Haglund exostosis; Haglund's deformity

Haglund syndrome: causes, symptoms and treatment

Haglund exostosis is a rare bony prominence on the heel bone near the Achilles tendon insertion. Most of the time, this particular phenomenon is triggered by excessive tension and pressure. In addition to a change in the shape of the bone, the Achilles tendon is particularly affected, which often leads to inflammation and pain in this area. Often longer-term conservative and alternative therapies help against the discomfort of a Haglund heel. But it is not always possible to do without surgery.

contents

• Haglund syndrome: causes, symptoms and treatment
• A short overview
• definition
• symptoms
• causes
• diagnosis
• treatment
• Naturopathic treatment

A short overview

Often a Haglund exostosis is mistaken for a heel spur. The symptoms are similar, but the explicit location of the bone protrusion at the Achilles tendon causes the specific disease of the Haglund heel.

Haglund exostosis causes discomfort on the heel and around the Achilles tendon. (Image: SENTELLO / fotolia.com)

The following short summary provides the most important facts about the special exostosis:

definition: The Haglund exostosis describes a special bony outgrowth on the heel bone in the area of ​​the Achilles tendon insertion. The namesake is Swedish orthopedist Patrik Haglund. It is not a heel spur.

symptoms: The complaints usually occur in a stress phase (sport). The most common are heel pain and pressure pain in the area of ​​the Achilles tendon. Also redness and swelling in the affected area are possible.

causes: In addition to other possible causes and risk factors, in most cases an overload of the affected structures is suspected. These include, among other things, a constant standing and excessive physical activity.

diagnosis: The clinical examination provides the most important information for the diagnosis with the medical history. In addition, X-rays, ultrasound examinations and, if necessary, a magnetic resonance tomography are consulted.

treatment: As a first therapeutic approach conservative treatment methods are used, such as a simple pressure relief on the heel, an immobilization of the foot, and a longer-term physiotherapy and physical therapy. If all this fails, an operation can be considered.

Naturopathy: TENS (transcutaneous electrical nerve stimulation), various homeopathic remedies and osteopathy are used to support treatment of heel discomfort.

definition

The medical term exostosis describes a bony outgrowth on the bone, which is covered by cartilage and can occur at various parts of the body. In the vernacular, this common phenomenon is also known as the overbone. The Haglund exostosis or Haglund heel (also Haglundferse) is a special bony protrusion on the heel bone (calcaneus) in the area of ​​the Achilles tendon insertion. This situation at the upper rear of the heel bone distinguishes the disease from the much more common heel spurs (calcaneus spur). This usually forms under the heel (or in the lower part of the heel bone), where the sole of the foot begins to attach to the bone. In professional circles in addition to this lower (plantar) heel spur other forms are distinguished. These include the upper (cranial) and the back (dorsal) heel spur, which are in principle to be distinguished from a Haglund exostosis. Nevertheless, it happens that these terms are used synonymously.

Not infrequently, a Haglund syndrome for a heel spur or tendinitis is considered. (Image: bilderzwerg / fotolia.com)

In addition, due to the protrusion of the bone at the base of the Achilles tendon, bursitis (bursitis calcanea) or inflammation of the sensitive periosteum (periostitis) on the heel occur. Also, the Achilles tendon itself may be inflamed or it forms a painful edema. In this combination one then speaks of a Haglund syndrome.

Eponym for this disease was the first describing Swedish orthopedist and surgeon Professor Patrik Haglund (1870-1937).

symptoms

A Haglund heel does not cause discomfort. When symptoms occur, they can generally be one-sided or bilateral.

Closed and firm shoes often lead to friction and pressure on the bone protrusion on the heel bone. As a result, redness and soft tissue swelling may occur, accompanied by heel pain or pressure pain around the Achilles tendon. The swellings are often accompanying symptoms of bursitis on the Achilles tendon.

The pain occurs in particular during the first steps after a resting phase or after a sustained stress. During a stress phase (for example, prolonged physical activity), the pain can also go back down. However, the overload and irritation of the soft tissue and the surrounding tissue remain, which ultimately contributes to the aggravation of the symptoms.

