Treatment options for Haglund's deformity: surgery and conservative treatment

Haglund's disease (Haglund-Schinz) is a type of osteochondropathy. It is characterized by a violation of the ossification processes of the apophysis of the calcaneus. It is the most common cause of Achilles tendon pain in adolescents with increased physical activity.

The main cause of the disease is hereditary predisposition and repeated microtrauma of the growth plates of the heel bone. It appears in the form of a bone growth “bump” in the back of the heel bone.

Haglund's deformity can be either unilateral or bilateral.

Osteophyte of the calcaneus

An osteophyte (bone spur) that appears on the back of the heel bone slightly above the insertion of the Achilles tendon is called Haglund's deformity, named after the author who first described this disease. Haglund's disease is a fairly common cause of posterior calcaneal pain. The clinical diagnosis of the syndrome is most often confused with Achilles tendon bursitis and rheumatoid arthritis, since the clinical picture is quite similar in these pathologies. See symptoms below.

Diagnostics

Based on an analysis of the clinical picture, x-ray, and medical history, the orthopedic doctor makes a diagnosis. In some cases, radiography is not sufficient and there is a need to use additional research methods.

MRI allows you to evaluate the condition of the bursa and tendon and exclude other pathologies of the hindfoot and ankle joint.

Anatomy of the heel region

The calcaneus is the largest bone in the foot. The Achilles tendon, the largest and most powerful tendon in the human body, is attached to its tuberosity. By contracting the posterior calf muscles (gastrocnemius and soleus), the Achilles tendon pulls on the heel bone, allowing plantar flexion of the foot. This function allows us to walk, run, stand on our toes, and jump. Between the tubercle of the calcaneus and the Achilles tendon is the posterior calcaneal mucous bursa, which helps the tendon glide easily when the foot moves. Such bags are found in almost all joints, for example, in the elbow, shoulder, etc.

Pathogenesis of Haglund's deformity

During constant friction of the Achilles tendon, inflammation of the mucous membrane of the bursa begins. This chronic multi-month impact is transmitted to the posterior calcaneal tubercle and pathological cartilage slowly begins to form, changed, often with sharp spines. This can even be seen on an x-ray. The formation of this cartilage occurs due to the body’s protective reaction. The desire to strengthen the area of ​​constant irritation and improve tendon gliding. But, unfortunately, pathological cartilage is not capable of this. It turns out to be a vicious circle.

The pressure on the bursa and Achilles tendon increases even more, which increases inflammation, pain and swelling. Inflammation of the mucous bursa and Achilles tendon without bone deformation is called achillobursitis (posterior calcaneal bursitis). Typically, bursitis precedes Haglund's deformity.

Patients do not pay much attention to the “bump,” thinking that it is a callus until it hurts. And as a rule, this condition is quite difficult to treat conservatively. This is why it is so important to see an orthopedist in the early stages of Haglund's disease.

Clinical picture

Valgus most often begins to manifest itself in the first year of a child’s life and is often combined with valgus deformity of the knee joints. It is characterized by an X-shaped curvature of the legs and a decrease in the height of the arches of the feet. If you bring your knees together and then straighten them, the distance between your ankles will exceed 4-5 cm. Being on a completely flat surface, the inside of the lower leg falls inward, and the toes and heel “look” outward. A flat-valgus foot develops with almost complete flattening of its natural arches.

Varus also begins to manifest itself in early childhood. With this pathology, the baby’s legs are O-shaped, resembling a wheel. The axis and dome of the foot are bent, with the main load falling on the outer edge of the sole. However, varus of the foot, like valgus, can be isolated and not combined with deformation of the entire lower limb.

Both deformities can be congenital or acquired. In the first case, pathological changes will be observed already during the period of intrauterine development of the fetus. A child is born with a defect. Acquired foot deformities begin to form after the baby is finally on his feet. As a rule, with foot valgus, parents notice that when the baby walks, he does not step on the entire sole, but only on its inner part.

The curvature of one lower limb may be more pronounced than the other and be combined with flat feet. If planovalgus feet are not treated, the pathology is likely to progress over time. The physiological position of the legs will change, provoking the development of diseases of the spine and large joints. Over time, poor posture will appear, which can develop into such a serious disease as scoliosis or kyphoscoliosis.

