Haglund’s deformity is a condition affecting the bones and soft tissues of the heel, characterized by a distinct bony enlargement on the upper-back portion of the heel bone, or calcaneus. This bony prominence is a common cause of posterior heel pain, often referred to colloquially as “pump bump” because of its frequent association with rigid-backed footwear. The condition arises from a combination of underlying foot mechanics and external friction, leading to inflammation and discomfort in the tissues surrounding the heel.
The Prevalence and Physical Manifestation of Haglund’s Deformity
Haglund’s deformity is widely recognized by foot and ankle specialists as a frequent source of posterior heel pain, though many mild cases go undiagnosed. Estimates of its prevalence in the general population range from 10% to 20%, though only a fraction of those individuals become symptomatic and seek treatment. The condition is disproportionately found in certain groups, with women being more frequently affected than men, often due to shoe-wear choices.
The physical presentation of the condition is a triad of abnormalities known as Haglund’s syndrome, which includes the bony deformity itself, retrocalcaneal bursitis, and sometimes Achilles tendinopathy. The bony enlargement, or exostosis, is located on the posterosuperior aspect of the calcaneus, just where the Achilles tendon attaches. This prominence creates mechanical irritation on the soft tissue that lies between the bone and a shoe’s rigid back.
Constant friction leads to inflammation of the retrocalcaneal bursa, a small, fluid-filled sac situated between the Achilles tendon and the heel bone. The resulting condition, called retrocalcaneal bursitis, causes swelling, redness, and tenderness on the back of the heel. Symptoms are highly variable, ranging from a noticeable cosmetic bump to debilitating pain that limits the ability to wear closed-back shoes or participate in activities like running.
Identifying the Underlying Anatomical and Mechanical Causes
The development of Haglund’s deformity stems from structural foot characteristics that create excessive pressure on the heel bone. A high arch, or pes cavus, is a significant predisposing factor because it causes the heel bone to tilt backward and slightly upward. This upward tilt effectively shortens the space between the heel bone and the Achilles tendon, increasing the likelihood of impingement on the soft tissues.
A chronically tight Achilles tendon pulls upward on its insertion point on the calcaneus. This constant pull further compresses the retrocalcaneal bursa and soft tissue against the rigid bone prominence, exacerbating friction. The body responds to this chronic stress by attempting to reinforce the area, which leads to the formation of new bone and the characteristic bony bump.
Footwear with a rigid heel counter is the most common external irritant, applying direct pressure to the prominent area. Rigid-backed shoes, such as dress shoes, boots, or pump heels, act like a constant vise on the posterior heel. This external pressure converts the internal mechanical compression into a painful, symptomatic condition, explaining the nickname “pump bump.”
Confirming the Diagnosis and Initial Conservative Management
Diagnosis of Haglund’s deformity begins with a thorough physical examination, where a physician will palpate the area to identify the bony bump and localized tenderness, particularly over the retrocalcaneal bursa. Imaging tests, most commonly X-rays, are necessary to visualize the specific contour of the heel bone and rule out other potential causes of heel pain. The lateral view X-ray clearly shows the posterosuperior prominence of the calcaneus.
Radiographic confirmation often involves measuring specific angles, such as the relationship of the bony prominence to the “parallel pitch lines.” This technique helps determine if the bony anatomy contributes to soft tissue impingement. While a positive finding does not automatically mean a patient has symptomatic Haglund’s deformity, it confirms the anatomical predisposition for the condition.
Initial treatment is conservative, focusing on reducing inflammation and alleviating mechanical friction. The first step involves modifying footwear to eliminate shoes with rigid or tight heel counters, replacing them with open-backed shoes or soft-backed athletic footwear. Anti-inflammatory measures, such as oral nonsteroidal anti-inflammatory drugs (NSAIDs) and applying ice, help reduce pain and swelling.
Physical therapy focuses on stretching the Achilles tendon to relieve upward tension on the heel bone. Heel lifts or specific orthotic devices may also be recommended to subtly change the angle of the foot, decreasing contact and pressure between the bony prominence and soft tissue. Surgery is typically only considered if a prolonged course of conservative care, often six to twelve months, fails to provide adequate relief.