Haglund’s deformity is a common condition affecting the heel, characterized by a painful bony enlargement on the back of the calcaneus (heel bone). This prominence is often called a “pump bump” because it frequently becomes irritated by the rigid backs of certain shoes. The bony growth irritates the nearby retrocalcaneal bursa, a fluid-filled sac located between the bone and the Achilles tendon, leading to inflammation known as bursitis. This persistent irritation can also affect the Achilles tendon itself, which attaches directly to the heel bone at the site of the enlargement. The resulting pain can make walking and standing difficult.
Conservative Management Strategies
Initial treatment focuses on non-invasive methods aimed at reducing inflammation and relieving pressure on the heel. Modifying footwear by selecting shoes with soft or open backs eliminates friction against the bony prominence. Using the RICE protocol (rest, ice, compression, and elevation) helps manage acute flare-ups by reducing swelling and pain. Applying ice for 15 to 20 minutes several times a day diminishes local inflammation.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended to alleviate pain and decrease the inflammatory response, though they do not change the underlying bone structure. Custom orthotic devices or heel pads placed inside the shoe can help manage the condition by altering foot mechanics. For individuals with high arches or a tight Achilles tendon, heel lifts are beneficial. They slightly raise the heel, reducing tension on the tendon and minimizing impingement on the posterior heel bone.
Physical therapy concentrates on stretching the Achilles tendon and calf muscles. Specific exercises, such as eccentric heel drops, help lengthen the tendon and reduce the pulling force it exerts on the attachment site. This decrease in tension lessens the friction and pressure against the bony enlargement. These conservative approaches control symptoms and improve function without requiring surgery.
Indicators for Surgical Consideration
The decision to move beyond conservative care is made when symptoms fail to improve consistently. Professionals look for a lack of sustained relief after non-surgical treatment lasting six to twelve months. Persistent pain, despite adhering to shoe modifications and anti-inflammatory regimens, indicates that the bony prominence causes mechanical irritation that conservative measures cannot resolve.
Functional limitation is another indicator, occurring when pain interferes with daily activities like walking or exercising. When pain prevents a person from maintaining a desired quality of life, surgery is considered. Imaging studies, such as X-rays, often confirm a steep heel bone angle or a large bony spur. Structural correction is necessary when the physical anatomy of the heel is the primary source of recurring inflammation.
Surgical Procedures for Haglund’s Deformity
Surgical treatment focuses on permanently removing the source of irritation and restoring proper heel anatomy. The most common approach is standard excision, where the surgeon removes the bony prominence from the calcaneus, often alongside an inflamed retrocalcaneal bursa (bursectomy). If the Achilles tendon shows degeneration, the procedure may involve debridement. If the tendon must be detached to access the spur, it is reattached to the bone using suture anchors.
A calcaneal osteotomy, such as a modified Zadek procedure, is used when the heel bone has an abnormally steep angle. This technique involves cutting and repositioning the heel bone to change its angle. Altering the bone’s orientation moves the prominence away from the Achilles tendon, reducing pressure and preventing future irritation. Both open and minimally invasive techniques are used, with the latter utilizing small incisions to reduce soft tissue disruption.
Minimally invasive approaches, including endoscopic surgery, allow for the removal of the bony spur and inflamed bursa through small portals. This technique often results in smaller scars and may reduce recovery time compared to traditional open surgery. The choice of procedure depends on the size of the spur, the angle of the heel bone, and the extent of Achilles tendon damage. The goal is to create a smooth surface and sufficient space between the heel bone and the Achilles tendon.
Post-Surgical Recovery and Rehabilitation
Recovery immediately following surgery involves strict adherence to rest, elevation, and pain management to minimize swelling and promote healing. The foot is immobilized in a cast or splint, and patients are non-weight bearing for the first two to four weeks, requiring crutches or a knee scooter. Non-weight bearing duration is extended if the Achilles tendon required detachment and reattachment. At the first post-operative visit, sutures are removed, and the patient transitions into a removable walking boot.
Physical therapy is introduced early, often starting around two weeks post-surgery, focusing initially on gentle range-of-motion exercises for the ankle. The rehabilitation program advances to include strengthening exercises for the calf and foot muscles to restore function and gait mechanics. Patients remain in the protective boot for several weeks, gradually increasing weight-bearing activity as directed by the surgeon. Full recovery, marked by a return to all normal activities, can take between six and twelve months.