Haglund syndrome, also known as Haglund heel, is caused by a bony change (overbone) on the heel bone in the area of the Achilles tendon insertion. It is named after the Swedish surgeon Patrik Haglund (1870 – 1937). Haglund’s heel can be extremely painful and can be treated conservatively or surgically.
What is Haglund’s heel syndrome?
Haglund’s heel, a form of heel spur, is recognizable by a bony change on the upper posterior (cranial and dorsal) portion of the calcaneus in the area of the Achilles tendon insertion. Ossification at the calcaneus can already occur during the growth phase at the growth plate of the bone (epiphyseal joint) or it can be an ossification at the calcaneus directly in the area of the Achilles tendon insertion (apophysis). Such bone enlargements with solid bone substance at the calcaneus are also called “Haglund’s exostosis”. Disorders at the growth plate occur exclusively in adolescents, because the growth plate closes by regular ossification after completion of bone growth. Such disorders at the growth plate of bones are “iuvenile osteochondroses”. Both forms of Haglund’s syndrome can cause similar symptoms and cannot be accurately differentiated.
Causes
The main causes of developing a Haglund heel are thought to be footwear that causes irritation to the tendons or puts direct pressure on one or more of the foot bones. For the bone, this can be a stimulus for increased bone formation in the affected area. Shoes with tight heel caps can cause constant irritation to the Achilles tendon insertion during walking and running, marking the beginning of the development of a Haglund heel. Other contributing factors for causing Haglund’s syndrome include excessive running training with non-functional footwear and obesity. The extent to which genetic predispositions may lead to premature and excessive ossification at the growth plate of the calcaneus has not yet been conclusively determined. Here, too, non-functional and too tight footwear in children can be considered as the main cause. Congenital or acquired foot deformities may also promote the development of a Haglund heel.
Symptoms, complaints, and signs
Haglund’s syndrome is primarily noticeable by stabbing pain at the posterior calcaneus. The pain occurs with weight-bearing and pressure on the heel and quickly subsides as soon as the leg is unloaded. The pain is intense at first and subsides with repeated weight bearing. The pain is most intense in the morning and after prolonged periods of rest. Externally, Haglund’s syndron can be recognized by the conspicuous gait. Affected individuals usually limp or drag their leg with the affected heel behind. Sometimes redness appears on the heel or a visible swelling develops that hurts when touched. In isolated cases, visible ossification may be noticed at the heels or at the upper posterior tendon insertion of the heel. These ossifications hurt to the touch and are occasionally associated with swelling and redness. If Haglund’s syndrome is not treated, it increases in intensity. The avoidance behavior can result in deformities and joint wear and tear. Some sufferers also experience nerve pain that can radiate from the heel to the knee. In isolated cases, paralysis and sensory disturbances emanate from Haglund’s heel, which sufferers find unpleasant.
Diagnosis and course
The first symptoms that indicate a Haglund heel are externally visible redness, pressure-sensitive areas or even thickening at the posterior upper part of the calcaneus. If orthopedic examinations confirm the initial suspicion of Haglund’s syndrome, diagnostic imaging procedures such as ultrasound, X-ray and computed tomography (CT, MRI, fMRI) can provide more precise findings. In the X-ray image, bony formations in particular are clearly visible. The computed tomographic procedures also provide meaningful images of the soft tissues, i.e. the condition of ligaments, tendons, muscles, bursae and articular cartilage. The clinical course of a Haglund’s heel varies greatly and ranges from completely painless to very painful and debilitating.Symptoms of the disease can develop over a long period of many years, so emerging symptoms – especially if there is no pain or serious impairment associated with them – go unnoticed and untreated.
Complications
Haglund syndrome primarily causes relatively severe pain. This pain has a negative impact on the patient’s daily life and can thus significantly reduce the quality of life and lead to movement restrictions. It is not uncommon for Haglund’s syndrome to also lead to pain at rest and thus to sleep disturbances in the patient. The skin is reddened by the disease and ossification occurs, especially in the patient’s heels. The pain can also spread to other regions of the body. Due to the movement restrictions, it is also not uncommon for patients to suffer from depression and other psychological upsets. In some cases, patients are also dependent on walking aids in order to cope with everyday life. No further complications arise during the treatment itself. Most complaints can be limited by appropriate footwear. In many cases, however, physiotherapy is still necessary. If there is no improvement, surgical intervention is usually necessary. Life expectancy is not affected by Haglund syndrome.
When should you see a doctor?
Since there is no self-healing in Haglund’s syndrome and the syndrome is usually associated with severe pain and limitations in everyday life, medical treatment must take place in any case. The affected person should consult a doctor if redness appears on the skin. This redness usually occurs without any particular reason and in different parts of the body. In addition, ossifications occur on the heel, especially at a young age. These become noticeable through pain, which can occur not only as pressure pain, but also as pain at rest. If the child complains of pain in the heel, a doctor should be consulted in any case. Usually, Haglund’s syndrome can be diagnosed by a pediatrician or by a general practitioner. However, the assistance of a specialist is necessary for further treatment. Early diagnosis increases the chances of a complete cure for Haglund syndrome.
