Management of Haglund's Deformity
Start with open-backed shoes, heel lifts, accommodative padding, NSAIDs, and physical therapy as first-line treatment, reserving bursal corticosteroid injections for refractory cases only, and refer to a foot and ankle surgeon if symptoms persist beyond 6-8 weeks of conservative management. 1
First-Line Conservative Treatment
The American College of Foot and Ankle Surgeons establishes a clear initial treatment protocol that should be implemented simultaneously 1:
- Immediately switch to open-backed shoes to eliminate direct pressure on the posterolateral calcaneal prominence 1
- Apply heel lifts or orthoses to alter Achilles tendon biomechanics and reduce tension 1
- Use accommodative padding around the bony prominence to protect the inflamed retrocalcaneal bursa from shoe pressure 1
- Prescribe NSAIDs for pain and inflammation control 1
- Recommend weight loss if the patient is overweight to reduce mechanical stress on the heel 1
- Modify activities that aggravate symptoms, particularly those involving rigid-heeled footwear 1
- Initiate physical therapy focusing on Achilles stretching and strengthening 1
Clinical Recognition Features
Pain characteristically improves when walking barefoot, which distinguishes Haglund's deformity from other posterior heel pathology 1. Tenderness localizes lateral to the Achilles tendon in association with the posterosuperior calcaneal prominence 1. The condition most commonly affects women aged 20-30 years, though it occurs in both sexes at any age 1, 2.
Second-Line Treatment for Refractory Cases
If initial conservative measures fail after several weeks 1:
- Consider retrocalcaneal bursa injection with corticosteroid, but exercise extreme caution to avoid the Achilles tendon itself 1
- Never inject directly into or near the Achilles tendon due to significant rupture risk 1
- Apply immobilization with a cast or fixed-ankle walker boot for particularly acute or refractory inflammation 1
- Immobilization reduces mechanical stress while allowing inflamed tissues to heal 1
Timing of Surgical Referral
Refer to a podiatric foot and ankle surgeon if symptoms do not improve within 6-8 weeks of appropriate conservative treatment 1. Surgical options include endoscopic or open resection of the posterosuperior calcaneal prominence, retrocalcaneal bursectomy, and debridement of any Achilles tendinopathy 3, 4. Endoscopic techniques offer lower morbidity and faster recovery compared to open procedures 4, though patients should understand that even after successful surgery, residual pain may persist for 6 months to 2 years before complete resolution 5.
Critical Pitfalls to Avoid
The most dangerous error is injecting corticosteroids into or near the Achilles tendon, which dramatically increases rupture risk 1. Always ensure bursal injections are placed within the retrocalcaneal bursa itself, not adjacent to tendon tissue 1. Additionally, recognize that bilateral involvement is common 2, so examine both heels even if the patient reports unilateral symptoms.