Key Pearls For Treating Haglund’s Deformity In Runners
This author offers insights on the surgical treatment of a 43-year-old runner with pain in her posterior Achilles tendon that had not responded to conservative treatment.
Pain in the posterior portion of the heel can result from various pathologies such as Haglund’s deformity, retrocalcaneal bursitis, insertional Achilles tendinopathy and posterior calcaneal exostosis.1 Many times, the pain is secondary to a combination of the aforementioned conditions, which can lead to challenges in therapy, especially in choosing the correct surgical pathway if necessary.1
In my practice, one of the more common causes of posterior heel pain I frequently encounter is the posterior calcaneal exostosis with associated intratendinous calcifications. Depending on the severity and failure or success of conservative care, my treatment for this typically involves resection of the prominence with detachment of the Achilles and debridement of the calcifications followed by reattachment of the Achilles and augmentation with a flexor hallucis longus transfer. I have had cases in which insignificant amounts of prominence went unresected and symptoms persisted so I tend to be more aggressive with my resection. This leads to the need for a transfer of the flexor hallucis longus tendon.
Although Haglund’s deformity is reportedly one of the most common causes of posterior heel pain, I infrequently encounter Haglund's deformity (according to its original description) in my practice.2 In fact, many times, the condition that is often referred to as Haglund's deformity is more of a retrocalcaneal exostosis than a Haglund's deformity.3 A true Haglund's deformity is an enlargement of the posterosuperior prominence of the calcaneus.4,5
Radiographic determination of the deformity occurs by drawing parallel pitch lines over the calcaneus and observing the enlargement extending above to the superior pitch line. The lower parallel pitch line is a straight line drawn tangent to the anterior tubercle, the medial tubercle and the posterior tuberosity. Create the upper parallel pitch line by first drawing a perpendicular line from the first pitch line and superior to the posterior lip of the talar articular facet. Then draw a parallel line from the end of the perpendicular line from the tip of the talus extending posteriorly.6
Surgical treatment may involve open resection, a wedge shape osteotomy known as the Keck and Kelly, or arthroscopic resection.1,5,7