Treatment and therapy
If a diagnosed Haglund’s syndrome can essentially be attributed to unsuitable footwear, the first measure is relief of the heel area. In addition, specific physiotherapy aimed at strengthening the leg muscles and relieving the Achilles tendon is recommended. It is also worth considering the use of extracorporeal shock wave therapy, which was originally developed for kidney stone disintegration. Shock wave therapy is particularly effective in “pulverizing” calcium deposits and hardening in the tissue so that they can be removed and flushed out by the body via the lymph and blood channels. If conservative forms of therapy do not lead to the desired success, two different surgical procedures can be considered. On the one hand, the ossification can be removed directly in a surgical procedure. However, this has the disadvantage that in the area of the Achilles tendon insertion, the tendon sheath must also be removed, which normally ensures problem-free gliding of the tendon. There is a risk that adhesions will form on the tendon postoperatively, which can hinder its function. On the other hand, a surgical procedure has become established that does not touch the area of the Achilles tendon, but instead cuts a wedge from the calcaneus a few centimeters further forward so that the calcaneus folds up a little in the area of the Achilles tendon insertion. Although this does not remove the spinous process, it no longer presses and rubs against the Achilles heel if successful, so symptoms improve or even disappear altogether.
Outlook and prognosis
The prognosis of Haglund syndrome is usually very good if treated. However, it is a very time-consuming therapy that is initially started with conservative measures. However, without treatment or after constant stress due to improper footwear, athletic stress on the foot, or obesity, the symptoms can worsen considerably.The bony prominence (haglundexostosis) on the calcaneus will increase under these conditions because the pressure on the inner edge of the shoe will continue to increase during running or walking. Conservative treatment initially begins with the provision of orthopedic shoes. With their help, the mechanical stress on the bursa should be reduced, thereby stopping the inflammatory processes. This treatment also includes local application of anti-inflammatory drugs and injection of corticosteroids into the Achilles tendon. The therapy should show initial success after about 6 months. However, if treatment is unsuccessful, surgery becomes necessary. This usually involves removal of the bursa subachillea and the adjacent bony prominence. In children and adolescents up to the age of 17, however, this operation may not yet be performed because the adjacent growth plates are not yet closed. After surgical removal or reduction of the bony prominence, the pressure of the inner edge of the shoe against the calcaneus decreases. This also decreases the pressure on the bursa, Achilles tendon and soft tissues. This treatment method usually leads to lasting success.
Prevention
One of the most important measures to prevent Haglund’s heel is to make sure your footwear fits and functions properly. Particularly in children, whose feet are subject to certain growth spurts, attention should be paid to appropriate footwear that gives the foot enough room to develop. Further preventive measures consist of carrying out athletic running training exclusively with running shoes and planning for sufficient stretching exercises. Consultation with an orthopedic specialist is recommended at the first signs of Haglund’s syndrome.
Aftercare
In Haglund’s syndrome, either very few or even no measures of direct aftercare are available to the affected person. In this case, the disease must first and foremost be detected quickly and, above all, at an early stage to prevent further damage or complications to the feet. The affected person should consult a doctor and initiate treatment at the first symptoms or signs of the disease. In this case, the treatment is usually carried out by means of a surgical intervention. The affected person should in any case take it easy and rest after such an operation. They should refrain from exertion or physical activities in order not to put unnecessary strain on the body. The help and support of family and friends can also have a positive effect on the recovery of the patient. After the operation, physiotherapy is usually necessary. Many exercises from such a therapy can also be performed at home to accelerate the treatment. Regular examinations by a doctor are also very useful. Haglund’s syndrome usually does not negatively affect the patient’s life expectancy.
What you can do yourself
In Haglund syndrome, the options for self-help are severely limited. Here, early diagnosis in particular can prevent further complications and discomfort. However, if Haglund syndrome has already occurred, only therapy or surgery can alleviate the symptoms. However, the syndrome can be easily prevented by children always wearing appropriate footwear. This is especially true during growth spurts. The feet must not be squeezed and must have sufficient free space. Furthermore, sporting activities should always be carried out in running shoes or in sports shoes. This can also prevent the syndrome. Should the syndrome occur, unnecessary stress on the feet should be avoided at all costs. At the first signs of the disease, an orthopedist should be consulted immediately, who can diagnose and treat the disease. Children should always be informed about the possible complications and risks of Haglund’s syndrome in order to avoid unanswered questions and possible psychological discomfort. As a rule, the disease can be treated relatively well by surgical intervention, so that there are no further restrictions in the child’s development.
