How To Treat Haglund’s Deformity In Runners

Given the challenges of addressing posterior heel pain in runners, these authors offer a closer look at Haglund’s deformity with keys to the diagnostic workup, highlight the advantages of the posterior tendon splitting approach and the Keck and Kelly osteotomy, and provide an illuminating case study.

Posterior heel pain can be a debilitating condition for avid runners and is often the result of overuse in combination with mechanical impingement of the local soft tissues, namely the retrocalcaneal bursa and Achilles tendon. One such mechanical condition is a “pump-bump” or more properly named, a Haglund’s deformity. First described by Haglund in 1928, a Haglund’s deformity is an enlargement of the posterosuperior calcaneus.¹ An isolated Haglund’s deformity can lead to posterior heel pain in runners due to adjacent soft tissue impingement by the heel counter. However, often patients will present with a combination of Achilles tendinopathy, retrocalcaneal bursitis or retrocalcaneal exostosis in addition to a Haglund’s deformity.

A thorough history, physical exam and radiographic assessment are therefore required for patients presenting with posterior heel pain as treatment varies based on etiology. Pain localized to the posterosuperior aspect of the calcaneus that is aggravated by shoes is suggestive of but not specific to Haglund’s deformity. Often, clinicians can observe and palpate a bony prominence in this region. One can distinguish this from a retrocalcaneal exostosis but an inflamed bursa or edema secondary to insertional Achilles tendonitis may obscure exam findings. Clinicians should also examine the Achilles tendon for pain and thickening at the insertion, and more proximally in order to identify the exact location and extent of pain.

One typically obtains plain radiographs for patients with posterior heel pain to identify if Haglund’s deformity, retrocalcaneal exostosis or calcification of the Achilles tendon is present. A weightbearing lateral oblique heel view is particularly helpful to identify Haglund’s deformity, which may not be apparent on the standard lateral view. Clinicians may consider a magnetic resonance image (MRI) for patients with pain or thickening of the Achilles tendon, even in the presence of intratendinous calcifications or posterior spur on plain films, keeping in mind that the patient may be suffering from a combination of Haglund’s deformity, retrocalcaneal exostosis and insertional Achilles tendinopathy. We find that calcifications within the Achilles tendon are less common and generally a sign of advanced or longstanding disease.

Traditional radiographic parameters one would use to measure Haglund’s deformity on plain films are calcaneal pitch, the Fowler and Philip angle, and parallel pitch lines.^2-4 However, radiographic findings do not often correlate with symptoms or clinical appearance related to bump size. In a recent study comparing patients with symptomatic Haglund’s deformity to a control group, only the calcaneal pitch angle was significantly different between the groups, leading the authors to hypothesize that a more vertical calcaneus will lead to prominence of the posterolateral calcaneus.⁵ While clinicians routinely measure traditional radiographic angles in patients with suspected Haglund’s deformity, there is a greater emphasis on the clinical presentation when determining appropriate treatment.

It is common to explore conservative measures for three to six months prior to pursuing surgical repair. We find that this can be a difficult sell to runners as they are eager to return to training. Non-steroidal anti-inflammatory drugs (NSAIDs), decreased or modified activities, changes in shoe gear, immobilization, stretching and functional orthotics are generally recommended upon the initial diagnosis of Haglund’s deformity. For highly active patients, we will make an early referral to physical therapy in an attempt to increase the success of conservative measures and accelerate the return to full activity, especially when the Achilles is involved.

Pertinent Surgical Considerations

Surgical management is often required in patients with Haglund’s deformity, even when conservative measures are initially successful, as the underlying structural deformity will commonly lead to recurrence of symptoms when the patient resumes full activity. As we stated earlier, identifying any concomitant etiologies of the posterior heel is crucial in determining the best surgical approach. In patients with Haglund’s deformity in the presence of a retrocalcaneal exostosis or in those with advanced Achilles tendinopathy, a posterior tendon splitting approach is often preferred. This approach has the disadvantage of violating the insertion of the Achilles tendon but allows broad access to remove all abnormal bony prominences and debride diseased portions of the Achilles tendon prior to reattachment. Additionally, if substantial debridement of the Achilles is required, typically greater than 50 percent, the surgeon can incorporate a flexor hallucis longus tendon transfer through the posterior approach.⁶

