Haglund's disease: notes on clinical diagnosis and surgical technique

Foot and Ankle Surgery 1997

3: 175–181

Haglund’s disease: notes on clinical diagnosis and surgical technique F. SERGIO 32 P.zza Carita, Naples, Italy

Summary After a careful review of the clinical, anatomical and radiological aspects of Haglund’s disease it is concluded that, although conservative treatment must always be employed first in order to reduce pain, limit injury to the Achilles tendon and reduce the inflammatory process, surgery is often necessary. The osteotomy is started at the superior margin of the insertion of the Achilles tendon. Attention must be given to the postoperative treatment of the scar. Keywords: Haglund’s disease, postero-superior edge, resection, conservative treatment, ‘fatidical value 0’

Introduction Haglund’s syndrome is a clinically important morphological alteration of the postero-superior edge of the greater tuberosity of the calcaneus, associated with painful swelling of the local soft tissue (the socalled ‘pump bump’). The anatomic contour of the calcaneal tuberosity is normally rounded off; in this zone there is a smooth area, known as the superior calcaneal prominence, situated in the upper third of the calcaneus, bounded on the upper side by the bursal projection. From a biomechanical point of view it represents the lever arm of the Achilles tendon and gives the triceps a mechanical advantage. Furthermore, it stabilizes the lateral column of the foot during the steady phase of gait. Jakobstal [1], Haglund [2] and Saxl [3] described the clinical condition of a retrocalcaneal bursitis, correlated to different shapes of the calcaneus and to wearing rigid shoes with low heels and low posterior shoe counter, thus differentiating it from the syndrome called achillodynia. Heneghen and Pavlov noted that a calcaneus which was not rounded but pointed and

Correspondence: F. Sergio, 32 P.zza Carita, Naples, Italy.  1997 Blackwell Science Ltd

sharpened – described as ‘prow-shaped calcaneus’ – predisposed the Achilles tendon and the surrounding soft tissue to compression against the posterior shoe counter causing a subsequent irritation [4]. Nisbett [5] in 1954 coined the word ‘winter heel’, since this condition is worsened by low temperature and by closed shoes during the winter [6]. The condition, which is prevelant in youth, is characterized by the occurrence of a shooting pain in the hindfoot when walking because of the repeated micro-injury to the tendon and to the soft tissues, due to the combined action of the posterior aspect of the calcaneus, which act ‘between the anvil and the hammer’ [7]. The soft tissue which covers the exostosis reacts with cutaneous hyperkeratosis and a superficial mucous bursa forms; this later changes, because of the ongoing friction, into an hygroma, with subsequent worsening of symptoms [8]. Various aetiopathogenetic theories have been put forward. 1. Dysplastic theory: according to some authors this disorder is due to dysplasia of the calcaneus, as one can infer from the radiographic evidence of onset during early youth that such a disorder is common.

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2. Rheumatic theory: this theory is supported both by the increase of the values of AST, esr and CRP in some patients affected from this disease and by the occurrence of this disorder in patients suffering from gout, rheumatoid arthritis [9], ankylosing spondylitis [6] and Reiter’s syndrome [10]. 3. Microtraumatic theory: characterized firstly by a sclerotic and then osteogenetic reaction because of the repeated stress due to the contraction of the triceps and plantar muscular system [8]. The radiographic warning of such pathological process is the loss of radiolucency in this area. 4. Pes cavus: due to tendency to verticalize the calcaneus inducing indirectly a prominent posterosuperior angle [4, 11–13]. 5. Plantar bone prominences: Heneghen and Pavlov [4] demonstrated by means of an experimental model that prominences situated on the medial tuberosity negatively influence the bone/soft tissue relation since they increase the inclination angle and displace the calcaneus posteriorly. This can convert negative parallel pitch lines (PPL) into a positive PPL effectively creating a protrusion of the bursal prominence. The disease affects mostly females and the young between 12 and 20 years of age, 6–45 years of age representing the upper and lower average age limits. The disorder is sometimes present during childhood but the clinical onset usually occurs later. A typical characteristic of the exostoses is the discrepancy between the radiographic finding and the clinical manifestation. Sometimes local symptoms are present although radiographs show no evidence of the disorder, especially in the young; sometimes although there is bilateral radiographic evidence of the disorder the trouble is felt in one foot only [14]. The diagnosis is based on medical history and physical examination, observing and palpating the patient, and above all by the careful examination of the changes of radiographic parameters [8], Steffensen-Evensen’s angle [15], Fowler-Philips’ angle [16], ‘Pitch-angle’ [13] and ‘Parallel Pitch Lines’ [10] (Figure 1). The identification of the site, of the characteristics of the pain and of the modifications of the aforementioned parameters allow an accurate differential diagnosis with:

Fow

lerPh angilip le

Pitch angle PPL

2

Ste

ff.-E

ven

. an

gle

PPL

1

Figure 1 Schematic presentation of radiographic measurements.

1. Calcaneal apophysis: (age of onset from 15 to 20 years of age). In this disorder alterations of the soft tissue are absent and the pressure-pain is stronger laterally and plantarly. 2. Posterior calcaneal spurs: 5–10-mm formations situated at the insertion of the Achilles tendon ‘inferior exostosis’, such formations are anatomically and radiographically differently located, from Haglund’s exostosis [8]. 3. Pre-Achilleal bursitis: the clinical manifestation is characterized by pain upon physical examination and by a swelling of the heel. This swelling is different from that of Haglund’s syndrome because it is not posterior but lateral, it appears on both sides of the tendon resembling a rucksack. If one palpates it one finds a little eminence on both sides of the swollen zone. The puncture of the swelling confirms the diagnosis and is at the same time therapeutically efficacious, without being prejudicial to eventual relapses [7]. 4. Lelievre postero-external exostosis: this is situated on the external surface of calcaneal tuberosity; the diameter averages 10–15 mm. It is diagnosed with the calcaneal axial radiographic projection. The lateral radiograph alone does not permit diagnosis; some authors have defined this disorder as ‘lateral calcaneal tuberosity hypertrophy’ [8]. 5. Gouty tophi: from a clinical point of view these can be deceptive, but radiography and laboratory findings allow an exact differential diagnosis.

Materials and methods Twenty-eight patients (51 heels – 23 patients showed bilateral symptoms) affected by Haglund’s syndrome  1997 Blackwell Science Ltd, Foot and Ankle Surgery, 3, 175–181

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Table 1 Preoperative data on 28 patients (51 heels) Pain

Heels (%)

‘Pump bump’

Ability to wear shoes

Severe

Moderate

Light

Present

Absent

Able

Unable

94

6

0

100

0

4

96

(19 females and nine males, between 15 and 49 years of age) were surgically treated between February 1994 and July 1996 at the Third Orthopaedic and Traumatological Department of the Orthopaedic and Traumatological Centre of Naples (CTO). Follow-up extended from 11 months to 40 months. After the recording of medical history, physical examination and laboratory investigations, all patients underwent the following radiographic measurements (Figure 1). 1. Steffensen’s and Evensen’s angle: formed between two lines, one passing through the deepest point of the sinus tarsi and the upper part of the insertion of the Achilles tendon, the other one passing through the aforementioned insertion of the Achilles tendon and the hindmost point on the tuber calcanei. 2. The posterior calcaneal angle of Fowler and Philip: formed between two lines, one tangent to the anterior tuber and the medial tuberosity, the other one tangent to the posterior aspect of the bursal process and the posterior prominence. The process is considered pronounced if the angle is greater than 75°. 3. The Parallel Pitch Lines (PPL): the lower PPL (PPL1) is drawn passing through the anterior tuber and the medial tuberosity, and the upper PPL (PPL2) passes through the posterior rim of the posterior articular facet which is parallel to the lower one (the bursal prominence is pronounced if it extends beyond the PPL2). 4. The Pitch angle: formed by the intersection of the lower line of the ‘Fowler and Philip angle’ with the horizontal (normal value: 25°). Remarkable morphological alterations were found in all the patients treated indicated by the changes of average values of the angular measurements (Tables 1–4). In two patients, aged 28 and 36 years respectively, we recorded a bilateral association of Haglund’s disease with exostosis situated at the back  1997 Blackwell Science Ltd, Foot and Ankle Surgery, 3, 175–181