Foot valgus can be combined and even be a consequence of varus of the knee joints.

Therefore, it is so important to promptly identify defects of the lower extremities and pay attention to any signs of the disease. Parents may notice that the child's gait is unsteady and awkward, causing discomfort and pain. Swelling of the knee and ankle joints often appears. When examining the shoes, it is clear that they wear unevenly, with a lot of wear on one side of the sole.

Children with varus and valgus often complain of fatigue after walking, pain in the legs and spine, cramps in the calf muscles, and even headaches. They cannot fully run, jump, perform physical exercises or play sports. Because of this, many children develop complexes and a reluctance to go to physical education or kindergarten. Sometimes the result is depression.

Causes of Haglund's deformity

• High arches can contribute to Haglund's deformity because in a person with high arches, the heel bone is tilted posteriorly and the Achilles tendon rubs more against the normal heel tubercle, causing it to enlarge. Eventually, due to this constant irritation, the bursa and tendon become inflamed.
• Stiffness (decreased elasticity) of the Achilles tendon may also increase the risk of Haglund's deformity as it rubs more against the heel tuberosity. In contrast, a tendon that is more flexible results in less pressure on the posterior calcaneal bursa.
• Planovalgus foot deformity or varus deviation of the calcaneus changes the biomechanics of foot movement and increases the pressure of the Achilles tendon on the heel bone, triggering this pathological mechanism.

Treatment of varus and valgus deformities

Hallux valgus and varus deformity of the foot in children usually requires long-term complex treatment. The sooner it starts, the better the prognosis. The main goal of conservative therapy is to create a correct arch of the foot by strengthening the ligamentous-muscular framework. Classic treatment methods include:

• Exercise therapy and gymnastics with exercises for the legs, in particular, with the help of various objects;
• massotherapy;
• plastering;
• water procedures (foot baths, swimming);
• use of orthopedic shoes and insoles;
• the use of special mats, balls and similar objects;
• physiotherapeutic procedures (magnetic therapy, applications with ozokerite and others);
• osteopathy.

Sometimes orthopedic splints, bandages and other fixing devices are used to eliminate the defect. In some cases, specialists turn to alternative methods, for example, kinesiotaping of the lower limb. In case of severe clinical manifestations, symptomatic therapy is prescribed (painkillers, hormonal and other drugs). If the measures taken are ineffective, surgical intervention is resorted to.

As a rule, varus and valgus feet in children respond well to conservative treatment.

Symptoms of Haglund's deformity

Haglund's deformity itself can occur without pain and inflammatory symptoms. Only pathological exostosis (bump on the heel) is noted on the back of the heel. The deformity usually does not cause any problems with foot function. But in most cases, the deformity is accompanied by inflammation of the mucous bursa and tendon sheath, and swelling. Then patients experience pain when walking, and sometimes at rest.

The syndrome can occur on one or both feet.

Signs and symptoms of Haglund's deformity include:

• A noticeable bump on the back of the heel;
• Pain in the area of ​​the Achilles tendon;
• Swelling, calluses on the back of the heel area;

It is pain that forces the patient to see a doctor.

Diagnosis of Haglund's deformity

Diagnosis begins with a patient interview and a detailed physical examination. Be sure to look at the back of the heels to make sure there is no heel varus (heel pointing inward).

In case of varus deviation of the calcaneus, a certain surgical technique is used - corrective osteotomy. Standard surgical methods will not exclude the possibility of relapse (recurrence of the disease). Usually the diagnosis is obvious without additional diagnostic methods. But radiographs must be taken to rule out other causes of heel pain.

In controversial situations, magnetic resonance imaging (MRI) is used to rule out a disease called achilles tendinitis, which is similar in symptoms. For example, after injuries to the Achilles tendon, a dense scar (in the form of a lump) appears at the site of injury and, as a rule, it is painful. It can be confused with Haglund's deformity if the patient does not remember the moment of injury.