Although an isolated Haglund’s deformity is less common, it typically occurs in younger and athletic patients. When there is an isolated Haglund’s deformity without a spur, the surgeon can address this with simple bump removal but it is frequently difficult to avoid disruption of the Achilles insertion. We prefer a dorsally-based wedge osteotomy of the posterior calcaneus, known as a Keck and Kelly osteotomy, for an isolated Haglund’s deformity as this procedure allows global reduction of the posterior heel prominence.^1,7,8 The main advantage of an osteotomy over bump resection is that one can spare the Achilles insertion, which is desirable in athletes and runners who desire a prompt return to their sport once the osteotomy heals. The following case highlights our surgical technique for the Keck and Kelly osteotomy.

Case Study: When A Runner Has Increasingly Worse Posterior Heel Pain With An Associated Bump

A 23-year-old non-diabetic female presented with a complaint of bilateral posterior heel pain. She is a former collegiate track and field athlete, and continues to enjoy running. However, she has developed worsening posterior heel pain over the past seven months with an associated bump. Consequently, the patient could no longer run without pain and had turned to alternative forms of exercise, much to her disappointment. Prior treatments included new shoes, rest, activity modification and NSAIDs. Her primary care physician referred her to physical therapy three months prior to presenting to our practice. The physical therapy mainly included Achilles tendon stretching. Unfortunately, she did not experience lasting relief and pain quickly recurred with each attempt to return to running.

The physical exam revealed pain with palpation of the posterior and superior calcaneus, which was quite prominent. The overlying skin was chronically irritated. We ruled out tendinopathy as there was no pain along the course of the Achilles tendon or thickening of the tendon itself. The radiographic exam revealed a Haglund’s deformity without associated retrocalcaneal spur or calcifications within the Achilles tendon. We did not think a MRI was necessary based on the lack of pathology of the Achilles tendon with the physical exam. We discussed the continuation of conservative measures as well as surgical repair with the patient. She opted for surgical repair, namely a Keck and Kelly osteotomy, based on prior failure of prolonged conservative care and expectations of recurrence associated with bone deformity.

Preoperative templates are useful in determining the size of wedge resection with the Keck and Kelly dorsally-based wedge resection. The posterior cut should have a dorsal exit point just anterior to the Achilles tendon. The inferior apex of the wedge is posterior to the weightbearing area of the plantar calcaneal tuberosity. The anterior cut should be vertical on the lateral weightbearing image. A 7 to 9 mm wedge is generally needed to gain adequate correction depending on the individual anatomy of the calcaneus. One would place a linear incision on the lateral heel directly over the osteotomy site and intraoperative fluoroscopy-guided incision planning is useful in this regard. The surgeon can make a full thickness incision down to bone as the sural nerve and peroneal tendons are well anterior with this approach. Perform blunt dissection superiorly near the Achilles tendon and free the periosteum from the lateral and dorsal aspects of the calcaneus. This enables the surgeon to gain only enough exposure for the planned osteotomy.  

One can employ intraoperative fluoroscopy to confirm that osteotomy exit points match the template. The surgeon can use an osteotomy guide over guide pins to facilitate cuts that are parallel from medial to lateral yet converge at the desired location at the plantar cortex. One would leave the plantar cortex intact for the final greenstick fracture. The strong plantar soft tissues act as a plantar hinge and prevent proximal migration of the posterior fragment in the sagittal plane. Dorsiflexing the foot manually allows the intact Achilles to compress the osteotomy. We used two cannulated cancellous screws to fixate the osteotomy.

Complete healing of the osteotomy occurred 10 weeks after the procedure. We kept the patient non-weightbearing for a period of six weeks with subsequent progressive weightbearing for an additional four weeks. We performed the same procedure six months later on the other foot. No further intervention has been required over the past three years and she has resumed running without symptoms.  

Procedure Recommendations For The Isolated Haglund’s Deformity In Athletes

Posterior heel pain is problematic and can be debilitating in avid runners and athletes. These athletes are particularly health-conscious, will often self-diagnose their pain and pursue treatments even prior to evaluation by a foot and ankle specialist. In their desire to return to high-level performance, athletes can be perceived as having higher than typical expectations regarding recovery and outcome. It is therefore critical that the clinician accurately diagnose the source of the pain and pursue the appropriate treatment. As the source of pain can include a Haglund’s deformity, retrocalcaneal exostosis, Achilles tendonitis, retrocalcaneal bursitis or often a combination of multiple pathologies, diagnosis can be difficult. Arriving at an accurate diagnosis requires a thorough history and physical, plain radiographs and often advanced imaging with an MRI to fully assess the problem.

