Have you been told that you have a Haglund's Deformity or heel spur that is causing the pain in your Achilles tendon or at the back of your heel? In this article, Maryke explains why you do not have to pay too much attention to the fact that you have a Haglund's Deformity and how the right physiotherapy treatment programme could get you pain-free and up-and-running again without having to go under the knife for that bony prominence in the back of your heel.
I've also discussed it in detail here:
Misconceptions about Haglund's Deformity
In the X-ray image below, there are two bony prominences. The top arrow points to the Haglund's Deformity and the bottom one to calcification – little bony bits – in the Achilles tendon where it is attached to the heel bone.
So how does the diagnosis of Haglund's normally happen? You develop pain in the back of your heel, and you go to the doctor. They do an X-ray, and it comes back like in the picture. Then, the doctor says, "Hmm, you've got a Haglund's Deformity. That’s the cause of your pain."
Well, not really. That bony bit on its own is not painful. It is just how your bone is shaped and it does not cause pain as such. If you look at an MRI scan, the pain you feel in the back of your heel is usually either coming from the Achilles tendon – insertional tendinopathy – or the bursa behind the tendon, which can develop a bursitis when it becomes inflamed and painful. You can have either or both of those.
Why am I saying that the Haglund's Deformity is not necessarily the cause of that pain? When you run or walk, your Achilles tendon pulls tight over your heel bone when your foot moves in dorsiflexion. This is normal and happens to all of us. The bursa is a little sac of fluid that is meant to decrease the friction between the tendon and the bone, and that is also normal.
Why some people say that Haglund's Deformity can cause pain is because it can decrease the space in the back of the heel so that the Achilles tendon and bursa are compressed more as it moves over the bone. However, here is why I say that the Haglund’s Deformity is not necessarily the cause of your insertional Achilles tendinopathy and/or your bursitis, and the latest research backs me up:
Many people who are diagnosed with a Haglund's Deformity have it in both feet, but their Achilles or bursitis pain is only in one foot.
Haglund's Deformity is not something that forms overnight or in a week or in a month. It would have been there for years and years without causing trouble before one fine day you suddenly developed heel pain.
Lastly, there are many people with insertional tendinopathy plus bursitis – remember these are the structures that are actually painful – who do not have a Haglund's Deformity.
The real cause of your heel pain
So, if Haglund’s Deformity (if you have it) is not the cause of your heel pain, what is? It is a classic case of overload. Your Achilles tendon as well as your bursa are used to handling a certain amount of compression load, and the body is brilliant at building these structures up to cope with that for your usual walking and running. However, if for some reason you make a sudden change in your habits and you massively increase the amount of compression, it will become too much, because you have not given your body time to slowly build up to that point, and that is when it flares up.
What type of activities can overload your insertional Achilles tendon and/or bursa so that they suddenly go, "Whoa this is much more compression than I'm used to"?
A classic example that I often see with non-runners as well as with runners is when they suddenly change from wearing shoes with a bit of a heel to flat shoes or no shoes.
It can be when you go from winter shoes to summer shoes, like flip-flops, or to walking barefoot a lot. Because of the increased dorsiflexion, with your heel now flat on the ground, the compression of the Achilles tendon and the bursa on the heel bone increases. In runners it's often when they change from regular running shoes with quite a bit of a drop from the heel to the toe to, for instance, flat minimalist shoes.
Another common cause could be if you do a lot of walking/running on the flat and then suddenly you add a lot of hill walking/running. When you walk/run uphill, again, you increase the dorsiflexion angle compared to when you walk/run on the flat, and that pulls your Achilles tendon tighter over your heel bone, increasing the compression.
So, yes, the Haglund's Deformity decreases the space in your heel, and it may predispose you to being more sensitive to increased compression over the heel bone, but it is that sudden increase in compression loads that has actually caused your pain.
In all the above cases, if you make that switch slowly and you build up to it, your body has time to adapt the necessary structures to cope with the load increase.
How do I get it better?
Is surgery to remove that Haglund's Deformity the solution? If you have read up to here, I hope you will realise that the answer is mostly “no”. The answer lies in treating the bits that are actually causing the pain.