Conservative treatment

If Haglund's disease is accompanied by pain, then the first step is to relieve inflammation from the affected mucous membrane of the bursa and Achilles tendon:

• During an exacerbation, wear shoes with a soft back or without a back (clogs);
• Local use of anti-inflammatory analgesic ointments (for example: dolobene gel, voltaren, traumeel);
• Taking non-steroidal anti-inflammatory drugs (for example: ketonal, nurofen, nise);
• Physiotherapeutic methods: magnetotherapy, laser therapy, shock wave therapy (SWT)
• Wearing an ankle orthosis that limits movement.

These simple and widely available methods will allow you to return to normal walking as quickly as possible.

We do not recommend injecting hormonal anti-inflammatory drugs, in particular Diprospan, into the area of ​​inflammation, as this greatly increases the risk of tendon rupture.

Hallux valgus - symptoms and treatment

Over the past hundred years, foot surgery has not only not lost its relevance, but is also making constant steps forward, with the advent of more advanced instruments and fixators. At the moment, more than 400 types of operations and their modifications have been developed to correct deformities of various parts of the foot.[5][16]

With initial changes, you can get by with a low-traumatic operation - McBride, Silver's method, R.R.'s method. Vredena.[13] In this case, the bone is not sawed, but the attachment site of the tendon of the adductor pollicis muscle is changed. The recovery period is minimal and lasts 2-3 weeks.

If grades II and III are diagnosed, then a more traumatic operation is performed - osteotomy (cutting of the bone) with setting the correct angle and fixation with screws or knitting needles.[12][15] There are many methods for correcting the first finger:

• Distal (used if the angle between the 1st and 2nd metatarsal bones is no more than 14°): Schede operation - removal of exostosis (“bump”), subcapitate wedge-shaped osteotomy according to J. Reverdin, TR Allen operation, DW Austin operation (chevron osteotomy);

• Diaphyseal (used if the angle between the 1st and 2nd metatarsal bones is from 15° to 22°): Z-shaped osteotomy M. Meyer (scarf), operation K. Ludloff, osteotomy CL Mitchell;

• Proximal (the angle between the I and II metatarsal bones is more than 22°): double osteotomy according to Logroscino, wedge-shaped osteotomy by M. Loison, E. Juvara, osteotomy according to GW Patton and JE Zelichowski;

Sometimes, if there is a deformity of the main phalanx of the first finger, an additional OF Akin (Moberg) osteotomy is required.[13]

The choice is made by an orthopedic traumatologist, taking into account the localization of the main changes, the congruence of the first metatarsophalangeal joint (preservation of articular surfaces) and the severity of the pathology.

If the first metatarsophalangeal or metatarsocuneiform joint is destroyed by deforming arthrosis or other pathology, then arthrodesis (jamming, immobilization of the joint) or, in rare cases, endoprosthetics is performed.[16]

After the operation, the patient walks for 4 weeks in special shoes (Baruka), which are needed to unload the forefoot. After control X-rays, the doctor allows you to walk, loading the entire foot, but limiting heavy and sports activities. As a rule, after 2 months the patient returns to his normal lifestyle. The fixing screws are not removed and do not cause any discomfort.

To correct the “small” rays of the foot (II-IV metatarsals), Weil techniques, subcapital hinge osteotomies, and DMMO are used.[9][15] To correct Taylor deformity (V metatarsal) - Willson, Bosh and DMMO techniques.

The following techniques are used to correct planovalgus deformities:

• tendon transposition;
• medializing osteotomy of the calcaneus; Cotton's operation;
• lengthening of the lateral column;
• arthrodesis of the Lisfranc joint;
• arthroeresis;
• three-joint arthrodesis.[1][6]

The main goal of modern treatment methods is to bring all anatomical and functional parameters as close as possible to normal. Ignoring the individual characteristics of the foot and choosing the wrong treatment method lead not only to recurrence of the deformity, but also to its aggravation.[18] Abandonment of well-known and proven operations and mass infatuation with new ones, as well as blind use of the same operations for decades, without taking into account the individual characteristics of each foot, are categorically unacceptable.[13]

Treatment of hallux valgus almost always begins with the selection of comfortable shoes that do not cause friction or stress. Nonsteroidal anti-inflammatory drugs and physical therapy may be prescribed to reduce inflammation and pain.[6] In addition, corticosteroid injections are possible.[11]

Various orthopedic products are used (instep supports, toe correctors, interdigital rollers). The use of orthopedic devices helps little in the early stages to stop further deformation.[10] With severe deformation, the use of orthopedic products can only slightly reduce pain.

