Haglund's Deformity (Pump Bump)
Brent S. E. Rich
Michael Devin Taylor
BasicsDescription
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Haglund's deformity is an abnormal prominence of the posterosuperior surface of the calcaneus. It can give rise to Haglund's disease, which consists of retrocalcaneal bursitis, insertional Achilles tendinitis, and pre-Achilles bursitis or superficial bursitis. These occur due to compression of the distal Achilles tendon and the surrounding soft tissues, between the os calcis and the posterior shoe counter.
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Synonyms(s): Haglund's disease; Haglund's syndrome; Pump bump
Epidemiology
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More common in females who start wearing high heels and shoes with restrictive heel counters
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Haglund's syndrome occurs in both sexes and is seen in all active age groups.
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Women age 20–30 yrs seem to have a slightly higher prevalence.
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More commonly seen in individuals/athletes wearing shoes with rigid heel counters (eg, pumps, ice skates, work boots)
Risk Factors
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Heel varus
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Cavus foot
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Rigid plantarly flexed 1st ray
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Rigid or poorly shaped heel counters
DiagnosisHistory
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Increase in training program, specifically number of miles run
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Change in shoe wear (shoes with rigid heel counters can irritate the subcutaneous tissues, and can inflame the underlying bursae)
Physical Exam
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Dull, achy, exertional posterior heel pain
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Tenderness and thickening of the overlying skin at the Achilles tendon attachment
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Palpable swelling anterior or posterior to the Achilles tendon
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Pain is intensified with active or passive dorsiflexion of the ankle.
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Prominent-appearing posterosuperior portion of the calcaneus
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Careful, discreet palpation to differentiate between swelling in the Achilles tendon and swelling in the retrocalcaneal bursa
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Palpation medially as well as laterally within the retrocalcaneal bursa
Diagnostic Tests & Interpretation
Imaging
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Lateral radiographs may show a 2–3-mm bony extrusion on the posterosuperior angle of the calcaneus.
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Calcaneal body index assesses the shape of the calcaneus, and the calcaneal inclination angle assesses the orientation of the calcaneus. Good predictors of posterior heel pain.
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Parallel pitch lines and Fowlers lines have been used in the past for diagnosis, but in recent studies have been found to have no statistically significant relationship to posterior heel pain
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Consider ordering MRI or musculoskeletal US to evaluate the integrity of the Achilles tendon and the retrocalcaneal bursa.
Differential Diagnosis
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Pre-Achilles bursitis
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Achilles tendinitis/tendinosis
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Retrocalcaneal bursitis
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Calcaneal stress fracture
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Ankle impingement
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Tibiotalar degenerative joint disease
P.283
Treatment-
Shoe modification
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Achilles stretching program
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U-shaped pad
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Heel pad
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Soft tissue modalities (ie, ice, US, iontophoresis)
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Decrease in mileage and hill work
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Minimization of hard-surface running
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NSAIDs
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Immobilization with a short-leg walking cast
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Aspiration and injection with corticosteroids
Additional Treatment
Additional Therapies
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Achilles stretching program
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Soft tissue modalities (ie, ice, US, iontophoresis)
Surgery/Other Procedures
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Partial calcaneal osteotomy (open or endoscopic): Complete resection of the bursal projection
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Postoperative course: Short-leg walking cast provided for 8 wks, 2 wks partial weight-bearing, full weight-bearing over succeeding 6 wks, until cast removal. Course shortened with endoscopic procedure.
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Rehabilitation program consisting of conditioning exercises and functional retraining
Ongoing CareFollow-Up Recommendations
Surgery as indicated above
Complications
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Achilles tendon rupture
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Chronic heel pain
Additional Reading
Aronow MS. Posterior heel pain (retrocalcaneal bursitis, insertional and noninsertional Achilles tendinopathy). Clin Podiatr Med Surg North Am. 2005;22:19–43.
Heneghan MA, Pavlov H. The Haglund painful heel syndrome. Experimental investigation of cause and therapeutic implications. Clin Orthop Relat Res. 1984:228–234.
Hoberg M, Gradinger R, Rudert M. [Heel pain] MMW Fortschr Med. 2007;149:36–39; quiz 40
Lu CC, Cheng YM, Fu YC, et al. Angle analysis of Haglund syndrome and its relationship with osseous variations and Achilles tendon calcification. Foot Ankle Int. 2007;28:181–185.
Ortmann FW, McBryde AM. Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis. Foot Ankle Int. 2007;28:149–153.
CodesICD9
732.5 Juvenile osteochondrosis of foot
Clinical Pearls
Physician responses to common patient questions:
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When can I return to play? The time to return to play is dependent on the severity and number of associated conditions involved. Return to play after conservative treatment ranges from 2–8 wks, whereas surgery and postoperative course limits and prevents strenuous activity for 4–6 mos. Athletes may return to strenuous activity when local symptoms have resolved at this time.