Because it is excessive compression when the foot goes into dorsiflexion that is causing the irritation in the Achilles tendon as well as in the bursa, we want to offload it – decrease that compression for a while. So, for a short time, we may get you to wear only shoes with a bit of a heel on it, such as most types of regular trainers, to decrease the dorsiflexion of the feet. An alternative is a heel insert for your shoes. That may mean that, for a while, you have to wear shoes even around the house, until the pain has calmed down. If you are into exercises such as doing squats in the gym, which increases the dorsiflexion, we would get you to raise your heels by, for example, putting a plate under them. How long this takes will depend on factors such as how sensitive your heel is and for how long it has been irritated.
Offloading also involves not stretching your calf and your Achilles into dorsiflexion. I was really shocked when I searched online for Haglund's Deformity to look for pictures for this article and found many articles by people who claim to know how to treat this, telling their readers to do calf stretches or to put a band around their foot to pull it towards them into dorsiflexion. If you are going to stretch your foot like that, it will only increase the compression, increase the load on those structures that are sensitive, and will be like poking a bruise repeatedly. Your pain will just escalate. So please, if you are doing calf stretches for an insertional tendinopathy or bursitis or Haglund's Deformity which you have been told is causing the pain, just stop. It is one of the best things you can do.
If there is a bursitis involved, then using a short course – no more than five to ten days – of anti-inflammatories may be useful to calm it down quicker, but remember to check with your doctor before taking any medication; there may be reasons why you should not take them. If a bursitis is really persistent and does not want to calm down, there are certain injections that can be useful for it, but only as a last resort. Usually, for bursitis, they will inject corticosteroid. However, the bursa is really close to the Achilles tendon and there will be a little bit of corticosteroid that spreads to the tendon and that is not good for the tendon. So, the injection is a last resort if the bursa does not want to calm down.
Anti-inflammatories do not help for tendinopathies. We know from the research that tendinopathies do not really have a massive inflammatory component to them, so do not take it just for healing a tendinopathy.
Usually, we find that neither anti-inflammatories nor an injection is necessary if we can offload the compression of the tendon with the shoe/orthotic treatment that I described above.
Once the acute pain has settled down, we need to start loading things up gently to strengthen your Achilles tendon. But the exercises have to be done in a way that they don't cause too much compression around the heel. We may opt for something like isometrics, where you just hold the heel raise in one position, or doing your heel raises from floor level.
Only once your heel has calmed down significantly should you start introducing exercises that involve more dorsiflexion e.g. heel raises over the side of a step.
Of course, this treatment will not work for 100% of people, and there are some cases that eventually go on to surgery and do well with surgery. It could be that your Haglund's Deformity is just so severe and so big that it does poke directly on that tendon, and because of the shape of your foot it just does not get to a position where this does not happen. In those cases, it may be useful to shave that piece of bone removed.
Another reason why a conservative treatment of offload-and-rehab may not work, is that you have neglected the injury for too long. If you have been annoying it for months on end and did not follow the right treatment advice, the bursa may be so thickened and there is just no way that it can be offloaded or made to be happy to carry bigger loads again. In those cases, taking the bursa out can be a solution.
However, I often find that people do not offload the tendon for long enough and do not give it enough time to recover and calm down. Insertional Achilles tendinopathy is not a situation where you can go, "Oh I offloaded it for a week or two and now it's still not getting better." Achilles tendinopathy and bursitis take at least three months to show good improvement. And then it can take several more months to get back to where you want to be.
Now, that may sound long, but recovery from surgery is going to take just as long. So please do not see surgery as a short-term solution. I work with patients who, a year after surgery for this, are not much better than before the surgery. Then again, I do have other patients who are massively better, so do not take this as, "Surgery is always a bad thing." It is just about making sure that you follow the guidelines properly before you decide to go on to surgery.
Alternatives to surgery
Also, there are other options to consider before surgery.
If offload-and-rehab has not worked, consider shockwave, especially for an insertional tendinopathy. I have had good results with patients when the injury has not reacted to other treatments.
Getting an injection is another option. Platelet-rich plasma (PRP) injections do not seem to work that well, judging by the available evidence – I do not think they have figured it out properly yet. Bursitis seems to react well to corticosteroid, but note my concerns above. I would not go for steroid injections into the Achilles tendon; in my book that is a little bit irresponsible because it does predispose you to Achilles tears. There are also high-volume injections to consider, as well as other experimental ones coming onto the market. If the risk is low with an injection, always try that first before you go on to surgery.
Need more help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.
About the Author
Tu, P. (2018). "Heel pain: diagnosis and management." American family physician 97.