OrthoVirginia Blog

Minimally Invasive Achilles: Haglund’s Syndrome and Endoscopic Calcaneoplasty

By: Paul J. Switaj, MD

What is Haglund's syndrome or deformity?

Haglund's syndrome is a condition where an enlargement of the heel bone causes irritation and inflammation. Just as nose sizes and shapes vary, so there can be variations in the size and shape of these bone variations.

The bony prominence can rub against the overlying Achilles tendon and causes pain in the tendon. A small sac (called bursa) that lies between the bone and the Achilles tendon usually becomes inflamed and swollen. This is called retrocalcaneal bursitis.

The syndrome is caused by repetitive impingement of the bursa between the Achilles tendon and the posterosuperior calcaneal prominence.

This is can be problematic in all types of individuals, including professional athletes
(https://www.cbssports.com/nfl/news/chiefs-eric-berry-reportedly-has-achilles-deformity-may-require-patience-in-recovery/)
(https://www.washingtonpost.com/sports/2018/12/31/by-opting-surgery-john-wall-hopes-avoid-tearing-achilles-tendon/?utm_term=.a976dd8e830c)

What are the symptoms?

  • Pain with walking, especially when they start to walk after a period of rest.
  • Painful enlarged bump on the back of the heel bone.
  • Swelling is often present and associated with a bursitis.
  • Often associated with an overlying callus or hard skin over the area.
  • Pain is often present in closed shoes as the heel bone presses against the back of the shoe.
  • Pain is often present while moving the foot up (dorsiflexion).

It is important to note that Haglund's syndrome (Figure 1&3) differs from insertional Achilles tendinitis (Figure 2&4), which is a degeneration of the fibers of the achilles directly at its insertion into the heel bone. Plain radiographs (XRays) taken in the office, as well as MRI if indicated, can help distinguish between the two diagnoses and help assess appropriate treatment plans.

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Figure 1. Haglund's Deformity
Figure 2. Calcific Insertional Achilles Tendinopathy
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Figure 3. MRI demonstrating bursitis and swelling in the calcaneus (blue arrow) with healthy appearing Achilles tendon (red arrow)
Figure 4. MRI demonstrating bursitis and swelling in the calcaneus (blue arrow) with significant degeneration in the Achilles tendon (red arrow)

What are the treatment options?

Non-Surgical Treatment

Conservative treatment of Haglund's deformity is aimed at reducing the inflammation of the bursa. While these approaches can resolve the bursitis, they will not shrink the bony protrusion. Non-surgical treatment can include one or more of the following:

  • Medication: Anti-inflammatory medications may help reduce the pain and inflammation. Some patients also find that a topical pain reliever, which is applied directly to the inflamed area, is beneficial
  • Injections: Injection of corticosteroids in the retrocalcaneal bursa can also be recommended to aid in diagnosis and treatment
    ** Steroid injections directly into the Achilles may weaken the tendon leading in some circumstances to a rupture of the tendon, and thus are not recommended**
  • Ice: To reduce swelling, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour. Do not put ice directly against the skin
  • Exercises: Stretching exercises help relieve tension from the Achilles tendon. These exercises are especially important for the patient who has a tight heel cord
  • Heel lifts: Patients with high arches may find that heel lifts placed inside the shoe decrease the pressure on the heel
  • Shoe modification: Wearing shoes that are backless or have soft backs will avoid or minimize irritation
  • Physical therapy: Inflammation is sometimes reduced with certain forms of physical therapy, such as ultrasound therapy
  • Immobilization: In some cases, casting may be necessary to reduce symptoms

Surgical Treatment

If non-surgical treatment fails to provide adequate pain relief, surgery may be recommended

Operative treatment consists of removal of the inflamed bursa and resection of the bony prominence. This can be done by the traditional open surgical technique with a 4 to 5cm scar or a minimally invasive endoscopic technique using 2 small stab incisions.

Following traditional open surgery, various complications have been reported, such as skin complications, persistent pain, and stiffness from extensive dissection and immobilization, amongst others.

In patients with isolated tenderness to palpation at the posterosuperior (upper/outer) calcaneal border, and without significant intrasubstance changes on MRI evaluation, endoscopic calcaneoplasty may offer decreased wound-healing complications, less soft tissue disruption, earlier weight bearing, and the potential for quicker recovery time and decreased morbidity.

Preoperative evaluation is vital to ensuring optimal, predictable results. Local anesthesia may be injected directly into the bursa between the tendon bones. Relief of pain for a few hours will help distinguish this condition from other associated problems and give us an indication of the benefits of decompression by an endoscopic calcaneoplasty.

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Figure 4. Patient with Haglund's deformity status post resection of bony prominence. A) Preoperative XR demonstrating Haglund's deformity outlined in blue. B & C) Intraoperative XRs demonstrating resection of bony prominence

What are the advantages of endoscopic calcaneoplasty?

  • Minimally invasive surgery with two incisions approximately 1 centimeter in length
  • Decreased risk of complications including infection and nerve injury
  • Quick return to shoes
  • Faster return to sports and activities
  • Does not weaken the Achilles tendon postoperatively.
  • Decreased postoperative pain

How is it performed?

  • Outpatient surgical procedure under a twilight or general anesthetic. This is usually the patient's choice as to the type of anesthesia that they desire to use.
  • Two small incisions approximately 1/6" in length are made on each side of the Achilles tendon.
  • Specialized instruments including a small camera and surgical burrs are used to visualize and remove the bony prominence of the heel bone against the Achilles tendon. If the Achilles tendon has some damage, this can be cleaned up as well to a certain degree
  • One stitch is used to close each incision.

What is recovery?

  • Weight bearing immediately after the surgery is allowed with the use of a boot and crutches
  • Surgical boot for 3 to 28 days may be necessary depending on the amount of bone that is resected.
  • Early range of motion begins once incisions have healed
  • Typically patients transition out a boot around a month from surgery, and can start resuming normal activities
  • Sports and running usually commence around 12 weeks from surgery, depending on patient's progression

Please note: In our experience, clinicians should avoid endoscopic calcaneoplasty in patients with bone formation within the distal Achilles tendon insertion, which can be seen on XR and MRI. Intrinsic disease of the Achilles tendon cannot be treated endoscopically. For these patients, we suggest a posterior longitudinal incision and a split of the Achilles tendon. After bone resection, the tendon is reattached with either transosseous sutures or bone anchors. Your doctor will be able to make this distinction via physical examination and imaging studies.

Preoperative evaluation by your fellowship trained Orthopaedic surgeon is vital to ensuring optimal, predictable results. In patients with isolated tenderness to palpation at the posterosuperior calcaneal border, and without significant intrasubstance changes on MRI evaluation, endoscopic calcaneoplasty may offer decreased wound-healing complications and the potential for quicker recovery time and decreased morbidity. Please make an appointment to further assess your treatment options

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