of the calcaneus (Figure 2). This exostosis was clinically characterized by dull persistent pain at the point of insertion of the Achilles tendon. All the patients had been non-surgically treated before undergoing surgery, in order to eliminate or to reduce the aggressive factors by means of the following therapeutic methods: 1. By modifying the type of shoe worn, e.g. by making the shoe-heels some centimetres higher in order to relieve tension on the Achilles tendon, and by using shoes which were larger or which were open at the back. 2. By treating the patient with anti-inflammatory drugs and applying local anaesthetic or corticosteroidal solutions in order to reduce the hygroma. 3. By using ultrasound therapy and analgic electrotherapy or by electromagnetic fixed therapy. However, these kinds of therapies have been proved to only address the symptoms and, therefore, to provide only temporary relief.. The treatment offered at the CTO consisted of the excision of the postero-superior aspect of the calcaneus [6, 9, 16–20] by a cutaneous para-Achilleal medial incision in the dimple situated anterior to the Achilles tendon [21]. The operation was performed bilaterally in 13 patients during the same operating session. It is advisable after the operation, in addition to the normal medications, to also apply corticosteroidal preparations associated with keratolytic compounds and deep de´collement-massage [22]. Partial weight-bearing with functional bandage and the foot slightly plantarly flexed lightly touching the floor was allowed approximately on the 5th day. Assisted weight-bearing was allowed on the 20th day, and total weight-bearing on the 30th day.

Surgical procedure This operation is performed with the patient in the supine position with a pillow placed underneath the

F–P: Fowler–Philip Angle; S–E: Steffensen–Evensen Angle; P: Pitch Angle; PPL: Parallel Pitch Lines; Q: Distance between the superior point of the insertion of the tendon and the upper point of the eventual remnant of calcaneal exostosis; SD: Standard Deviation; POS: Heels with degree positive; TOT: total heels.

3.65 28.39 mm 82.5 6.57 29.84° 33.38° 66.5

82.38°

2.78

74.84° 11.20

60.8

68.03°

2.91

63.56°

6.19

70.5

3.65

Heels Mean POS Height 42 (%) (23 mm–34 mm) SD Mean SD POS Degree TOT TOT (15°–40°)

Mean Degree POS (28°–40°) Heels POS 36 (%) SD Mean SD POS Degree TOT TOT (54°–74°)

Mean Degree POS (77°–88°) Heels POS 34 (%)

F–P

SD Mean SD POS Degree TOT TOT (53°–88°)

Heels POS 31 (%)

Mean Degree POS (63°–74°)

S–E

P

PPL

Q

SD

F. SERGIO

Table 2 Preoperative radiographic parameters of 28 patients (51 heels)

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hip of the opposite side. The limb is externally rotated and the knee is flexed. After a medial para-achilleal incision in the dimple situated anterior to the Achilles tendon and after introducing two Hohmann’s levers the posterosuperior aspect of the calcaneus is exposed. The foot is maximally flexed in order to obtain good exposure during the operation. The Achilles tendon is dislocated backwards with careful attention paid to the protection of its superior insertion. The osteotomy is performed without elevating the periosteum, by means of a large osteotome or an electric saw, immediately above the superior point of insertion of the tendon [23]. The excision-plane must be slightly posteroanteriorly oblique; the bursal prominence is excised and completely removed en bloc. The excision rims must then be smoothed in order to avoid the occurrence of sharp edges. The wound is then sutured by applying a small vacuum drain-tube. An intracutaneous skin suture is used. Finally, an elastic compressive bandage is applied to the foot.

