CHAPTER 36

HAGLUND'S DEFORMITY AND POSTERIORHEEL PAIN: A Retrospective Analysis of Tieatment

D, Scot Malay, D.P.M.

The two most common osseous abnormalities thatcause symptomatology at the posterior aspect ofthe heel ate Haglund's disease and posteriorcalcaneal exostosis (step defect). Either conditioncan be associated with retrocalcaneal bursitisand/or dystrophic calcification within the Achillestendon. Prominence of the posterosuperior process(bursal projection) of the calcaneus, due either tostructural hypertrophy or protrusion or due topositional prominence related to an increase incalcaneal inclination (CIA greater than 21 degrees),is termed Haglund's deformity. Haglund's disease is

used to describe inflammatory symptomatologyrelated to the Haglund's deformity, and is almostalways associated with retrocalcaneal bursitis.'

The point of maximum tenderness, edema,and cutaneous compromise in Haglund's disease issituated posterosuperolaterally on the heel, and isoften referred to as a "pump bump." On the otherhand, the posterior calcaneal exostosis, or stepdefect, is localized distal to the posterosuperiorprominence and occurs at the attachment of thetendoAchillis to the posterior aspect of the oscalcis. The exostosis is commonly associated withdystrophic calcification at the insertion of the heelcord, and is usually seen in cases of longstandingdisease. Methods for the treatment of posteriorheel pain, either Haglund's disease or posteriorexostosis, range from heel elevation and counterpadding, stretching and physical therapy, adminis-tration of anti-inflammatory medication, andsupportive immobilization, as well as surgicalremodeling of the posterior aspect of thecalcaneus, and debridement of the heel cord. Aretrospective analysis was undertaken to try andmake generalizations about treatment options,comparisons between patients requiring operativeintervention versus those who respondedsatisfactorily to conservative care, and to develop a

hierarchy of Lreatment intervention.

BACKGROUND AND SIGNIFICAI\CE

Previous review' has detailed the historical effortsmade toward our current understanding of therecognition, evaluation, and lreatment of posteriorcalcaneal symptomatology. It is well understoodthat a prominent posterosuperior aspect of thecalcaneus will protrude into the constant retrocalcaneal bursa, situated berween the distal portionof the Achilles tendon and the calcaneus, duringankle dorsiflexion. Repetitive wear-and-tear ofthe tendoAchillis, retrocalcaneal bursa, andenveloping connective tissues that becomeconfluent with the periosteum of the calcaneus,effects chronic inflammation and progressivedegeneration that ultimately leads to the develop-ment of dystrophic calcification and posteriorexostosis formation.

There continues to exist some question as tothe clinical significance and relationship of variousradiographic measurements of the posterior aspect

of the calcaneus,3 and recent interest in themeasurement of parallel pitch lines (PPL) continuesto lead to some confusion with respect to theindication for surgical interuention.3 It is also

common to obserue a relatively low or normalFowler and Philip angle (FPA), in the presence of a

symptomatic and prominent calcaneal bursalprojection (posterosuperior process) when therecoexists an abnormally high calcaneal inclinationangle (CIA).a Moreover, concern also exists as towhether or not local infiltration of corticosteroidshould be used at or fiear the insertion of theAchilles tendon, and whether or not immobilizationof the ankle is warranted as an adjunct treatmentmodality whenever steroid infiltration is used aboutthe tendon. Still other areas of concern involve thedegree to which the tendoAchillis should bereflected when progressive degeneration has ledto the development of a large posterior calcanealexostosis, with or without degenerativecalcification within the Achilles tendon at or neatits insertion.5

224 CHAPTER 36

TREATMENT PROTOCOLAND TECHNIQUE

In this study, J1 patients with 34 symptomaticposterior heels were evaluated and treated by theauthor over a two-year period. The evaluationinvolved assessment of the patient's age, sex, bodymass index, side of symptomatology, activity level,onset and duration of symptoms, the presence orabsence of bursitis, degree of pre- and post-treatment pain, the presence of antalgic gait;radiographic measurement of the Fowler and Philipangle (FPA), calcaneal inclination angle (CIA),Ruch's total angle, and parallel pitch lines (PPL);length of treatment and follow-up period,complications encountered during the course oftreatment, and the type of treatment required tosatisfactorily alleviate the patient's pain.

\Teight-bearing activity was classified as

sedentary, wherein the patient was never on theirfeet more than one hour consecutively; pafiialweight bearing, wherein the patient was requiredto stand berween 1 and 4 hours; and constant,wherein the patient was required to stand forgreater than four hours at a time, regularly. Painwas graded using an analog scale with zetorepresenting no pain; and one, two, and threerepresenting mild, moderate and severe pain,

Table 1

respectively, and four representing excruciatingpain. Conservative and surgical treatment optionswere organized into a hierarchy (Table 1).

