures easy tendon gliding. If the tendon is regularly traumatized, it becomes inflamed and loses its function. In response, pathological cartilage tissue is formed, and abnormal cartilage is formed as a protective structure. Its appearance should strengthen the area of constant irritation and improve tendon gliding, but the pathologic structure makes this impossible.

The cartilage can grow for years, gradually forming spikes that traumatize the tendon. Thus, a vicious circle appears. As a result of regular tendon trauma, aseptic (i.e., not associated with infection) necrosis gradually develops in the calcaneal tuberosity. The pathology originates in childhood, gradually develops, and manifests clinically in adolescence. 

Causes

The causes of the development of Haglund’s deformity are not definitively clarified, but experts identify several provocative factors that accelerate the development of this pathology. These include:

• II-III degree obesity;
• traumatic tendon sprain;
• destruction of the hip and knee joints;
• varus (O-shaped) or valgus (X-shaped) curvature of the lower leg;
• incorrect foot placement (transverse and longitudinal flat feet, clubfoot) and other pathologies.

The development of an abnormal process in the calcaneal tuberosity is manifested by gradually increasing pain, which increases with load and movement. Gradually, the pain syndrome becomes so pronounced that a person is forced to walk, leaning only on the front part of the foot. The diagnosis is made based on clinical and radiologic signs. Conservative treatment of this pathology of the musculoskeletal system is not always effective, so in most clinical cases, patients are prescribed surgical intervention.

Classification

Haglund’s deformity can be unilateral or bilateral, depending on whether the abnormal process has spread to one or both legs. In orthopedics and traumatology, the five stages of Haglund disease are conventionally distinguished.

1. Aseptic necrosis. The nutrition of the area of the bone structure is disturbed, and a focus of necrosis appears.
2. Impression (depressed) fracture. The necrotized area cannot withstand normal loads, so healthy bone tissue is “pressed” into it.
3. Fragmentation. The part of the bone affected is separated into individual fragments.
4. Lysis of tissues that have undergone necrosis.
5. Repair. Connective tissue forms in place of the resorbed necrotized structures, which new bone structures will replace.

In terms of clinical manifestations, Haglund syndrome can be:

• non-obvious; the deformity is visually poorly visible; there are no clinical and MRI signs of conflict tendinopathy (active progression of the inflammatory process accompanied by osteophyte overgrowth);
• obvious; the tuberosity is visually bright; there are pronounced signs of conflict tendinopathy (inflammatory process progresses, gradually leading to tissue destruction and tendon rupture); bursitis on MRI has different severity;
• hiding; the disease is indicated only by clinical manifestations of conflict tendinopathy, and there are no MRI signs of any pathologic changes.

According to the site of localization, Haglund deformity is subdivided into five variants:

• upper type – the pathologic structure is located only on the top of the hillock, and the heel area outwardly looks normal;
• upper-lateral type – the deformity involves the apex of the calcaneal tubercle and the upper part of the lateral flank;
• arc-shaped – deformity localized at the apex and pronounced on the sides;
• total type – abnormality, expressed approximately evenly on the apex and sides, almost “squeezes” the Achilles tendon backward;
• atypical variants – visually similar to the above forms but have radiologic differences: the classic bump, which has a dome-shaped or mushroom-shaped form, is combined with a half-free bone fragment.

Symptoms

Initially, Haglund syndrome is mistaken by external signs for a large callus. This abnormal growth is initially soft but gradually begins to harden and become inflamed. The main physical sign of Haglund’s syndrome, present from the beginning, is severe pain that appears at the beginning of walking. The localization of the pain is usually in the middle of the area where the Achilles tendon attaches to the heel bone.

After the onset of the inflammatory process in the Achilles tendon and bursa, additional signs are added to the pain syndrome:

• swelling and redness of the tissue;
• The appearance of blisters in the affected area;
• pain when walking and then at rest;
• discomfort when touching the growth;
• pain and discomfort when taking off and putting on shoes.

The X-ray clearly shows the “high heel bone,” the surface of which is covered with spikes. Most often, before the appearance of severe pain, people perceive this pathology as an ordinary cosmetic defect. The signs of pronounced soreness and inflammation and apparent difficulties in choosing shoes make people consult a doctor.

Diagnosis

The diagnosis of Haglund syndrome can only be made by a qualified and experienced orthopedist, as the symptomatology of this pathology is similar to rheumatoid arthritis and Achilles tendon bursitis. In addition, difficulties in diagnosis cause a long latent course of the pathological process. During the asymptomatic period, the disease becomes an incidental finding when X-rays are performed to detect another pathology.

The accompanying tendinopathy of the Achilles tendon (pain, swelling, dysfunction) is essential in diagnosing and treating Haglund syndrome.

An experienced specialist will easily suspect the development of Haglund’s deformity by the following clinical signs, which are undoubted diagnostic criteria:

• signs of Achilles tendon bursitis;
• a pronounced heel tubercle;
• aching, sharp, or diffuse pain in the area of the osteophyte.

When a patient presents with such clinical symptoms, the physician makes a preliminary diagnosis of Haglund’s syndrome and prescribes a series of diagnostic optical examinations to confirm and clarify it. The diagnostic protocol for this osteochondropathy includes the following:

• radiography, which allows the determination of the exact size and localization of the osteophyte to detect the localization of softened bone areas with heterogeneous structures; 
• Ultrasound, which makes it possible to distinguish deformities corresponding to this pathology from pathological changes accompanying other diseases of the musculoskeletal system;
• MRI is an adjunctive technique that allows visualization of the abnormal mass and provides additional data necessary to develop a complete treatment protocol.

Surgical treatment

Most orthopedists consider surgery the method of choice for achieving excellent long-term results in Haglund syndrome. Tactical approaches, volumes, and complexity of surgery are directly related to the degree and form of changes in the bone structure. Most often, surgical intervention in this pathology involves removing the exostosis (bone and cartilage deformity). It allows to:

• relieve the pain syndrome;
• reduce the inflammation process;
• reduce the pressure on the tendon and joint bag.

In some clinical cases, inflamed articular bags and cystic neoplasms are additionally excised during surgery.

The most effective measure to remove the abnormal growth is minimally invasive arthroscopy. This surgery to remove Haglund’s deformity of the heel bone includes diagnosis and treatment at the same time. 

A wedge osteotomy of the heel bone is performed if the patient has a high foot arch. This type of surgery involves pre-cutting a wedge on the posterior surface of the heel bone and then fixing the remaining parts to each other with titanium screws. It reduces the pathologic angle and eliminates severe pressure on the tendon.

All these treatment options are available in more than 800 hospitals worldwide (https://doctor.global/results/diseases/haglunds-deformity). For example, Haglund’s deformity surgery can be performed in these countries at following approximate prices:

Turkey$2.6 K in 32 clinics

Germany$9.1 K – 11.1 K in 41 clinics

China$9.5 K in 6 clinics

United States$12.4 K in 19 clinics

Israel$15.1 K in 16 clinics.

Rehabilitation

In the postoperative period, it is necessary to strictly follow all medical recommendations. Rehabilitation measures are prescribed to each patient individually. Standard recommendations:

• wear only orthopedic shoes;
• make sure your legs are entirely rested so that the swelling goes down faster;
• exclude any physical activity on the foot for one month;
• use ointments prescribed by a doctor to accelerate tissue regeneration.

After surgery to correct Haglund’s deformity, foot taping (applying special elastic patches) is also recommended.