What are the options for non-surgical management of Haglund's deformity?

Non-Surgical Management of Haglund's Deformity

Initial treatment of Haglund's deformity should include open-backed shoes, orthoses, accommodative padding, NSAIDs, weight loss if indicated, and physical therapy, with corticosteroid injections into the bursa (avoiding the Achilles tendon) reserved for refractory cases. 1

First-Line Conservative Measures (0-6 weeks)

The American College of Foot and Ankle Surgeons provides clear guidance for managing bursitis associated with Haglund's deformity, which forms the foundation of treatment:

Footwear Modifications

• Open-backed shoes are essential to eliminate direct pressure on the posterolateral prominence 1
• Avoid rigid, closed-heel footwear that aggravates the bony prominence 2, 3
• Consider heel lifts or orthoses to alter biomechanics and reduce Achilles tension 1, 2

Padding and Orthotic Support

• Accommodative padding around the prominence protects the inflamed bursa from shoe pressure 1
• Custom orthoses may be beneficial for redistributing pressure 1

Medical Management

• NSAIDs for pain and inflammation control 1, 2, 3
• Weight loss if indicated to reduce mechanical stress 1

Physical Therapy

• Stretching exercises targeting the Achilles tendon to reduce tension on the posterior calcaneus 2, 3
• Activity modification to avoid aggravating movements 1

Second-Line Treatment (6-8 weeks if no improvement)

If symptoms persist after 6-8 weeks of initial conservative management:

Corticosteroid Injections

• Bursa injection may be considered, but must carefully avoid the Achilles tendon itself 1
• This is a critical caveat: direct Achilles tendon injection is contraindicated due to rupture risk 1

Immobilization

• Immobilization cast or fixed-ankle walker-type device for particularly acute or refractory cases 1
• This reduces mechanical stress while allowing healing of inflamed tissues 1

Specialist Referral Timing

Refer to a podiatric foot and ankle surgeon if symptoms do not improve within 6-8 weeks of appropriate conservative treatment 1. At this point, other diagnoses should be considered and surgical options may be discussed 1.

Clinical Pearls and Pitfalls

Key Diagnostic Features

• Pain is typically relieved when walking barefoot (distinguishing feature) 1
• Tenderness is present lateral to the Achilles tendon in association with posterolateral prominence 1
• Most common in women aged 20-30 years, though can occur in both sexes at any age 1
• Often bilateral presentation 2

Critical Contraindication

Never inject corticosteroids directly into or near the Achilles tendon - this significantly increases rupture risk 1. Bursal injections must be performed with careful technique to avoid tendon involvement.

Conservative Treatment Success Rate

Approximately 65% of patients fail conservative management after an average of 62 weeks and ultimately require surgical intervention 4. This underscores the importance of appropriate patient counseling about realistic expectations and the potential need for surgery if conservative measures fail 4.

Pathophysiology Considerations

The condition involves a prominent posterosuperior calcaneal exostosis with associated retrocalcaneal bursitis and often Achilles tendinitis 2, 3. A tight Achilles tendon, high arch foot, and hereditary factors are probable contributing causes 2.