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 extra part of the heel bone sticks out and 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 part 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 swollen bursa is called retrocalcaneal bursitis.

The syndrome is caused by the bursa repeatedly being pressed between the Achilles tendon and another piece of bone, called the posterosuperior calcaneal prominence.

This syndrome can cause problems in all types of people, including professional athletes.

What are the symptoms?

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

It is important to note that Haglund's syndrome (Figures 1 & 3) is different from insertional Achilles tendinitis (Figures 2 & 4), which is when the Achilles tendon is wearing away where it goes into the heel bone. Regular X-rays taken in the office, as well as MRI if needed, can help distinguish between the two diagnoses and help figure out 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, or non-surgical, treatment of Haglund's deformity is aimed at reducing the inflammation of the bursa. While these treatments 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 helpful.
  • Injections: Injection of corticosteroids in the bursa may help in diagnosis and treatment. ** Steroid injections directly into the Achilles are not recommended because they may weaken the tendon, which can lead to the tendon rupturing.**
  • Ice: To reduce swelling, apply a bag of ice over a thin towel to the swollen area for 20 minutes every hour you are awake. 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: Some forms of physical therapy, such as ultrasound therapy, can sometimes reduce inflammation.
  • Immobilization: In some cases, you may need to wear a cast to reduce symptoms.

Surgical Treatment

If non-surgical treatment doesn’t help the pain enough, you may need surgery.

The surgical treatment is removing the inflamed bursa, or sac, and removing the bony part that is sticking out. The surgery can be done by the traditional open surgical technique with a 1.5”-2” (4 to 5cm) scar or a minimally invasive endoscopic technique using 2 small stab incisions. Your doctor can talk to you about the potential side effects of each type of surgery, and which one is best for you.

In certain patients, having an endoscopic calcaneoplasty, or removing part of the heel bone using minimally-invasive surgery techniques, can be a good choice for treating Hagland’s syndrome. This technique results in fewer complications in healing from the surgery, allows standing on your affected foot sooner, and may result in a quicker recovery time and less time spent with the condition.

Having a proper evaluation before the surgery is necessary to make sure that surgery is the right choice for you. Local anesthesia may be injected directly into the bursa between the tendon bones. Not having pain for a few hours will help make sure that the condition is Hagland’s syndrome and not another diagnosis, and help give an idea of how helpful the endoscopic calcaneoplasty will be.

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Figure 4. Patient with Haglund's deformity status post resection of bony prominence. A) X-ray before the operation showing Haglund's deformity outlined in blue. B & C) X-rays during the operation showing removal of the bony part sticking out

What are the advantages of endoscopic calcaneoplasty?

  • Minimally invasive surgery with two incisions each approximately 0.5” (1 cm) in length
  • Decreased risk of complications including infection and nerve injury
  • Quick return to wearing shoes
  • Faster return to sports and activities
  • Does not weaken the Achilles tendon after surgery
  • Decreased pain after surgery

How is the surgery performed?

  • Outpatient surgical procedure under a twilight or general anesthetic. Usually you as a patient can choose which type of anesthesia you would like.
  • 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 like?

  • You can put weight on your foot immediately after surgery if you use a boot and crutches.
  • You may need to wear a surgical boot for 3 to 28 days depending on the amount of bone that is removed.
  • You will have an early range of motion once the incisions have healed.
  • You can typically start resuming normal activities after about a month after surgery, when you transition out of a boot.
  • You can usually start doing sports and running about 12 weeks after surgery, depending on how you are healing.

Talk to your doctor today to see if surgery is the right treatment for you.