An isolated Haglund’s deformity generally occurs in younger patients with a shorter duration of symptoms. More commonly, patients with posterior heel pain present with chronic enthesopathy of the Achilles insertion with findings that are consistent with retrocalcaneal exostosis and Achilles tendinosis with or without a Haglund’s deformity. For these patients, we advocate a central tendon splitting approach to gain exposure to the retrocalcaneal spur as well as debriding diseased tendon. In patients with an isolated Haglund’s deformity, one should preserve the Achilles tendon insertion. Therefore, a Keck and Kelly osteotomy is our preferred approach as the lead author described previously in the Journal of Foot and Ankle Surgery in 2012.⁷

There are several advantages to the Keck and Kelly osteotomy. The lateral approach is clear of important structures and limited dissection provides adequate exposure for the dorsally-based wedge osteotomy. The surgeon does not violate the Achilles tendon with this approach. This is the main advantage of this procedure as high-level runners and athletes are generally wary, and often have a preference to avoid any procedure that involves extensive debridement of the Achilles tendon. The osteotomy tilts the posterior calcaneus forward and away from the heel counter, thereby reducing mechanical impingement of the soft tissues in this area. Additionally, the osteotomy slightly elevates the Achilles tendon insertion, which reduces equinus stress that is often a contributing factor to posterior heel pain. Rotation of the posterior fragment also changes the orientation of the Achilles fibers at the insertion point on the posterior heel, which is intended to decrease stress.

Surgeons can achieve fixation with cannulated cancellous screws buried deep to the Achilles or external placement of Steinmann pins. Advantages of pin fixation include a less invasive approach near the Achilles tendon insertion and no residual hardware after removal at six weeks. Advantages of screw fixation include permanent fixation, compression of the osteotomy and no external protrusion of fixation.

Final Notes

In conclusion, posterior heel pain can be difficult to treat in highly active individuals. Proper diagnosis and treatment are required in this demanding patient population. Conservative measures can be very helpful but symptoms commonly recur with return to sport or even wearing shoes. Proper procedure selection is critical based on individual anatomy and pathology, and surgeons should be comfortable with all three surgical approaches including simple exostectomy, Achilles detachment/reattachment, and the Keck and Kelly osteotomy.

Dr. Boffeli is a board-certified foot and ankle surgeon practicing at HealthPartners Specialty Center in St. Paul, Minn. He is a Fellow of the American College of Foot and Ankle Surgeons, and the Director of the Foot and Ankle Surgical Program at Regions Hospital/HealthPartners Institute for Education and Research.

Dr. Gervais is the Chief Resident at Regions Hospital/HealthPartners Institute for Education and Research in St. Paul, Minn.

References

1.     Haglund P. Beitrag zur Klinik der Achillessshne. Arch Orthop Chit. 1928; 49:49.
2.     Chauveaux D, Liet P, Le Huec JC, Midy D. A new radiologic measurement for the diagnosis of Haglund’s deformity. Surg Radiol Anat. 1991;13(1):39-44.
3.     Fowler A, Phillip JF. Abnormality of the calcaneus as a cause of painful heel: its diagnosis and operative treatment. Br J Surg. 1945; 132:494-498.
4.     Pavlov H, Heneghan MA, Hersh A, Goldman AB, Vigorita V. The Haglund syndrome: initial and differential diagnosis. Radiology. 1982; 144(1):83-88.
5.     Bulstra G, van Rheenen T, Scholtes V. Can we measure the heel bump? Radiographic evaluation of Haglund’s deformity. J Foot Ankle Surg. 2015;54(3):338-340.
6.     Den Hartog, BD. Flexor hallucis longus transfer for chronic Achilles tendonosis. Foot Ankle Int. 2003; 24(3):233-237.
7.     Boffeli T, Peterson M. The Keck and Kelly wedge calcaneal osteotomy for Haglund’s Deformity: a technique for reproducible results. J Foot Ankle Surg. 2012;51(3):398-401.
8.     Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients. J Bone Joint Surg Am. 1965; 47:267-73.