Diseases

Haglund exostosis; Haglund heel


Haglund syndrome: causes, symptoms and treatment

The Haglund exostosis is a rather rare bony bulge on the heel bone in the area of ​​the Achilles tendon insertion. Most often, this special phenomenon is triggered by excessive tensile load and pressure. In addition to a change in the shape of the bones, the Achilles tendon is particularly affected, which often leads to inflammation and pain in this area. Long-term conservative and alternative therapy methods often help against the symptoms of a Haglund heel. But surgical intervention is not always possible.

A brief overview

A Haglund exostosis is often mistaken for a heel spur. The symptoms are similar, but the explicit location of the bulging of the bones at the base of the Achilles tendon causes the special clinical picture of the Haglund heel.

The following brief 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 Swedish orthopedist Patrik Haglund is named after it. It is not a heel spur.

Symptoms: The complaints mostly occur during a stress phase (sport). The most common are heel pain or pressure pain in the Achilles tendon. Redness and swelling in the affected area are also possible.

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

diagnosis: The clinical examination and the medical history provide the most important information for the diagnosis. In addition, X-ray images, ultrasound examinations and, if necessary, magnetic resonance imaging are included.

treatment: Conservative treatment methods are used as the first therapeutic approach, such as simple pressure relief on the heel, immobilization of the foot, as well as long-term physiotherapy and physical therapy. If all of these are unsuccessful, an operation can be considered.

Naturopathy: The TENS procedure (transcutaneous electrical nerve stimulation), various homeopathic remedies and osteopathy are used for supportive treatment of complaints on the heel.

Definition

The medical term exostosis describes a bony outgrowth on the bone, which is covered with cartilage mass and can occur on different parts of the body. This common phenomenon is popularly known as over-leg. The Haglund exostosis or Haglund heel (also Haglund heel) is a special bony protrusion on the heel bone (calcaneus) in the area of ​​the Achilles tendon insertion. This position at the upper rear area of ​​the heel bone delimits the clinical picture from the heel spur (calcaneus spur), which occurs far more frequently. This usually forms under the heel (or in the lower area of ​​the heel bone), where the insole tendons attach to the bone. Specialists distinguish between this lower (plantar) heel spur and other shapes. This also includes the upper (cranial) and the back (dorsal) heel spurs, which are principally to be distinguished from a Haglund exostosis. Nevertheless, it happens that these terms are used synonymously.

Frequently, due to the bulging of the bones at the base of the Achilles tendon, bursitis (calcaneal bursitis) or inflammation of the sensitive periostitis (periostitis) on the heel. The Achilles tendon itself may also be inflamed or painful edema may develop. In this combination one speaks of a Haglund syndrome.

The namesake for this clinical picture was the first descriptive Swedish orthopedist and surgeon Professor Patrik Haglund (1870-1937).

Symptoms

A Haglund heel doesn't have to cause any discomfort. If symptoms occur, they can generally be one-sided or two-sided.

Closed and firm shoes often lead to friction and pressure on the bulging bones on the heel bone. As a result, redness and swelling of the soft tissues can occur, which are accompanied by heel pain or pressure pain in the area of ​​the Achilles tendon. The swellings are often side effects of bursitis on the Achilles tendon.

The pain occurs especially in the first steps after a rest phase or after an ongoing exercise. The pain can also decrease during an exercise phase (for example, prolonged sporting activity). However, the overload and irritation of the soft tissues and the surrounding tissue remain, which ultimately contributes to the worsening of the symptoms.

In extreme cases, the state of pain can lead to the patient no longer being able to stand on tiptoe. It is possible that further complications such as painful bone edema may occur due to later changes in the bones, soft tissue or tendons.

Causes

The Haglund exostosis can be a congenital bone protrusion or the heel bone is bulging from birth, which increases the risk of developing a Haglund heel.

