Haglund’s deformity is a bony enlargement that develops on the back of the heel, near the insertion of the Achilles tendon. This prominence can irritate the surrounding soft tissue, leading to inflammation of the bursa (retrocalcaneal bursitis) and degeneration of the Achilles tendon. Together, these findings are often referred to as Haglund’s syndrome or Haglund’s triad. The condition commonly affects people who wear rigid-backed shoes or engage in repetitive, high-impact activities.
How Common It Is and Who Gets It? (Epidemiology)
Haglund’s deformity can occur in both men and women but is often seen in middle-aged adults who are physically active. Women who wear pump-style shoes, athletes who run or jump frequently, and individuals with inherited foot structures—such as high arches or tight Achilles tendons—are more prone to developing this condition. It may affect one or both heels and tends to worsen over time if untreated.
Why It Happens – Causes (Etiology and Pathophysiology)
The condition develops when repetitive friction or pressure occurs between the back of the heel and the rigid heel counter of shoes. Over time, this irritation leads to bony overgrowth on the upper part of the calcaneus (heel bone). Key contributing factors include:
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High-arched feet (cavus foot): Increase contact between the heel bone and shoe.
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Tight Achilles tendon: Pulls on the heel bone, increasing stress.
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Abnormal gait: Walking on the outer heel edge increases pressure on the back of the heel.
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Improper footwear: Rigid shoes like pumps, dress shoes, or ice skates aggravate the area.
Inflammation of the surrounding bursa and degeneration of the Achilles tendon often follow, causing chronic heel pain.
How the Body Part Normally Works? (Relevant Anatomy)
The calcaneus (heel bone) is the largest bone in the foot and serves as the attachment point for the Achilles tendon, which connects the calf muscles to the foot. Between the tendon and the bone lies the retrocalcaneal bursa, a small fluid-filled sac that reduces friction. When the bony prominence enlarges, it irritates the bursa and tendon during motion, especially in tight footwear, resulting in pain and swelling.
What You Might Feel – Symptoms (Clinical Presentation)
Common symptoms include:
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Pain in the back of the heel, especially when wearing shoes with rigid backs.
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Swelling, redness, and tenderness near the Achilles tendon.
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A noticeable bump on the back of the heel.
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Pain when standing on tiptoes or walking uphill.
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Stiffness and discomfort that worsen after activity or prolonged standing.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis is based on medical history, physical examination, and imaging studies.
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Physical Exam: Reveals a bony bump, localized tenderness, and swelling over the Achilles tendon.
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X-rays: Show the size and shape of the bony prominence on the calcaneus.
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MRI: Evaluates associated Achilles tendon degeneration or bursitis.
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Ultrasound: May be used to assess soft tissue inflammation and guide injections if needed.
Classification
Haglund’s deformity may be categorized by the severity of the bony enlargement and the involvement of surrounding tissues:
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Mild: Soft tissue irritation without significant bone prominence.
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Moderate: Bony bump with inflammation of the bursa and tendon.
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Severe: Large exostosis with Achilles tendinosis or partial tearing.
Other Problems That Can Feel Similar (Differential Diagnosis)
Conditions that may mimic Haglund’s deformity include:
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Insertional Achilles tendinitis
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Retrocalcaneal bursitis without bone prominence
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Calcific tendinopathy
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Posterior ankle impingement
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Sever’s disease (in adolescents)
Treatment Options
Non-Surgical Care
Conservative management aims to reduce pain and inflammation and prevent worsening of the deformity.
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Footwear Modification: Choose backless or soft-backed shoes and avoid rigid heel counters.
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Heel Pads or Lifts: Reduce pressure on the heel and Achilles tendon.
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Orthotic Devices: Custom inserts correct foot alignment and offload stress.
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Physical Therapy: Stretching exercises for the Achilles tendon and calf muscles relieve tension.
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NSAIDs: Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen) reduce pain and swelling.
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Ice Therapy: Applying ice for 20 minutes helps control inflammation.
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Immobilization: Short-term casting or a walking boot may be used in severe inflammation.
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Steroid Injections: Occasionally used to reduce bursitis but applied cautiously near the tendon to avoid rupture.
Surgical Care
If symptoms persist after months of conservative treatment, surgery may be necessary to remove the bony prominence and address tendon or bursa issues.