The heel lift was fabricated of sponge rubberor a cork-latex composite material, while the heelcounter pad was made of soft plastazote with anaperrure situated around the most prominent sur-face of the heel. Application of a cool compressafter strenuous activity, or before retiring for theevening, was routine; as was administration of non-steroidal anti-inflammatories (NSAIDs) early on(unless contraindicated for other medical reasons).Flexibility exercises consisted of calf and pedalarch stretching, reinforced with written and oralinstructions and demonstration. Orthoses wereinitially commercially available, and subsequentlyconverted to custom molded devices on an as-needed basis. Moreover, the use of more potentNSAIDs, or methylprednisolone, or prednisoneorally, was undertaken if symptoms persisted afterStage I therapy.

The decision to move on to the next stage oftreatment was made after 5 to 8 weeks of less than50o/o to 60o/o improvement using the precedingtreatment regimen. Guidelines for progression tothe next level of treatment varied, and dependedsignificantly on individual patient needs andexpectations. The use of a roller sole (r'unning shoe

HAGLUND'S DEFORMITYHEEL PAIN

TREATMENT HIERARCTIY FORAND POSTERIOR

THERAPY STAGE I STAGE TI STAGE Itr STAGE IV

MECHANICAL Heel Lift,Counter PadOrthoses

Orthoses,Roller Sole

Immobilize,NIMR

lmmobilize,NIMR

PHYSICAL Ultrasound,Cold,Flexibility

Flexibility,Cold,(Utrasound)

Flexibility,Cold,(Ultrasound)

Flexibility,Cold

PHARNIACOLOGICAI NSAID Indomethacin,Oral Steroid,NSAID

Local Steroid NSAID

SURGICAL N/A N/A N/A Bursectomy,Exostectomy,DebrideTendon

CI]APTER 35 22s

or tapered roller) was encouraged, as this has beenshown to decrease tension in the plantar fascia andheel cord during late midstance and propulsion.Local infiltration of corticosteroid (7 to Z cc ofmethylprednisolone acetate) into the inflamedretrocalcaneal bursa was only undertaken inconjunction with adjunct ankle immobilization andreduced weight bearing over a 2 to 3 week period.Weight bearing would be allowed with the use ofa rigid, removable cast boot (velcro closure);whereas non-weight bearing would be advised inconjunction with a gel-cast and surgical shoe.Patients failing to satisfactorily respond to non-surgical treatment were offered a surgical approachwith appro priate consent.

The surgical management of Haglund'sdisease and posterior calcaneal exostosis involvedvarying degrees of reflection of the tendoAchillis,remodeling of the posterior aspect of thecalcaneus; followed by repair of the tendon andclosure, after which rehabilitation would ensue.

Generally speaking, patients were positionedeither prone or in the contralateral decubitusattitude, and anesthelized with loca1 anestheticcombined with intravenous sedative. The surgerywas usually performed without the use of a

tourniquet, and dilute epinephrine (1:200,000) wasused unless contraindicated medically. Dissectionwas carried out using a varieqr of incisions,including lateral paratendinous, lazy-S, and doubleparatendinous. A tendon splitting incision waspreferred when intra-tendinous calcification and a

large posterior exostosis were present. Care wastaken to resect only as much of the posterior aspectof the os calcis as was necessary. Followingthorough lavage, the tendon was re-attached as

necessary, either using suture closure of the fibrousretenacular expansion (Haglund's disease) or a

tendon anchoring device (the author prefers PEBA,Orthopedic Biosystems, Ltd., Scottsdale, AZ.)directly into the tendon and bone.

Postoperative immobilization and weight-bearing activity varied with the degree of tendondetachment. Preservation of the primaryattachment of the tendoAchillis warrantedcompressive dressing and cast/brace immoblliza-tion for 1 to 3 weeks in a weight-bearing attitude.Disruption and repair of the primary attachment ofthe tendon warranted 5 to 5 weeks of non-weightbearing immobilization.

ANALYSIS OF TREATMENTA]\D RESULTS

The results of the retrospective analysis aredepicted in Table 2. There was no evidence of heelcord rupture or soft tissue or bone compromisesecondary to local infiltration of corticosteroidin this set of patients. Two of the five patientsrequiring operative intervention displayedsignificant postoperative disability. One patient, a37-year-old moderately overweight and markedlybusy female with bilateral, posterior heel pain,developed persistent edema in the postoperativephase that did not satisfactorily subside until sheinitiated regular use of an Achilliotrain (Bauerfeind,USA, Inc., Kennesaw, GA). She also displayed a

very large posterior exostosis, and undetwentextensive heel cord reflection and complete remod-eling of the posterior os calcis. Only one patientsuffered with recurrent moderate pain (2/4, analogscale), and she never displayed malingering, drug-seeking behavior, or signs of reflex sympatheticdystrophy syndrome (RSDS).