However, it is often assumed that overload is the cause. The body usually tries to counteract excessive stress. In the context of the Haglund heel, limescale deposits form on the overloaded attachment of the Achilles tendon in order to provide more stability. For example, people who stand constantly, or many athletes who do excessive running training or jumping, suffer from the special exostosis. In particular, running on hard surfaces and with rigid shoes has a negative effect. Even without sporting activity, new or poorly fitting shoes with a heel counter that is too tight can cause the formation of the bone protrusion through direct pressure. In addition, a strong overweight (obesity) can be a particularly large burden on the (deformed) heel bone.

Other triggers include misalignment of the foot and heel bone. A frequent occurrence of the Haglund heel together with a hollow foot (Pes cavus or Pes cavovarus) is known. This mostly congenital deformity is characterized by a particularly high foot span or by a pronounced longitudinal arch. These or other malpositions can cause excessive tensile stress on the tendon plate in the area of ​​the sole of the foot, which is also referred to as plantar fascia (aponeurosis plantaris). In most cases, sole pain indicates such a connection.

Another conceivable cause is a shortened or heavily loaded calf muscles, which results in excessive pulling on the Achilles tendon at the base of the bone or can cause the tendon to twist. It is possible that there is a connection to frequent calf cramps in this connection. In addition, connective tissue layers between the muscles (fascia) can be glued, which in addition to increased tensile stress can also lead to reduced removal of metabolic residues. These excessive stresses and irritants can promote the development of Haglund syndrome.

If one looks at other possible relationships, even more distant tension states, for example in the buttocks, can continue through the muscles and fasciae of the thighs and calves down to the heel and show certain effects there. A sciatic nerve that is pinched elsewhere can also cause complaints on the heel. Those affected with corresponding complaints on the back, buttocks or on the sole of the foot should consider these possible connections when clarifying the cause.

Diagnosis

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

The most important part in the diagnosis is the clinical examination together with the patient survey (anamnesis). Above all, the exact location and description of the symptoms and pain in the heel (and possibly in other parts of the body) is determined.

With the help of a lateral X-ray image of the heel bone, you can usually see the bony changes and hump formation of the Haglund heel. An ultrasound examination (sonography) is then usually used to assess the Achilles tendon. It can be determined whether the tendon and tendon attachment are thickened or a partial rupture is present. Inflammation and swelling of the bursa can also be diagnosed.

In addition to the assessment of soft tissues, magnetic resonance imaging (magnetic resonance imaging, MRI for short) is also often performed using contrast media. This procedure maps possible limescale deposits in the Achilles tendon and bone edema and also allows further information about the stage of the disease. The latter is an important criterion, especially for the choice of treatment.

It is important to distinguish whether it is a Haglund exostosis or other diseases of the Achilles tendon, such as Achilles tendonitis or Achillodynia (Achilles tendon pain). A tendon insufficiency (insertion tendinopathy) and a heel spur must also be excluded. The latter can form at different positions on the heel bone and can even be connected to the Achilles tendon attachment. Anatomically, however, a heel spur in this area is always below the site of a Haglund exostosis. Connections between the different clinical pictures are, however, quite common, which makes it difficult to distinguish them.

Treatment

The goal of the therapy is to relieve the pain and restore the resilience of the foot. In addition to the first so-called conservative therapy, surgery can also be considered in certain cases. In general, the therapeutic measures depend on the stage of the disease.

Conservative therapy

Different approaches to conservative therapy already lead to success in many cases. As a first measure, those affected are advised to wear open shoes as often as possible in order to quickly release pressure on the heel. It is also recommended to use a heel pad or inserts with a heel increase in closed shoes. In the long term, this should prevent pressure from the inside of the shoe on the affected area. An elevated position of the heel also reduces the tensile load that comes from the Achilles tendon.

To relieve the heel bone, ankle bandages can also be used, which compensate for incorrect loads and stimulate the soft tissue, which supports the healing process. In severe cases, immobilization of the foot can also make sense, for example with an orthosis or plaster.

If the pain is too severe despite pressure relief or even in a relaxed state, pain-relieving and anti-inflammatory drugs (e.g. aspirin or ibuprofen) can be used at times. A short-term use of cortisone is usually only considered in particularly severe or complicated cases.