In extreme cases, the state of pain can lead to those affected no longer being able to stand on tiptoe. It is possible that further sequelae, such as painful bone edema, will result from subsequent changes to the bones, soft tissue, or tendons.

A Haglund heel can be caused by incorrect footwear and cause severe heel pain. (Image: DimaBerlin / fotolia.com)

causes

Haglund exostosis may be a congenital bone bulge or the heel bone is heavily bulging from birth, which poses an increased risk of developing a Haglund heel.

However, it is often assumed that overload is the cause. As a rule, the body tries to counteract an excessive load. The Haglund heel causes calcification of the overused Achilles tendon in order to provide more stability. So people who are constantly standing, or even many athletes who exercise excessive running or jumping sport, suffering from the special Exostose. In particular, running on a hard surface and with rigid shoes has a negative effect. Even without physical activity, new or poorly fitting shoes that have too tight a heel cup can cause the formation of the bony prominence by direct application of pressure. In addition, however, a strong overweight (obesity) can represent a particularly large burden on the (deformed) heel bone.

Other triggers include deformities of the foot and heel bone. Known is a frequent occurrence of Haglund heel together with a hollow foot (Pes cavus or Pes cavovarus). This usually congenital malposition is characterized by a particularly high foot span or by a pronounced Fußlängsgewölbe. These or other misalignments can cause excessive tension on the tendon plate in the area of ​​the sole of the foot, also referred to as plantar fascia (aponeurosis plantaris). In most cases, pain in the soles of the feet indicates such a connection.

Another conceivable cause is a shortened or heavily loaded calf muscle in question, which has too strong a pull on the Achilles tendon on the bone neck result or can cause a rotation of the tendon. It is possible that in this connection there is a connection to frequent leg cramps. In addition, connective tissue layers between the muscles (fascia) can be glued, which in addition to an increased tensile load can also lead to a reduced removal of metabolic residues. These excessive loads and irritation may favor the development of Haglund syndrome.

A common cause is excessive exercise, such as excessive running. (Image: Thaut Images / fotolia.com)

Considering other possible connections, even more distant states of tension, for example in the buttocks, can continue through the muscles and fascia of the thighs and calves to the heel and show certain effects there. Thus, a sciatic nerve pinched elsewhere can cause discomfort to the heel. For those with appropriate back, buttocks or foot sores, these possible connections should be considered when explaining the cause.

diagnosis

There are still no precise diagnostic criteria for a Haglund exostosis, which is why a combination of different causes and complaints often lead to this diagnosis. In order to be able to make a detailed diagnosis and to exclude similar clinical pictures, in addition to the condition of the bone, the Achilles tendon, its approach and the surrounding bursa must be included in the examination.

The most important part of the diagnosis process is the clinical examination together with the patient survey (anamnesis). In particular, the exact localization and description of the complaints and pain in the heel (and possibly in other parts of the body) is determined.

With the help of a lateral x-ray of the heel bone, one can generally recognize the bony changes and humps of the Haglund heel. To assess the Achilles tendon, an ultrasound examination (sonography) is then usually used in addition. Here it can be determined whether the tendon and tendon insertion are thickened or there is a partial rupture. Likewise, inflammation and swelling of the bursa can be diagnosed.

Complementary to the assessment of the soft tissues is often a magnetic resonance tomography (magnetic resonance imaging, MRT short) performed with contrast agent. This procedure replicates possible calcifications in the Achilles tendon and bone edema and also provides further information about the stage of the disease. The latter is an important criterion, in particular for the choice of treatment.

When diagnosing, it is important to rule out other diseases of the Achilles tendon as the cause of the symptoms. (Image: bilderzwerg / fotolia.com)

It is important to distinguish whether it is a Haglund exostosis or other diseases of the Achilles tendon, such as achilles tendonitis or Achillodynie (Achilles tendon pain). Likewise, a tendon insertion disease (insertion tendinopathy) and a heel spur are excluded. The latter may form at different positions on the heel bone and may even be connected to the Achilles tendon insertion. Anatomically, however, a heel spur in this area always lies below the site of a Haglund exostosis. However, correlations between the different clinical pictures are quite common, which makes the differentiation more difficult.

treatment

The aim of the therapy is to relieve the pain and restore the resilience of the foot. In addition to a first so-called conservative therapy, surgery may be considered in certain cases. In general, the therapeutic measures are based on the stage of the disease.

