What is the treatment for Haglund's deformity in a young active adult?

Treatment of Haglund's Deformity in Young Active Adults

Begin with open-backed shoes, accommodative padding, heel lifts, NSAIDs, and physical therapy as first-line treatment, reserving surgery only for cases that fail 6-8 weeks of appropriate conservative management. 1

Initial Conservative Management (First-Line)

The American College of Foot and Ankle Surgeons recommends a structured conservative approach as the primary treatment strategy 1:

• Immediately switch to open-backed shoes to eliminate direct pressure on the posterolateral heel prominence—this is the single most important intervention 1
• Apply accommodative padding around the bony prominence to protect the inflamed retrocalcaneal bursa from shoe pressure 1
• Use heel lifts or custom orthoses to alter foot biomechanics and reduce Achilles tendon tension 1
• Prescribe NSAIDs for pain control and reduction of bursal inflammation 1
• Recommend weight loss if the patient is overweight to decrease mechanical stress on the heel 1
• Initiate physical therapy focusing on Achilles stretching and strengthening exercises 1
• Modify activities that aggravate symptoms, particularly those involving rigid-backed footwear 1

Clinical Diagnostic Clues

• Pain typically improves or resolves when walking barefoot—this is a distinguishing feature of Haglund's deformity 1
• Tenderness localizes lateral to the Achilles tendon in association with the posterolateral calcaneal prominence 1
• The condition most commonly affects women aged 20-30 years, though it occurs in both sexes 1, 2
• Bilateral involvement is common 2

Second-Line Conservative Treatment

If initial measures provide insufficient relief after 2-4 weeks 1:

• Consider corticosteroid injection into the retrocalcaneal bursa for refractory inflammation, but this must be performed with extreme caution 1
• Never inject corticosteroids directly into or near the Achilles tendon itself—this significantly increases rupture risk and is absolutely contraindicated 1
• For particularly acute or refractory cases, use a short period of immobilization with a cast or fixed-ankle walker boot to reduce mechanical stress and allow inflamed tissues to heal 1

Surgical Referral Criteria

Refer to a podiatric foot and ankle surgeon if symptoms persist despite 6-8 weeks of appropriate conservative treatment 1. This timeframe is critical—most patients respond to conservative care within this period 2, 3.

Surgical Management (When Conservative Treatment Fails)

For the subset of patients who fail conservative therapy 4, 5, 3:

• Surgical excision of the posterior calcaneal prominence with retrocalcaneal bursectomy produces good to excellent results in 90-97% of cases 4, 3
• The procedure typically involves removing the posterosuperior calcaneal tuberosity through a medial longitudinal incision 4, 3
• The osteotomy should achieve an angle of approximately 49 degrees to adequately decompress the retrocalcaneal bursa and remove the calcaneal step 5
• Achilles tendon reattachment using bone anchors may be necessary 3
• Postoperative immobilization for 4 weeks is standard 3

Critical Surgical Caveat

Patients must be counseled that even after successful surgery, residual pain commonly persists for 6 months to 2 years before complete symptom resolution occurs 4. In one series, 83% of successfully treated patients experienced residual pain for this extended period before becoming symptom-free 4. This prolonged recovery is a normal part of the healing process and does not indicate surgical failure.

Treatment Algorithm Summary

1. Weeks 0-6: Aggressive conservative management with open-backed shoes, padding, heel lifts, NSAIDs, and physical therapy 1
2. Weeks 4-8: Add bursal corticosteroid injection (avoiding Achilles tendon) or immobilization if inadequate response 1
3. Week 6-8: Refer to foot and ankle surgeon if no improvement 1
4. Surgical consideration: Only after documented failure of 6-8 weeks of appropriate conservative care 1, 3