DISCUSSION AND CONCLUSIONS

The diagnosis of Haglund's deformiry, and/orposterior calcaneal exostosis, is made basedprimarily on clinical judgment. Radiographicinspection can yield helpful information, howeverthe diagnosis of a prominent bursal projection is

not necessarily confirmed simply by assessing thelateral radiograph. It is interesting to note that PPLs

do not correlate with the need to go to theoperating room as much as does the combinedpresence of a large FPA in conjunction withincreased CIA. It was also observed that extensivereflection of the tendoAchillis at its insertion, withextensive osseous remodeling, led to persistentedema postoperatively. Moreover, it appears as

though posterior heel pain caused by posteriorosseous and soft tissue abnormaliry is less likely torespond to consetwative care than is plantarcalcaneal spur syndrome. Nonetheless, the majorityof posterior heel pain patients do not requireoperative intervention for treatment.

In summary, this retrospective analysis of thetreatment of 34 painful heels in 37 patientspresenting with Haglund's disease and/or posteriorcalcaneal exostosis, attests to the effectiveness of a

226 CHAPTER 36

Table 2

TREATMENT OF HAGLUND'S DISEASE AND POSTERIOR CALCANEALEXOSTOSTS (N=34 HEELS rN 31 PATTENTS)

AGE 33.3 x 8.6 YearsSEX 24 (77.4VA Female, 7 (22.5o/o) MaleBMI 28.01 t 5.04 Female, 30.04 t 4.33 rualeSIDE 75 G8,3%o) Right, 73 G7.90/o) Left, 3 (9.7o/oi) BilateralACTIVITY 1.0 (32.30/o) Consrant, 16 67.60/o) partial, 5 06.gA SedentaryONSET 29 O3.5o/A Insidious, 2 (6.50/o) AcureDURATION 9,7 t 4.8 Months (STAGE V Therapy B.B t 4.1 Months)BURSITIS PRESENT All heels initially, 2/J (40o/o) of surgical casesPAIN (PRE-) 3.3 x 0.59 (0-4 Analog Scale)PAIN (POST-) O.6l t 0.61 (.0-4 Analog Scale)ANTALGIC GAIT 18 (58.1%)Yes, 13 (41.9%o) NoPROMINENT PSP 31 Patients, 34 Heels (100%o)

FP ANGLE 74,O x 4.1O (Nonsurgical), 76.80 ! 3.90 (Surgical)CI ANGLE 25.40 t 4.10 (Nonsurgical), 2BO r 1.BO (Surgical)TOTAL ANGLE 89.80 t 3.80 (Nonsurgical), 98.40 t 2.30 (Surgical)PPL 14 (47.2o/o-) Positive, 20 (5B.Bo/o) NegativeFOLLO\(/-UP 7.9 x 3.9 MonthsSTAGE OF Tx 77 (.32.4o/o) Stage I, 72 (35.30/o) Stage II, 5 O4.7o/o) Stage III, 5 14.70/;) Stage IV

(BMI=Body Mass Index, FP:Fowler & Philip, CI= Calcaneal Inclination, PPl:Parallel Pitch Lines)

rigorous course of non-surgical care. The meanaverage follow-up period for the J1 patients was8.9 months. Posterior heel pain was obserwed toaffect primarily middle-aged individuals that werenot excessively overweight, and whose dutiesrequired primarily weight-bearing acrivities.Females out numbered males 3:7, and this isthought to correlate with more frequent use of ahigh-heeled shoe with a rigid heel counter.Posterior heel pain was noted to usually developinsidiously secondary to repetitive strain, and toexist for approximately nine months prior to thepatient seeking professional treatment. There wasno observed difference in the outcome of treatmentbetween the group of patients undergoing surgicaitreatment and those who satisfactorily respondedto non-surgical care, based on the duration ofconserwative care provided prior to makingthe decision to operate in an effort to alleviaterecalcitrant pain.

A clinically palpable posterior calcaneaTprominence was obseled in all 34 painful heels.

The Fowler and Philip angle, the CIA, and Ruch'stotal angle, were obserwed to be significantlyhigher in those patients requiring operativeintervention in order to alleviate pain, whilemeasurement of parallel pitch lines was lessclinically relevant. Overall, 85.3o/o of patientsresponded satisfactorily to nonsurgical therapy, andthe combined rate of success for both non-surgicaland surgical management was 94.70/o

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l. Pavlov H, Heneghan M, Hersh A, Goldman AB, Vigorita V; TheHagluncl syndrome: initial and cliffcrential diagnosis. Diag Radiol143:83-88, 1981.

2. Malay DS: Heel Surgery. In McGlamry ED, ed., ComprehensiueTextboctk ctf ?'ctot Suryery, 2nd ed. Baltimore, Md: rWilliams &\7ilkins: 1992:440-455.

J. Stephens MM: Haglund's deformity and retro calcaneal bursitisOrtbop Clin N Amer 25:47-46, 1.994.

4. Rnch JA: Haglund's disease J Am Podidtty,4ssoc 6.1:1000-10003,1974.

5. Neese E, Finsen V: Poor results after resection for Haglund's heel.Acta Ofihop Scan 65:707-709, 1994.