Intro

Haglund's Deformity is one component of the myriad of painful heel maladies. Commonly referred as "the pump bump", Haglund's Deformity and its associated soft tissue pathology may be the primary source of pain in the back of the heel. The counter of the shoe further aggravates this area, also known as the posterior heel. The patient and podiatric physician can encounter much frustration trying to relieve the pain associated with conservative care.

Anatomy

The Tendo-Achilles (heel cord) inserts into the posterior middle one third surface of the calcaneus (heel bone). Superior to this insertion site is a bursal sac located between the Tendo-Achilles and the superior one third of the posterior surface of the calcaneus. The bursal sac functions as padding for this tendon and also provides protection from the rigid surface of the calcaneus. Superficial to the Tendo-Achilles is another bursal sac that develops from the pressure of shoegear. This bursal sac is covered by the skin. Therefore, the Tendo-Achilles, the strongest tendon in the human body, is further protected by "sandwiching" the tendon between two bursal sacs. The superior surface of the posterior calcaneus has a ridge of bone known as the bursal projection. The entire surface of the superior portion of the calcaneus to the posterior facet of the subtalar joint is concave. The area that is superior to this part of the calcaneus is called Kager's Triangle. Kager's Triangle is outlined by the top of the posterior one half of the calcaneus as the base of the triangle. The Tendo-Achilles and the posterior aspect of the tibia define the legs, or sides, of this triangle.

Pathology

In the Haglund's deformity, the bursal projection has marked osseous enlargement. This enlargement (pump-bump) impinges upon the bursal sac and the Tendo-Achilles. Furthermore, compression from the heel counter of shoegear causes inflammatory reaction to occur. The skin will appear reddened, boggy and/or painful during palpation. Pain may be felt with dorsiflexion of the foot at the ankle joint. This is due to the inflammatory component of this disorder.

Root et al and Ruch in their articles have appropriately indicated the function of calcaneus. For example, in a pes cavus foot, the calcaneus has an increase in the calcaneal inclination angle causing the posterior-superior calcaneus to be more impinged. Furthermore, forefoot varus, compensated rearfoot varus and compensated forefoot valgus leads to abnormal subtalar joint motion causing again increase prominence of the bursal projection, thus pushing the pump-bump against the heel counter.

As the condition of chronic pulling of a tendon at its insertion occurs, local inflammatory conditions cause osseous spurring. Therefore, it is not uncommon to find a posterior heel spur in this painful area. Therefore, the development of an enlarged bursal sac, enlarged bursal projection of the calcaneus and development of a posterior spur are usually seen together.

Treatment

Conservative care includes eliminating the heel counter causing pressure. This is accomplished by a heel lift in the shoe or moving to a sling back shoe. Resting the affected area with ice packs can help reduce the inflammation. Anti-inflammatory medications like Aspirin or Ibuprofen can slow the inflammatory response from worsening.

Steroid injections should be avoided due to possible tendinopathy of the Tendo-Achilles. However, a steroid used in an iontophoretic application may be of benefit. In iontophoresis, a nine volt current is used to move (transduce) the cationic structure of dexamethasone through the dermis to the inflammed tissue, however, the concentration is low and administered slowly.

Other conservative care includes orthotic management to control the biomechanical deformity. Physical therapy of whirlpool, contrast baths, ultrasound, and deep massage may be employed.

Should the conservative care fail, (some suggest 6 months or more of non-surgical care) then surgical resection of the Haglund's deformity and the spur if present. Often, the Tendo-Achilles will be partially or totally detached to resect the spur. The tendon will be reattached with tendon anchors. A non-weight bearing cast for 6-8 weeks is recommended. Complications include failure to reduce pain, nerve entrapment of the sural nerve, tendon dysfunction, delayed healing, infection and reoccurrence of the deformity.

Dr. Graham has been in private practice in Effingham since 1989 and is on staff at St. Anthony's Memorial Hospital and Effingham Ambulatory Surgical Treatment Center. He is Board Certified by the American Board of Podiatric Surgery and American Board of Podiatric Orthopaedics and Primary Podiatric Medicine. Dr. Graham is a Fellow of the American College of Foot and Ankle Surgeons, the American College of Foot and Ankle Orthopaedics and Medicine, and American Professional Wound Care Association. He is also a member of the American Podiatric Medical Association and the Illinois Podiatric Medical Association.

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