Haglund's (Chronic Achilles Tendonitis) Repair

A Haglund's deformity refers to a prominence on the posterior heelbone (also known as the calcaneus).  The area of enlargement consists of abnormal bone growth and is called an enthesophyte (bone spur) or exostosis, which is a result of chronic inflammation where the Achilles tendon inserts into the bone.  The inflammation can lead to swelling of the retrocalcaneal bursa and persistent pain.  It has been referred to as a "pump bump" because of the propensity to develop in women who frequently wear high-heeled or hard-backed shoes.  

Anatomy

The Achilles tendon is a long, thick band of tissue that lies directly beneath the skin and connects the calf muscles to the heel bone. 

Cause

The Achilles tendon is designed to absorb the high stresses and strains we place on our foot/ankle when walking, running, and doing other activities like playing sports. But, sometimes, too much pressure damages or tears the tissues. The body's natural response to injury is inflammation, which results in persistent heel pain and swelling of the retrocalcaneal bursae.

Risk Factors

In most cases, chronic Achilles tendinosis develops without a specific, identifiable reason. There are, however, many factors that can make you more prone to the condition:

• New or increased activity
• Repetitive high impact activity (running/dancing/sports)
• Prolonged standing on hard surfaces (especially among nurses, factory workers, and teachers)
• Anatomy (flat feet or a high arch)
• Tight calf muscles
• Obesity
• Age
• Improper shoe wear 

Symptoms

The most common symptoms of chronic Achilles tendonitis include:

• Pain on the back of the foot near the heel.
• Pain with the first few steps after getting out of bed in the morning, or after a long period of rest, such as after a long car ride. The pain can subside after a few minutes of walking
• Greater pain during/after exercise or activity.

Doctor Examination

After you describe your symptoms and discuss your concerns, your doctor will examine your foo and ankle. They will look for these signs:

• A high arch or flat foot
• An area of maximum tenderness on the posterior heel bone
• Limited dorsiflexion, or "up" motion, in your ankle
• The absence of symptoms from other conditions, such as plantar fasciitis or plantar nerve entrapment

Tests

Your doctor may order imaging tests to help make sure your heel pain is not caused by another problem.

X-rays

X-rays provide clear images of bones. They are useful in ruling out other causes of heel pain, such as fractures or arthritis.

Heel spurs can be seen on an X-ray. A heel spur can be the result of longstanding tension on the Achilles insertion (the spot on the heel bone where the tendon attaches). However, some people who have bone spurs on their heels do not have pain. 

Other Imaging Tests

Other imaging tests, such as magnetic resonance imaging (MRI) and ultrasound, are not routinely used to diagnose chronic achilles tendonitis. They are rarely ordered.

An MRI scan may be used if the heel pain is not relieved by initial treatment methods or if your doctor is concerned that a different problem is causing your pain.

Treatment

Nonsurgical Treatment

Rest. Decreasing or even stopping the activities that make the pain worse is the first step in reducing the pain. You may need to stop athletic activities where your feet pound on hard surfaces (for example, running, dancing, or step aerobics). Your provider may recommend that you use a walking boot and crutches for a short period of time to allow your foot to rest.

Changing your activity. Low impact exercise, such as cycling or swimming, puts less stress on your joints and feet than walking or running.

Stretching. Achilles tendonitis is aggravated by tight muscles in your feet and calves. Stretching your calves and plantar fascia is the most effective way to relieve the pain that comes with this condition.

•   Calf stretch
  Lean forward against a wall with one knee straight and the heel on the ground. Place the other leg in front, with the knee bent. To stretch the calf muscles and the heel cord, push your hips toward the wall in a controlled fashion. Hold the position for 10 seconds and relax. Repeat this exercise 20 times for each foot. A strong pull in the calf should be felt during the stretch.
• Plantar fascia stretch
  This stretch is performed in the seated position. Cross your affected foot over the knee of your other leg. Grasp the toes of your painful foot and slowly pull them toward you in a controlled fashion. If it is difficult to reach your foot, wrap a towel around your big toe to help pull your toes toward you. Place your other hand along the plantar fascia. The fascia should feel like a tight band along the bottom of your foot when stretched. Hold the stretch for 10 seconds. Repeat it 20 times for each foot. This exercise is best done in the morning before standing or walking.

Nonsteroidal anti-inflammatory drugs (NSAIDs). Medications such as ibuprofen or naproxen reduce pain and inflammation. Using the medication for more than 1 month should be reviewed with your primary care doctor.

Physical therapy. Your doctor may suggest that you work with a physical therapist on an exercise program that focuses on stretching your calf muscles and plantar fascia. In addition to exercises, a physical therapy program may involve specialized ice treatments, massage, and other therapies to decrease inflammation around the calf/Achilles.

Supportive shoes and orthotics. Shoes with thick soles and extra cushioning can reduce pain with standing and walking. As you step and your heel strikes the ground, a significant amount of tension is placed on the fascia, which causes microtrauma (tiny tears in the tissue). A cushioned shoe or insert reduces this tension and the microtrauma that occurs with every step. Soft silicone heel pads are inexpensive and work by elevating and cushioning your heel. Pre-made or custom orthotics (shoe inserts) are also helpful.  Soft heel pads can provide extra support.  Avoid unsupportive and worn-out shoes. Make sure to replace your old athletic shoes before they wear out and no longer support your feet. 

Night splints. Most people sleep with their feet pointed down. This relaxes the achilles tendon and is one of the reasons for morning heel pain. A night splint stretches the foot and ankle while you sleep. Although it can be difficult to get used to, a night splint is very effective at reducing heel pain.

Other Treatments

Your healthcare provider may recommend the following procedures if you remain symptomatic after several months of conservative treatments.

Casting. Wearing a cast for a short period of time can be extremely helpful in the treatment of chronic Achilles tendonitis because it provides an immobilized (no movement) environment for healing. Since a cast is custom-molded to your foot and cannot be removed, it is often a better option than boot immobilization.

Cortisone injections are generally not recommended as they can increase the risk of Achilles tendon rupture

Platelet-rich plasma (PRP) injections. PRP is obtained from your own blood and can be injected into the Achilles tendon fascia to promote healing. PRP injections do not have the same risk of leading to rupture. However, this treatment can be expensive, and more research is needed on the effectiveness of PRP injections.

Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged tissue. ESWT has not shown consistent results and, therefore, is not commonly performed.

ESWT is noninvasive — it does not require a surgical incision. Because of the minimal risk involved, ESWT is sometimes tried before surgery is considered.

Ultrasonic tissue repair. This is a minimally invasive treatment for patients with persistent (ongoing) pain.  The tip of the probe then vibrates to break up and remove damaged tissue.

Surgical Treatment

Surgery is generally reserved for people who have not seen improvement after 12 months of aggressive nonsurgical treatment.

• Complications. The most common complications of release surgery include incomplete relief of pain and nerve damage.
• Recovery. A short period of protected weightbearing is recommended after surgery to allow the incision to heal.

Most patients have good results with surgery. However, because surgery can result in chronic pain and dissatisfaction, it is recommended only after all nonsurgical measures have been exhausted.