Surgical Techniques:
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Open Excision (CPT 28118):
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A traditional approach involving a direct incision to remove the bony bump, excise the inflamed bursa, and repair the Achilles tendon if damaged.
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Requires immobilization in a cast or boot postoperatively.
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Endoscopic Excision:
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Minimally invasive technique using small incisions and a camera (arthroscope) to guide bone removal and tissue debridement.
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Offers smaller scars, less pain, and faster recovery but requires specialized surgical expertise.
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Recovery and What to Expect After Treatment
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Immobilization: The foot is kept in a cast or boot for several weeks to protect the tendon and surgical site.
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Gradual Weight-Bearing: Patients transition from crutches to full walking as healing progresses.
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Physical Therapy: Essential for restoring strength, range of motion, and gait balance.
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Timeline:
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Light activity: 6–12 weeks
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Return to sports or strenuous activity: 3–6 months
Most patients experience substantial pain relief and improvement in function within months of surgery.
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Possible Risks or Side Effects (Complications)
Potential risks include:
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Infection or delayed wound healing
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Nerve irritation (especially sural nerve)
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Recurrence of heel pain
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Weakness of the Achilles tendon
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Persistent stiffness or scar formation
Complications are uncommon with proper technique and postoperative care.
Long-Term Outlook (Prognosis)
Both open and endoscopic surgeries have excellent success rates, with studies showing significant pain reduction and functional improvement. Long-term results are highly favorable when rehabilitation is followed diligently.
Out-of-Pocket Cost
Medicare
CPT Code 28118 – Excision of Haglund’s Deformity: $140.01
Medicare Part B typically covers 80% of the approved cost for this procedure after your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield usually cover that remaining 20%, minimizing or eliminating out-of-pocket expenses for Medicare-approved procedures. These plans coordinate with Medicare to fill the coverage gap and help patients avoid unexpected costs.
If you have Secondary Insurance such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans typically cover remaining coinsurance or small deductibles, which generally range from $100 to $300, depending on your plan and provider network.
Workers’ Compensation
If your Haglund’s deformity developed due to repetitive stress or a work-related condition, Workers’ Compensation will cover all costs related to the surgery, rehabilitation, and postoperative care. You will not have any out-of-pocket expenses, as the employer’s insurance carrier pays directly for all approved treatments.
No-Fault Insurance
If your Haglund’s deformity or associated heel pain was caused or aggravated by an automobile accident, No-Fault Insurance will typically cover the entire cost of the procedure and recovery. The only potential out-of-pocket expense may be a small deductible or co-payment, depending on your insurance policy.
Example
Jennifer Morales had chronic heel pain from Haglund’s deformity that did not improve with conservative treatment. She underwent excision of Haglund’s deformity (CPT 28118) with an estimated Medicare out-of-pocket cost of $140.01. Because Jennifer had supplemental insurance through Blue Cross Blue Shield, her remaining balance was fully covered, leaving her with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What is Haglund’s Deformity?
A. Haglund’s deformity is a bony enlargement that forms on the back of the heel, often at the insertion point of the Achilles tendon. It can cause inflammation of the bursa and Achilles tendinosis, leading to pain and discomfort.
Q. How is Haglund’s Deformity diagnosed?
A. Diagnosis is typically made through a physical examination, with imaging techniques such as X-rays or MRI scans used to assess the extent of the deformity and check for any damage to the Achilles tendon or bursa.
Q. What are the treatment options for Haglund’s Deformity?
A. Non-surgical treatments include rest, physical therapy, custom orthotics, and pain-relieving medications. If conservative treatments fail, surgery may be recommended to remove the bony prominence and repair the Achilles tendon.
Q. What is the difference between open and endoscopic surgery for Haglund’s Deformity?
A. Open surgery involves a larger incision to directly access the heel, while endoscopic surgery is minimally invasive, using smaller incisions and a camera to guide the procedure, resulting in quicker recovery and smaller scars.
Q. What are the benefits of surgery for Haglund’s Deformity?
A. Surgery provides pain relief, restores foot function, and corrects the deformity. Most patients experience significant improvements, with many returning to regular activities and sports within a few months.
