Haglund ‘s syndrome, also known as Haglund’s heel, is caused by a bony change (ganglion bone) on the heel bone in the area of the insertion of the Achilles tendon. The name goes back to the Swedish surgeon Patrik Haglund (1870 – 1937). Haglund heel can be extremely painful and can be treated conservatively or surgically.
What is Haglund Syndrome?
Haglund’s heel, a form of heel spur, is recognizable by a bony change on the upper rear (cranial and dorsal) part of the heel bone (calcaneus) in the area of the insertion of the Achilles tendon.
Ossifications on the heel bone can already occur during the growth phase at the growth plate of the bone (epiphyseal plate) or it can be a question of ossification on the heel bone directly in the area of the Achilles tendon attachment (apophysis). Such bone extensions with solid bone substance on the heel bone are also referred to as “Haglund exostosis”.
Disorders of the growth plate only occur in adolescents because the growth plate closes through regular ossification after bone growth is complete. Such disorders in the growth plate of bones are called “iuvenile osteochondrosis “. Both forms of Haglund syndrome can trigger similar symptoms and cannot be distinguished from each other exactly.
Causes
The main causes of Haglund’s heel development are seen in footwear that irritates the tendons or puts direct pressure on one or more of the bones of the foot. For the bone, this can mean an incentive for increased bone formation in the affected area.
Shoes with tight heel cups can cause constant irritation at the insertion of the Achilles tendon during walking and running, marking the beginning of Haglund’s heel development. Excessive running with improper footwear and obesity are other contributing factors in causing Haglund syndrome.
The extent to which genetic dispositions can lead to premature and excessive ossification of the growth plate of the heel bone has not yet been finally clarified. Here, too, non-functional and too tight footwear in children can be considered as the main cause. Congenital or acquired foot deformities can also favor the development of a Haglund heel.
Symptoms, Ailments & Signs
Haglund syndrome is primarily noticeable through stabbing pain in the rear heel bone. The pain occurs when there is weight and pressure on the heel and quickly subsides as soon as the leg is relieved. The pain is very intense at first and decreases with repeated exertion. The pain is strongest in the morning and after a long period of rest.
Externally, Haglund syndrome can be recognized by the conspicuous gait. Those affected usually limp or drag the leg with the affected heel behind them. Sometimes redness occurs on the heel or a visible swelling develops that is painful to the touch. In individual cases, visible ossification can be noticed on the heels or on the upper rear tendon attachment of the heel.
These ossifications are painful when touched and are sometimes associated with swelling and redness. If left untreated, Haglund syndrome will increase in intensity. Avoidance behavior can result in malpositions and joint wear. Some sufferers also suffer from nerve pain that can radiate from the heel to the knee. In individual cases, the Haglund heel causes symptoms of paralysis and sensory disturbances, which those affected find uncomfortable.
Diagnosis & History
The first symptoms that indicate a Haglund heel are externally visible redness, pressure-sensitive areas or even thickening on the rear upper part of the heel bone.
If orthopedic examinations confirm the initial suspicion of Haglund syndrome, imaging diagnostic methods such as ultrasound, X-rays and computer tomography ( CT, MRT, fMRT ) can provide more precise information. Bony formations in particular are clearly visible in the X-ray image. The computed tomography methods also provide meaningful images of the soft tissues, i.e. the condition of ligaments, tendons, muscles, bursae and articular cartilage.
The disease progression of a Haglund heel is very different and ranges from completely painless to very painful and disabling. The symptoms of the disease can develop over a long period of many years, so that emerging symptoms – especially if they are not associated with pain or serious impairment – are ignored and not treated.
Complications
Haglund syndrome is primarily associated with relatively severe pain. This pain has a negative effect on the patient’s everyday life and can thus significantly reduce the quality of life and lead to restricted mobility. Not infrequently, Haglund syndrome also leads to rest pain and thus to sleep disorders in the patient. The skin is reddened by the disease and ossification occurs, which occurs mainly on the patient’s heels.
The pain can also spread to other regions of the body. Due to the movement restrictions, patients often suffer from depression and other mental disorders. In some cases, patients are also dependent on walking aids in order to be able to cope with everyday life. There are no further complications during the treatment itself.
Most complaints can be limited by wearing suitable footwear. In many cases, however, physiotherapy is still necessary. If there is no improvement, surgical interventions are usually necessary. Life expectancy is not affected by Haglund syndrome.
When should you go to the doctor?
Since Haglund syndrome does not heal itself and the syndrome is usually associated with severe pain and limitations in everyday life, medical treatment must take place in any case. The affected person should consult a doctor if reddening of the skin occurs. This redness usually occurs for no particular reason and on different parts of the body. In addition, ossification occurs on the heel, which occurs primarily at a young age.
