Vitor Alves Osteopata

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🦶 Haglund's Deformity: Understanding the "Pump Bump"

■ Definition:
Haglund's deformity is defined as an abnormality of the bone and soft tissues in the foot.
It is an enlargement of the bony section of the heel where the Achilles tendon inserts.
It is characterized clinically as a symptomatic osseous prominence of the posterolateral corner of the calcaneus.
This prominence results in posterior heel pain and swelling around the insertion of the Achilles Tendon.
Haglund’s deformity is often associated with retrocalcaneal bursitis.

📜 Key Facts and History

■ Described by Patrick Haglund in 1928.
■ Previously known as “winter heel” and “pump bump.”
■ “Pump bump” refers to pressure from the rigid backs of pump-style shoes that aggravate posterior heel pain and swelling.

👩‍🦰 Epidemiology

■ Occurs mostly in young females.
■ Most common in women aged 15–35 years, especially those who wear heels regularly.
■ Also common in runners.

⚙️ Etiology and Predisposing Factors

While largely idiopathic, several factors predispose individuals to developing it:

■ Genetics (hereditary): Bone structure may predispose to the deformity.
■ High foot arches (Cavo varus deformities): The heel tilts backward into the Achilles Tendon, leading to bony protrusion and inflamed bursa.
■ Tight Achilles Tendon: Causes pain by compressing the inflamed bursa.
■ Walking on the outside of the heel: Causes calcaneus to grind against the tendon, forming an inflamed bursa.
■ Increase in weight.
■ Injury.
■ Improper/tight shoes: Aggravate symptoms and cause bursitis due to impingement from hard heel edges.
■ Over-practice in runners.
■ Altered biomechanics of foot joints from a dealigned subtalar joint.

⚠️ Signs and Symptoms

■ Pain and swelling at the back of the heel.
■ Noticeable bump or enlarged bony prominence on the back of the heel.
■ Heel pain and constant sharp feet pain.
■ Swelling and pain in the Achilles tendon.
■ Episodic pain after long periods of inactivity in mild cases.
■ Redness and swelling.
■ Severely restricted ankle joint mobility.
■ Friction between soft tissue and shoes causes bursae inflammation.

🧠 Diagnosis and Differential Considerations

■ Diagnosis involves physical examination with history assessment of the bursa, tendon, and calcaneus.
■ Functional tests to elicit pain include:
– Tensile tests (hopping on toes)
– Compressive tests (jumping lunge)
– Combination loading tests
■ Signs of inflammation: swelling, warmth, redness, tenderness over the posterior heel.
■ Visible bump on the posterior heel.

Differential diagnosis includes:
■ Achilles tendinitis
■ Retrocalcaneal bursitis
■ Calcaneal bursitis
■ Plantar fasciitis
■ Avulsion of calcaneal tendon

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💊 Treatment

Management begins with conservative care and progresses to surgical intervention if needed.

👉

🩹 Conservative Management

■ Relieves symptoms but cannot resolve the bony problem.
■ Focuses on controlling inflammation and modifying aggravating factors.

Methods:
■ Medication: Anti-inflammatory drugs for pain relief.
■ Avoidance: Corticosteroid injections avoided due to risk of Achilles tendon rupture.
■ Rest and Immobilization: Essential for inflammation management; casting may reduce pain.
■ Cryotherapy: Ice helps with swelling.
■ Physiotherapy:
– Key role in managing associated bursitis.
– Stretching and physiotherapy relieve tendon tension.
– Includes eccentric training program.

👉

Surgical Management

■ Considered when conservative management fails.
■ Consists of partial or full removal of the bony protrusion.

Options:
■ Removal of bony protrusion: Possible Achilles tendon injury.
■ Partial removal: High risk of Achilles tendon avulsion.
■ Closing wedge calcaneal osteotomy (Keck & Kelly technique).
■ Surgical risks: Nerve irritation and deep vein thrombosis.

👉

🦵 Post-Operative Management and Rehabilitation

■ Post-operative care must address risk of Achilles tendon rupture and injury.
■ Full rehabilitation may take up to one year.

Day 0 – 10:
■ Moon boot or below-knee backslab.
■ Non-weight bearing for 3 days to 2 weeks.
■ Rest, Ice, Elevation, and lower leg strengthening.
■ Achilles stretches contraindicated if tendon was repaired.

Day 10 – 6 Weeks (without Achilles repair):
■ Moonboot with raised heel.
■ Progress from toe-touch → partial → assisted full weight bearing.
■ Full activity possible at 6 weeks.
■ Continue oedema management.

Day 10 – 6 Weeks (with Achilles repair):
■ Moonboot or cast in equinis.
■ Non-weight bearing for 4 weeks.
■ Oedema management as needed.

Weeks 6 – 12 (without Achilles repair):
■ Wean from moonboot.
■ Progress to full weight bearing.
■ Focus on strengthening and endurance of foot and ankle muscles.
■ Begin scar management after wound healing.

Weeks 6 – 12 (with Achilles repair):
■ Moonboot in equinis (if cast was used).
■ Gradual weight bearing over 4 weeks (toe-touch → partial → full).
■ Continue oedema management and strengthening exercises.

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🛡️ Prevention

■ Focus on patient education and friction reduction.
■ Footwear: Avoid shoes with rigid backs.
■ Orthotics:
– For high arches or tight Achilles tendon, use supportive shoe inserts.
– Refer to podiatry for arch support or orthotic devices.
■ Weight Management: Provide advice on weight loss if applicable.
■ Runners: Avoid hard surfaces and uphill running; perform Achilles stretches to prevent stiffness.

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