Orthotics are an integral part of the treatment of foot deformities.[17] In most cases, standard insoles are not effective, so it is better to use custom insoles made specifically for your foot.[12] A prerequisite: if you wore orthopedic insoles before surgery, you need to replace them with new ones afterward, since the corrected foot changes its characteristics.

Surgery

If conservative methods of treating Haglund's deformity are ineffective, surgical treatment is performed using various techniques, which depend on the shape and degree of the deformity. The goal of most surgeries is to remove bony exostosis at the back of the heel to relieve pressure on the bursa and Achilles tendon. Inflamed, swollen tissues will return to normal volume when the pressure is removed.

If the clinical picture is dominated by pain, swelling, and inflammation of the calcaneal structures, then in addition to resection (cutting off) of the exostosis, the mucous bursa is removed. Because it will continue to hurt even after surgery.

Removal of exostosis (spurs) of the heel bone. This operation can be performed under conduction or local anesthesia in an open traditional way through a small (4-5 cm) incision outward from the Achilles tendon, or minimally invasively through 2 5 mm incisions using video endoscopic technology.

1. Open method.
   During the operation, the Achilles tendon is moved medially (inward) with instruments to eliminate the possibility of damage. Next, the exostosis is cut off with a medical saw. Sharp edges are cleaned by cutting with side sharpening. If necessary, the mucous bursa is excised. The wound is sutured and a sterile dressing is applied.
2. Endoscopic method.
   As a rule, patients move in an orthosis for the first week to reduce mobility of the foot and, consequently, swelling, pain, and hematoma.

   Wedge-shaped osteotomy of the calcaneus.

   This method of surgical treatment of Haglund syndrome is used if the patient has a high arch of the foot and, as a result, the angle of the heel bone is greater. It follows from this that the pressure of the posterior calcaneal tubercle on the Achilles tendon will be greater. To do this, the surgeon cuts out a wedge during the operation in the posterior part of the heel bone and fixes it with titanium screws, as shown in the diagram. This results in a relative decrease in the angle and the tubercle no longer exerts strong pressure on the tendon.

3. Corrective osteotomy of the calcaneus.
   This is the third type of operation - elimination of varus deviation of the calcaneus.

Treatment options for Haglund's deformity: surgery and conservative treatment

What can be done about this, and how is it treated? In most cases, of course, this is conservative treatment. The main and simplest thing is to select more comfortable shoes, or with such a back so that, for example, the seam does not go straight through the center. That is, the main goal and task is to maximally improve the comfort of the existing deformation, so that wearing shoes itself does not aggravate or provoke a further problem.

As another option, you can try to play and see with the height of the so-called shin part of the shoe. Yes, that is, you can wear shoes with a higher top and still have a softer heel there. Select shoes by size. In some cases, you can glue some kind of silicone gasket into the shoes, into the heel, which will improve shock absorption.

In cases where this deformation has already passed there, there is bursitis behind the Achilles tendon, or there are already such bone growths that are visible even on x-rays, and the Achilles tendon is constantly injured, then simply selecting shoes may not be enough, but that’s all There is also conservative treatment.

Use cold therapy. That is, cold is applied there or special cold compresses are applied. The point is to reduce inflammation in this area as much as possible, which should then lead to a decrease in swelling. When there is no such swelling, it will be less of a concern.

In cases where this deformation is accompanied by changes in the tendon itself, then, as one of the options, there are special boots that eliminate movement in the ankle joint, then mobilization in such shoes is about four to six weeks, followed by rehabilitation.

That is, well, special exercises are done that will make the Achilles tendon more extensible. And then this problem can also go away, but you need to clearly understand that the bone itself will not go anywhere, that is, there are no options that it will resolve there or become different.