Results The clinical and radiographic review of the surgically treated patients was performed by means of a followup study which extended from 11 months to 40 months (Figures 2 & 3). Clinical assessment was performed by considering the following parameters: pain, motion and function; and the radiographic assessment was based on the same measurements which were used prior to the operation. Furthermore, we evaluated the magnitude of the bone resection by calculating the distance (Q) between the superior point of the insertion of the tendon (which can be recognized by a cortical sclerosis) and the upper point of the eventual remnant of the calcaneal exostosis [23]. The best results were found in those cases where the distance was close to 0. On the basis of these parameters we found the following results: 16 patients with 32 calcanei (16 bilateral) had perfectly healed both clinically and radiographically; nine patients with 14 calcanei (five bilateral) complained of occasional pain; and three patients with five calcanei (two bilateral) didn’t find any relief after the surgical treatment (Table 3). As for the postoperative complications, no dehiscence was found, nor infection of the wound,  1997 Blackwell Science Ltd, Foot and Ankle Surgery, 3, 175–181

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Table 3 Postoperative data on 28 patients (51 heels)

Pain

Heels (%)

Ability to wear shoes

Absent

Improved

No change

Able

Unable

62.8

27.4

9.8

90.2

9.8

Table 4 Postoperative radiographic parameters of 28 patients (51 heels) F–P Mean degree (26°–70°) 40.66°

S–E SD

11.29

P

Mean degree (54°–74°)

SD

63.56°

6.19

PPL

Q

Mean degree (15°–40°)

(%) Pos

Average height (0 mm–18 mm)

SD

Tot

29.84°

6.57

9.8

4.01 mm

4.54

SD

F–P: Fowler–Philip Angle; S–E: Steffensen–Evensen Angle; P: Pitch Angle; PPL: Parallel Pitch Lines; Q: Distance between the superior point of the insertion of the tendon and the upper point of the eventual remnant of calcaneal exostosis; SD: Standard Deviation; POS: Heels with degree positive; TOT: total heels.

sensitive alteration, or pain in the scar. In the three patients who didn’t find any relief with the surgical treatment the excision was found to be incomplete.

Discussion

Figure 2 (a) Preoperative lateral radiograph: Haglund’s exostosis with retro-calcaneal exostosis. (b) Radiographic follow-up 6 months postoperatively demonstrating resection of exostosis.  1997 Blackwell Science Ltd, Foot and Ankle Surgery, 3, 175–181

Haglund’s calcaneus is a necessary, but not the only, condition to determine a clinical syndrome [24]. In fact, on the basis of clinical evidence, one can distinguish a symptomless phase, where the exostosis is occasionally present on the radiograph, and a characteristic symptomatic phase [8] which is always bilateral with volumetric and monolateral prevalence of symptoms. Experience has shown that the best radiographic parameters, which show the exostosis, are the ‘parallel Pitch lines’. The procedure used at CTO is the excision of the postero-superior aspect of the calcaneus since the authors believe that the closing wedge osteotomy described by Zadeck [25] is an excessive procedure which requires a long period of immobilization [26–28]. A medial para-achilleal cutaneous incision is performed [21] in the dimple situated anterior to the Achilles tendon as this approach, besides offering a clear view, avoids the formation of secondary neuromas if the terminal branches of peroneal nerve are perhaps damaged (which is a risk inherent in the lateral approach [22]). The transverse incision does not offer a clear view and access and can also cause

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a painful swelling around the zone of insertion of the tendon [23]. The excision plane must be slightly posteroanteriorly oblique. If it inclines too much when the foot is extended there will be friction between the tendon and the rough and uneven bone surface which causes a persistent achillodynia. This disappears when one wears high-heeled shoes [23]. One must take good care that the scar does not touch the upper edge of the shoe counter, and that it is not situated directly over the tendon. All the patients received an intracutaneous skin suture so that the remaining small scar would not give any trouble. Finally, it is advisable after the operation, in addition to the normal medications, to also apply corticosteroidal preparations associated with keratolytic compounds and deep de´collementmassage [22]. In conclusion, the authors believe that non-surgical treatment must always be chosen in order to suppress and limit the aggressive inflammatory processes, but the final solution is only obtainable by means of surgical treatment. The osteotomy is started at the superior border of insertion of the tendon, paying attention to the postoperative treatment of the scar.

Reference

Figure 3 (a) Preoperative lateral radiograph. (b) Radiographic follow-up 10 months postoperatively.

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