Haglund’s disease, a painful foot deformity

Haglund's disease, a painful foot deformity

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Haglund’s disease is named after the Swedish surgeon who first described it in 1928, Dr. Patrick Haglund. This bony malformation in the back of the foot can cause pain when putting on shoes and hamper activities. Dr. Gauthier Gracia, orthopedic and trauma surgeon at the Polyclinique Côte Basque Sud in Saint-Jean-de-Luz and at the Belharra clinic in Bayonne, explains the causes of Haglund’s disease, the symptoms and treatments.

Haglund’s disease is a relatively uncommon pathology, which affects women more than men and which generally appears between the ages of 20 and 30.

What is Haglund’s disease?

Haglund’s disease corresponds to a malformation of the calcaneus bone (or calcaneus), located at the back of the heel and which causes conflict with the Achilles tendon. “Described by Dr. Patrick Haglund, this hypertrophy of the posterosuperior tuberosity of the calcaneus results from an abnormal outgrowth of this heel bone on which the Achilles tendon is inserted. There are two forms of Haglund’s disease: the morphological form described as a high, pointed and bumpy bony prominence, and the static form due to verticalization of the calcaneus.specifies Dr. Gauthier Gracia, orthopedic and trauma surgeon at the Polyclinique Côte Basque Sud in Saint-Jean-de-Luz and at the Belharra clinic in Bayonne.

What causes Haglund’s disease?

The main causes of Haglund’s disease are anatomical in origin. “Haglund’s disease mainly results from a morphological abnormality. People with cavus foot, with accentuation of the concavity of the arch of the foot, therefore have a greater risk of developing this disease.says Dr. Gracia.

Other factors can nevertheless come into play, notably genetic factors and footwear, continues the orthopedic surgeon. Wearing unsuitable, rigid or too tight shoes, causing abnormal and painful pressure on the posterior heel, leads to repetitive and continuous inflammation of the Achilles tendon.

What are the symptoms of Haglund’s disease?

Pain at the back of the heel when putting on shoes is the main symptom of Haglund’s disease. “The pain results directly from the retro-calcaneal conflict between the bony tuberosity and the heel counter of the shoe which causes redness, inflammation or even bursitis (inflammation of the bursae which surround the Achilles tendon, editor’s note), explains Dr Gracia. This pain can be very intense to the point of causing an inability to put on shoes.. It is sometimes associated with indirect pain linked to inflammation of the tendon itself (Achilles tendon insertion enthesopathy) – this is then called Haglund syndrome. In these cases, the heel is red and swollen.

The greater prevalence of Haglund’s disease in women is undoubtedly explained by the wearing of heeled shoes, whose counters are generally very rigid, suggests Dr. Gracia. “In certain patients, Haglund’s disease can be accompanied by retraction of the suro-achileo-plantar complex, in other words of the posterior muscular chains, which leads to very significant pain or even an inability to place the foot flat..

How to diagnose Haglund’s disease?

The diagnosis of Haglund’s disease is essentially clinical, says the specialist. It can be placed by the attending physician or a podiatrist after highlighting a conflict area and a bump at the back of the heel. “The practitioner must also look for inflammation, swelling in the area of ​​retro-calcaneal conflict, signs of bursitis and examine the morphology of the foot for cavus foot which he knows constitutes a risk factor. Haglund’s diseaseadds the surgeon.

Imaging examinations will complete the clinical examination. “A weight-bearing lateral radiograph allows the posterior hypertrophy of the calcaneus to be visualized and its importance to be assessed. It is also useful to prescribe an ultrasound to look for signs of bursitis or inflammation in the calcaneus, as well as an MRI to confirm or not the existence of insertion enthesopathy, which will determine the treatment. patient burden”.

How to treat Haglund’s disease?

Treatment of Haglund’s disease depends on the degree of calcaneus hypertrophy. “Initially, treatment is medical and symptomatic, it aims to relieve pain. We recommend suitable footwear with wider shoes with more flexible posterior buttresses. For people with hollow feet, the prescription of orthopedic insoles aimed at re-horizontalizing the calcaneus is recommended. In terms of medication, taking analgesics and non-steroidal anti-inflammatories orally or applied locally can relieve pain. Rehabilitation sessions based on stretching and massages with the physiotherapist can complete the treatment in the event of retraction of the suro-achilleo-plantar complex.

On the other hand, cortisone infiltrations are not recommended because they risk weakening the Achilles tendon and its insertion, or even leading to its rupture.

It is very common for Haglund’s disease to be painless or for medical treatment to be sufficient to relieve the pain. If these persist despite well-conducted medical treatment, surgical treatment may be considered.indicates Dr. Gracia, specifying that there are three main procedures depending on the importance of the damage:

  • In the absence of tendinitis or crack of the Achilles tendon, a “simple” bone resection is enough. The procedure can be done by traditional incision or endoscopically to limit the risk of infection and skin healing problems. It is carried out on an outpatient basis, under loco-regional anesthesia. The patient can walk again directly, wearing a removable walking orthosis for analgesic purposes for 3 weeks, while healing takes place. Standard analgesics are sufficient to relieve any pain;
  • In patients with cavus foot, a calcaneal osteotomy or Zadek osteotomy is necessary. This heavier operation consists of breaking the bone to horizontalize it and thus reduce the conflict with the tendon. In this case, the patient is prohibited from placing his foot on the ground for 5 to 6 weeks, which is immobilized by a rigid orthosis;
  • Finally, in case of insertion enthesopathy associated with Haglund’s disease, the surgeon must carry out a disinsertion-reinsertion of the Achilles tendon at the level of its enthesis. Concretely, once the tendon has been removed, the surgeon cleans the inflammation, repairs the cracks and removes any calcifications present, he resects the bone then reinserts the tendon. “After such an intervention, the patient’s foot must be immobilized for 3 weeks in equinus, that is to say with the tip of the foot downwards, so as not to pull on the Achilles tendon. He therefore needs a custom-made anterior splint. He is forbidden from putting his foot on the ground. After 3 weeks, he can walk again wearing a boot with an adjustable heel pad..

The risks associated with these interventions are those that we observe for any surgical procedure, indicates Dr. Gracia. “An infectious but negligible risk (<3%), a risk of algodystrophy which we can try to prevent using vitamin C, a risk of phlebitis which we avoid by prescribing anticoagulants, and a risk of skin complications, particularly in smokers and people with poorly controlled diabetes. It is therefore strongly recommended not to smoke during healing,” advises the surgeon. The results are generally there. “It’s a satisfactory surgery”.

A work stoppage of 1 to 2 months will be necessary for a bone resection, and resumption of sport will be possible after 2 months. A calcaneal osteotomy or an Achilles tendon removal-reinsertion operation requires a longer work stoppage, of 3 to 4 months, and resumption of sport can be considered after 4 to 6 months of rest.