That is, whatever the anatomy of the heel was, that’s how it will remain. And outwardly it is not always possible to remove this problem. That is, you need to clearly understand that there is just the structure of the heel and the so-called protruding bump, and there are those periods when this is accompanied by an exacerbation in the form of increased swelling, well, inflammation of the bursa, and then this can more likely cause some, well, discomfort and inconvenience. In the vast majority of cases, about 70-80%, everything works out and is resolved conservatively, without surgery.

If we talk about the operational solution of the issue, then in order to determine the scope of the operation, it is absolutely necessary that these are radiographs, a lateral projection, and often it is necessary to perform a magnetic resonance imaging of this area to see if there are any changes in the tendon to understand the extent of the operation.

If we are talking about surgery, then it consists of sawing off the heel bone, this excess. At the same time, the Achilles tendon, which is attached to the heel, we see so blue, it needs to be cut off, that is, detached from the bone that we are going to remove in excess. And then this Achilles tendon needs to be refixed back.

There are absolutely different implants and possibilities for how to do this. It depends more on how much the tendon itself is changed. If the tendon is intact, normal, and there are no problems, then special screws are screwed into the heel bone, they are called anchors.

If we see from MRI and during surgery that there are already changes in the tendon itself, that is, it is degeneratively changed, then it is possible that a stronger structure will be required for fixation. There is a slightly different access, but the meaning still remains the same. The excess modified bone is cut down, and then special screws are screwed into the bone, which attract the tendon to the heel. This is how we solve this problem.

As an option to solve the problem, of course, you can wear shoes without backs, and probably the people who live there in warm countries and wear flip-flops most of the time, I think that this problem does not bother them at all.

As for the operation, everything looks exactly the same as most operations in our clinic. This is a certain list of preoperative tests that need to be taken, hospitalization on the day of surgery, surgery, discharge the next day. Wearing the leg is allowed immediately the next day, but there is one caveat: if it does not cause any severe discomfort in the patient. I'll explain what's going on.

Often after surgery on the Achilles tendon, patients keep their foot in this relaxed position, because this way there is the least tension and the least pain. Accordingly, when we begin to advance, this zone becomes tense and causes discomfort, therefore, in my experience and in the experience of my patients, well, for about the next one or two weeks after the operation, many of them, and I also advise, use crutches for the purpose of partial load, Gradually get used to these unpleasant sensations and stretch the Achilles tendon a little so that it is comfortable.

As for the postoperative period, it is strictly six weeks in a special postoperative boot that eliminates movement in the ankle joint. That is, what seems to be the main danger here. Due to flexion in the ankle joint, we have excessive tension, load on the Achilles, nothing has grown there yet, it just can increase the likelihood of rupture of the Achilles tendon or separation from the place of fixation.

As a rule, six weeks in a post-operative boot is enough for the Achilles tendon to grip more or less firmly. And you can start walking in regular, familiar shoes. Well, the wound heals, again, it does not come into contact, well, it does not cause such concern when in contact with shoes. You can return to full physical activity about two to three months after surgery.

After operation

As a rule, during the first week after surgery for Hoogland's deformity, patients move independently, limiting the load on the operated leg, but sometimes crutches are required. In the early postoperative period, anti-inflammatory painkillers and antibiotics are prescribed. Dressings are carried out until the wound heals. Physiotherapy can be performed from the first day after surgery. These methods can reduce swelling and pain after surgery. Typically, 10 sessions of magnetic therapy and laser therapy are prescribed. Stitches are usually removed between 10 and 14 days. Sometimes the suture is removed intradermally with absorbable sutures. In this case, there is no need to remove anything. Complete rehabilitation takes place in 4-6 weeks with the first type of operation (removal of exomtosis). For the other two types of surgery, recovery may take 2-3 months. While the heel bone is healing.

Prevention of Hoogland's deformity

• Wearing shoes with soft backs.
• Use shoes with 2-4 cm heels for high arches.
• If you have flat feet or planovalgus deformity, you need to wear custom orthopedic insoles every day.

Don't self-medicate!

Only a doctor can determine the diagnosis and prescribe the correct treatment. If you have any questions, you can call or ask a question by email.