Conservative therapy

Various approaches of conservative therapy already lead to success in many cases. As a first step, those affected are advised to wear open footwear as often as possible to allow quick relief of pressure on the heel. In addition, it is recommended to use a heel pad or inserts with a heel lift in closed shoes. In the long term, this should prevent the pressure from the inside of the shoe to the diseased area. An elevated heel position also reduces the tensile load exerted by the Achilles tendon.

Ankle braces can also be used to relieve the heel bone, compensate for stress and stimulate the soft tissue, thereby assisting the healing process. In severe cases, immobilization of the foot can also be useful, for example with an orthosis or a plaster.

In the conservative treatment of a Haglund exostosis, appropriate inserts are often used to relieve pressure on the heel. (Picture: Pixelot / fotolia.com)

If the pain is too strong despite pressure relief or even in the unloaded state, occasionally analgesic and anti-inflammatory drugs (for example, aspirin or ibuprofen) may be used. A short-term use of cortisone is usually considered only in particularly severe or complicated cases.

Diseased athletes should refrain from running training until the complaints go back. Thereafter, the training should be resumed slowly and the training scope adjusted (reduced).

In addition, in most cases different physiotherapeutic treatment methods are used. One focus is on certain stretching exercises of the entire back of the leg and the foot area. This is to reduce the tensile stress on the tendons and strengthen the foot and calf muscles with regular implementation. Even methods in the field of physical therapy show very good treatment success. These include, for example, the ultrasound therapy and the current application (electrotherapy) and the method of shock wave therapy in heel pain.

Surgical intervention

If extensive conservative therapy does not prove successful over a period of several months, permanent overloading can not be counteracted for a variety of reasons, or if it is already a very severe condition, operational measures are usually necessary. During a surgical procedure, the outgrowth of the bone is ablated and, if necessary, removal of inflamed bursa (bursectomy) as well as calcification of the Achilles tendon. Experience has shown better postoperative courses of indirect removal of exostosis (in which the soft tissue under the Achilles tendon remains intact) than in superficial ablation.

Removal of the bony prominence permanently removes the harmful pressure from the Achilles tendon and other affected tissue parts. After the operation, a plaster ensures temporary immobilization and good regeneration. After each operation should be waived some time on sporting activity and a burden should be rebuilt slowly.

If the Haglund heel is clearly due to foot deformity, foot or heel bone transposition surgery (heel bone osteotomy) may be another treatment option. Individuals then discuss individually adapted options with those affected.

Naturopathic treatment

In addition to the conservative treatment approaches, naturopathy offers various ways to relieve the symptoms.

Osteopathy offers alternative options for diagnosis and treatment. (Image: Dan Race / fotolia.com)

As a proven, effective home remedy for swelling and pain on the heel (especially after strenuous exercise sessions) cool quark wrap or ice packs can be used for self-therapy.

A special form of electrotherapy is transcutaneous electrical nerve stimulation (TENS), where electrical impulses stimulate the body's own pain-relieving systems. The application is virtually risk-free and can be carried out by those affected themselves.

Homeopathy also offers various means of natural treatment for congestion and pain. A common drug of choice for a Haglund syndrome is Hekla lava (volcanic ash of the Hekla volcano), which shows a high level of effectiveness in drilling and periodic pain. After (overworking) overuse Arnica or Ruta graveolens (garden rue) is recommended for external use.

If the sufferer is severely overweight, which also leads to heel overstress, dietary advice and individualized diet can help reduce body weight and relieve discomfort. Other possible causes of heel discomfort, such as an irritated sciatic nerve, or back or buttocks, can also be resolved using osteopathic diagnostic and treatment methods. (tf, cs; updated on 26.10.2018)