Haglund's exostosis

Haglund's syndrome

• is an inflammation of the bursa and a bony enlargement on the back of the heel that most often leads to painful bursitis, is a rare cause of retrocalcaneal pain (1,2)
• clinical diagnosis is often confusing as the clinical picture may mimic other causes of hindfoot pain such as isolated retrocalcaneal bursitis or hindfoot involvement from more systemic disorders such as seronegative spondyloarthropathies (Reiter's syndrome, ankylosing spondylitis) or rheumatoid arthritis
  • Haglund's syndrome was first described in 1928 as retrocalcaneal bursitis in the setting of an abnormal protuberance of the posterosuperior border of the calcaneus, identified in the association with golf shoes, which have a hard posterior shoe contour
  • in Haglund's syndrome, the pain is located at the postero-superior calcaneal prominence
    • although originally, Haglund described pain in the hindfoot caused by a prominent postero-superior corner of the calcaneus in combination with wearing a rigid low-back shoe
      • today, when using the term Haglund's exostosis, physicians are usually referring to a clinical situation of pain and tenderness at the postero-lateral aspect of the calcaneus, where a calcaneal prominence can often be palpated. This is also known as 'pump-bump', with alternative names as calcaneus altus, high prow heels, knobbly heels, and cucumber heel (2)
        
        
• a distinction between Haglund's disease and other conditions such as a superficial Achilles bursitis must be made. Haglund's disease must be differentiated from Haglund's syndrome, which involves a painful swelling of an inflamed retrocalcaneal bursa, sometimes combined with insertional tendinopathy of the Achilles tendon. It must also be distinguished from Haglund's disease, which is the term of osteochondrosis of the accessory navicular bone (2)

Clinical features:

• a prominent calcaneal posterosuperior protuberance is observed, usually on the lateral side, often with swelling and regional inflammatory changes
• a rigid, plantarflexed first toe may predispose one to Haglund's deformity and retrocalcaneal bursitis by resulting in hindfoot varus
• prominent plantar osseous projections can also alter the bone-soft tissue interface of the hindfoot
• by physical examination alone, it may be difficult to distinguish Haglund's syndrome from other causes of hindfoot pain such as Reiter's disease, rheumatoid arthritis, or isolated local conditions such as superficial tendo-achilles bursitis secondary to poor shoe fit

Investigations:

• radiographic features have been described, including a measurement method, (parallel pitch line) to confirm the presence of a prominent bursal projection and the Haglund's complex
  • when the posterior calcaneal border is prominent but subtle, objective measurement on the radiographic evaluation is important, to distinguish Haglund's syndrome from isolated retrocalcaneal bursitis, superficial tendo Achilles bursitis, or Achilles tendinosis (1)
  • with more systemic conditions such as Reiter's syndrome or rheumatoid arthritis, retrocalcaneal bursitis is usually an isolated finding and more diffuse; additionally, associated erosive changes of the calcaneal bursal projection may be present.
• MRI and ultrasound can be used in diagnosis of this condition

Management:

• conservative treatment options include reassessment of the footwear the patient is currently wearing, the use of heel inserts, and oral anti-inflammatory medication
  • modification of footwear - avoidance of shoes that rub the area
  • effects of heel elevation on the relationship between the calcaneal bursal projection and the Achilles tendon and retrocalcaenal bursa have been described
    • although the size of the calcaneal bursal projection remains the same when the heel is elevated, the plantar calcaneal pitch angle decreases and shifts the osseous calcaneal bursal projection away from the retrocalcaneal soft tissues, decreasing friction and irritation
  • steroid/local anaesthetic injections
    • clinically, the symptoms that lead the patient to seek medical care are often the pain and inflammation associated with retrocalcaneal bursitis and Haglund's syndrome from chronic friction and pressure from the calcaneal bursal projection (1)
    • using ultrasound guidance to inject the retrocalcaneal bursa is a simple, reliable method of ensuring accurate delivery of medication into the bursa and avoiding intratendinous injection (1)
      
      
• surgical treatment options, including retrocalcaneal decompression and calcaneal ostectomy or osteotomy, have varying results
  • inadequate bone resection can lead to recurrence of symptoms, with other postsurgical complications potentially including scar formation with nerve entrapment, weakening or rupture of the Achilles tendon, and nonunion of the calcaneal osteotomy
  • endoscopic calcaneoplasty is a minimally invasive procedure for the treatment of patients with calcaneal exostosis

Reference:

• (1) Sofka CM et al. Haglund's syndrome: diagnosis and treatment using sonography. HSS J. 2006 Feb;2(1):27-9.
• (2). van Dijk CN et al. Terminology for Achilles tendon related disorders. Knee Surg Sports Traumatol Arthrosc. 2011 May;19(5):835-41.