Haglund’s Deformity

One of the most common pathologies encountered by foot and ankle physicians is posterior heel/Achilles tendon pain. Two of the most common causes of Achilles tendon pain are a “Haglund’s Deformity” and Insertional Calcific Achilles Tendonosis (ICAT).   Both of these causes can be extremely painful and often debilitating to patients. When inflammation is at its worst, you may not want to walk because of the pain and burning felt. In this blog, we will explore both issues and how to solve them when the pain strikes. Haglund’s Deformity

A Haglund’s Deformity is an enlargement of the top of the heel bone. This enlargement leads to soft tissue irritation from rubbing in shoe gear.  It is traditionally referred to as a “pump bump” due to irritation with pump style shoes, however, any shoe with a rigid back can lead to rubbing and irritation in the area. The enlarged boney prominence also leads to increased pressure on the retrocalcaneal bursa (fluid filled sac) which is naturally present in this area of the ankle between the Achilles tendon and the bone. This increased pressure usually results in a condition known as “bursitis”. Certain foot structures that are more prone to developing a Haglund’s Deformity include a high arched foot, tight Achilles tendon (equinus), and a tendency to walk on the outside of the foot. Symptoms consistent with a Haglund’s Deformity include a palpable bump on the back of the heel, swelling/redness to the back of the heel, and pain in the area of the Achilles insertion. Treatment of a Haglund’s Deformity starts with shoe modification and preventing irritation to the area. Other conservative treatment options consist of heel lifts, oral steroids, NSAIDs, walking boot, Stretching exercises, and/or physical therapy. In cases where pain continues following conservative therapy, surgical intervention may be needed. Surgical treatment options include open exostectomy (bone spur removal) with debridement of the underlying bursa and tendon. Typically, with open surgery the patient is placed in a walking boot for 4-6 weeks. A less invasive alternative is the Tenex procedure which involves ultrasound guided debridement of the Achilles tendon and underlying bursa. For the Tenex procedure the patient is typically placed in a walking boot for 2-3 weeks, cutting recovery time in half in most instances.

Insertional Calcific Achilles Tendinosis (ICAT)

Insertional Calcific Achilles Tendinosis, or ICAT, occurs when an exostosis (bone spur) forms at the level of the tendons insertion into the calcaneus secondary to excessive tension at the insertion. This excessive tension and

ubsequent exostosis leads to inflammation of the tendon as well as the underlying bursa. The exostosis can also become inflamed from mechanical friction of shoe gear. In majority of ICAT cases conservative treatment is effective. Conservative treatment for ICAT usually consists of oral NSAIDs, heel lifts, eccentric stretching exercises, and modification of shoe gear. In cases where pain continues following conservative therapy, surgical intervention may be needed. Surgical treatment for an ICAT usually involves detachment of the tendon with debridement of the bone spur and underlying bursa with reattachment of the tendon. The patient is then placed in a non weight bearing lower leg cast or boot for 4-6 weeks followed by physical therapy. A less invasive alternative is the Tenex procedure which involves ultrasound guided debridement of the Achilles tendon and underlying bursa. For the Tenex procedure the patient is typically placed in a walking boot for 2-3 weeks.  Again, the Tenex can cut recovery time in half and get you back on your feet faster.