Ill athletes should refrain from running training until the symptoms go away. After that, the training should only be slowly resumed and the scope of training adjusted (reduced).

In addition, various physiotherapeutic treatment methods are used in most cases. One focus is on certain stretching exercises on the entire back of the leg and the foot area. If carried out regularly, this should reduce the tensile load on the tendons and strengthen the foot and calf muscles. Procedures from the field of physical therapy also show very good treatment success. These include, for example, ultrasound therapy and the use of electricity (electrotherapy) as well as the procedure of shock wave therapy for heel pain.

Surgical intervention

If extensive conservative therapy is unsuccessful over several months, permanent overload cannot be counteracted for various reasons, or if it is already very severe, surgical measures are usually required. During a surgical intervention, the outgrowth of bone is removed and, if necessary, inflamed bursae (bursectomy) as well as calcifications on the Achilles tendon are removed. Experience shows better postoperative courses with an indirect removal of the exostosis (in which the soft tissue under the Achilles tendon remains intact) than with a superficial ablation.

Removal of the bony prominence permanently removes the damaging pressure from the Achilles tendon and other compromised tissue parts. After the operation, plaster provides temporary immobilization and good regeneration. After each operation, sporting activity should be avoided for a while and a load should only be slowly rebuilt.

If the Haglund heel is clearly attributable to a misalignment of the foot, adjustment operations on the foot or heel bone (heel bone osteotomy) can also be further treatment options. Individually adapted options are then discussed with those affected.

Naturopathic treatment

In addition to the conservative treatment approaches, naturopathy also offers various options for alleviating the symptoms.

As well-tried, effective home remedies for swelling and pain in the heel (especially after stressful training sessions), cool curd wrap or ice packs can be used for self-therapy.

Transcutaneous electrical nerve stimulation (TENS) offers a special form of electrotherapy, whereby electrical impulses stimulate the body's pain-relieving systems. The application is practically risk-free and can be carried out by those affected themselves.

Homeopathy also offers various means of natural treatment for overwork and pain. A common means of choice for Haglund syndrome is Hekla lava (volcanic ash from the Hekla volcano), which in principle shows a high effectiveness for boring and periodic pain. After (sportive) overuse, Arnica or Ruta graveolens (garden rhombus) is also recommended for external use.

If the affected person is extremely overweight, which then also leads to overloading of the heel, nutritional advice and individual dietary changes can help to reduce body weight and alleviate the symptoms. Other possible causes of complaints on the heel, such as an irritated sciatic nerve or tension in the back or buttocks, can also be remedied using diagnostic and treatment methods of osteopathy. (tf, cs)

Author and source information

This text corresponds to the specifications of the medical literature, medical guidelines and current studies and has been checked by medical doctors.

Dr. rer. nat. Corinna Schultheis

Swell:

  • MVZ Joint Clinic Dres Baum, Schneider & Partner, medical partnership: Haglund heel or Haglund syndrome: heel pain, diagnosis and operative therapy (available: July 8th, 2019), gelenk-doktor.de
  • Dr. med. Thomas Schneider: Haglund Exostosis (Haglund Heel) (accessed: July 8, 2019), gelenk-klinik.de
  • Clinic for General, Trauma and Reconstructive Surgery at the LMU Munich: Haglundferse / Fersensporn (accessed: July 8, 2019), Klinikum.uni-muenchen.de
  • Ruchholtz, Steffen / Wirtz, Dieter Christian: Orthopedics and trauma surgery essentials: Intensive course for further training, Thieme, 3rd edition, 2019
  • Mayo Clinic: Heel pain (accessed: July 8, 2019), mayoclinic.org
  • American Academy of Orthopedic Surgeons: Heel Pain (accessed: July 8, 2019), orthoinfo.aaos.org

ICD codes for this disease: M77ICD codes are internationally valid encodings for medical diagnoses. You can find e.g. in doctor's letters or on disability certificates.


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