These become noticeable through pain, which can occur not only as pressure pain, but also as pain at rest. If the child complains of pain in the heel, a doctor must be consulted in any case. Haglund syndrome can usually be diagnosed by a pediatrician or general practitioner . However, further treatment requires the support of a specialist. Early diagnosis increases the chances of a full cure for Haglund syndrome.
Treatment & Therapy
If a diagnosed Haglund syndrome can essentially be traced back to unsuitable footwear, the first measure is to relieve the pressure on the heel area. In addition, special physiotherapy is recommended, which aims to strengthen the leg muscles and relieve the Achilles tendon.
Also worth considering is the use of extracorporeal shock wave therapy, originally developed for kidney stone crushing. Using shock wave therapy, calcium deposits and hardening in the tissue can be “pulverized” particularly well so that they can be removed and flushed out of the body via the lymphatic and bloodstream.
If conservative forms of therapy do not lead to the desired success, two different surgical interventions can be considered. On the one hand, the ossification can be removed directly in a surgical procedure. However, this has the disadvantage that the tendon sheath, which normally allows the tendon to slide without problems, has to be removed in the area where the Achilles tendon attaches. There is a risk that adhesions will form on the tendon postoperatively, which can impair its function.
On the other hand, a surgical procedure has been established that does not touch the area of the Achilles tendon, but separates a wedge from the heel bone a few centimeters further forward, so that the heel bone folds up a little in the area of the Achilles tendon attachment. The spur process is not removed, but if successful, it no longer presses and rubs on the Achilles heel, so that the symptoms improve or even disappear completely.
Outlook & Forecast
The prognosis for Haglund syndrome is usually very good with treatment. However, it is a very time-consuming therapy that is initially started with conservative measures. However, without treatment or after constant strain from the wrong shoes, physical strain on the foot or being overweight, the symptoms can increase considerably. The bony prominence (haglundexostosis) on the heel bone will increase under these conditions because the pressure on the inner edge of the shoe increases when running or walking.
Conservative treatment begins with the provision of orthopedic shoes. With their help, the mechanical stress on the bursa should be reduced and the inflammatory processes stopped as a result. This treatment also includes topical application of anti-inflammatories and injection of corticosteroids into the Achilles tendon. The therapy should show first successes after about 6 months.
If the treatment is unsuccessful, however, an operation is necessary. The bursa (bursa subachillea) and the adjacent bony prominence are usually removed. However, this operation must not be performed on children and adolescents up to the age of 17 because the adjacent growth plates have not yet closed.
After the surgical removal or reduction of the bony prominence, the pressure of the inner edge of the shoe against the heel bone is reduced. This also reduces the pressure on the bursa, the Achilles tendon and the soft tissues. This treatment method usually leads to lasting success.
Prevention
One of the most important steps you can take to prevent Haglund’s heel is to wear appropriate, functional footwear. Especially with children, whose feet are subject to certain growth spurts, attention should be paid to suitable footwear that gives the foot enough space for their development.
Further preventive measures consist of carrying out athletic running training exclusively with running shoes and planning enough stretching exercises. At the first sign of Haglund syndrome, consultation with an orthopedic specialist is recommended.
Aftercare
In the case of Haglund syndrome, the affected person has either very few or even no direct aftercare measures available. First and foremost, the disease must be recognized quickly and, above all, at an early stage, so that there is no further damage or complications to the feet. The affected person should consult a doctor and initiate treatment as soon as the first complaints or symptoms of the disease appear.
The treatment usually takes the form of an operation. The person concerned should rest and rest after such an operation in any case. Efforts or physical activities should be avoided in order not to unnecessarily strain the body. The help and support of one’s own family and friends can also have a positive effect on the recovery of the person concerned.
Physiotherapy is usually necessary after the operation. Many exercises from such a therapy can also be carried out at home to speed up the treatment. Regular check-ups with a doctor are also very useful. Haglund syndrome usually does not have a negative effect on the patient’s life expectancy.
You can do that yourself
With Haglund syndrome, the possibilities for self-help are severely limited. Early diagnosis can prevent further complications and symptoms. However, if Haglund syndrome has already occurred, only therapy or surgery can alleviate the symptoms.
However, the syndrome can be avoided simply by ensuring that children always wear appropriate footwear. This is especially true during growth spurts. The feet must not be crushed and must have enough free space. Furthermore, sports activities should always be carried out in running shoes or sports shoes. This can also prevent the syndrome.
Should the syndrome occur, unnecessary stress on the feet should be avoided at all costs. At the first signs of the disease, an orthopedist should be consulted immediately, who can diagnose and treat the disease.
Children should always be informed about the possible complications and risks of Haglund syndrome in order to avoid open questions and possible psychological problems. As a rule, the disease can be treated relatively well with surgery, so that there are no further restrictions in the child’s development.