Q. What is the recovery time after surgery for Haglund’s Deformity?
A. Recovery typically takes 6 to 12 weeks for light activities, with most patients able to resume full activities, including sports, within 3 to 6 months, depending on the type of surgery and individual healing.
Q. Are there any risks involved with surgery for Haglund’s Deformity?
A. Potential risks include infection, nerve damage, and recurrence of symptoms. However, these complications are rare, and with proper care, surgery is generally very effective in providing long-term relief.
Q. How long does it take to perform surgery for Haglund’s Deformity?
A. The procedure typically takes about 1 to 2 hours, depending on the complexity of the deformity and whether any additional procedures, like tendon repair, are needed.
Q. Will I need to wear a cast after surgery for Haglund’s Deformity?
A. Yes, most patients will need to wear a cast or a walking boot for several weeks after surgery to protect the heel and ensure proper healing of the tendon and bone.
Q. Is physical therapy necessary after surgery for Haglund’s Deformity?
A. Yes, physical therapy is usually recommended to help restore strength, flexibility, and mobility to the foot and ankle, as well as to promote proper healing and prevent stiffness.
Q. Can Haglund’s Deformity come back after surgery?
A. While recurrence is rare, it is possible for Haglund’s deformity to return if the underlying cause of the condition is not addressed or if rehabilitation is not followed properly.
Q. What are the signs that surgery for Haglund’s Deformity was successful?
A. Success is typically indicated by reduced pain, improved range of motion, and the ability to resume normal activities without discomfort. Follow-up appointments will assess healing and recovery progress.
Q. Can Haglund’s Deformity surgery be done on both feet at the same time?
A. While it is possible to perform the surgery on both feet at the same time, it is typically done one foot at a time to allow for proper healing and minimize the risk of complications.
Q. Are there any non-surgical treatments for Haglund’s Deformity?
A. Yes, non-surgical treatments include rest, ice, anti-inflammatory medications, stretching exercises, custom orthotics, and using heel lifts or padding to reduce pressure on the deformity.
Q. Is surgery for Haglund’s Deformity permanent?
A. Surgery is generally considered a permanent solution to remove the bony prominence and alleviate pain. However, patients must follow proper rehabilitation to ensure long-term results and prevent recurrence.
Q. What is Haglund’s deformity?
A. A bony enlargement at the back of the heel that irritates nearby tissues and causes pain, especially when wearing rigid shoes.
Q. Can Haglund’s deformity heal without surgery?
A. Non-surgical measures can control symptoms but do not remove the bone bump. Persistent pain may require surgical correction.
Q. Is surgery painful?
A. Postoperative discomfort is manageable with medication, and most patients report significant long-term pain relief.
Q. What is the difference between open and endoscopic surgery?
A. Open surgery involves a larger incision, while endoscopic surgery uses small incisions and a camera for a less invasive procedure with faster recovery.
Q. How long does recovery take?
A. Most patients return to light activity within 6–12 weeks and resume full activity by 3–6 months.
Q. Can Haglund’s deformity come back?
A. Recurrence is rare but can occur if contributing factors, such as tight shoes or high arches, are not addressed.
Summary and Takeaway
Haglund’s deformity is a painful bony enlargement at the back of the heel that can lead to bursitis and Achilles tendon irritation. Non-surgical treatments—including stretching, footwear changes, and orthotics—are often effective, but surgery may be needed for lasting relief. Both open and endoscopic approaches have excellent outcomes, with endoscopic surgery offering faster recovery and smaller scars. Early evaluation and appropriate treatment help prevent long-term pain and deformity.
Clinical Insight & Recent Findings
A recent study reviewed 20 clinical trials on the surgical management of Haglund’s deformity and found that both open and endoscopic procedures provide significant pain relief and functional improvement. Patients’ average scores on the American Orthopaedic Foot & Ankle Society (AOFAS) scale improved by roughly 30–35 points after surgery, confirming excellent long-term outcomes.
While both methods were effective, endoscopic surgery demonstrated several advantages, including smaller incisions, fewer wound complications, faster recovery, and better cosmetic results. However, the authors noted that the endoscopic technique requires greater surgical expertise due to its steep learning curve.
Overall, the study concluded that endoscopic excision is a safe, minimally invasive, and equally effective alternative to open surgery, offering comparable success rates with lower complication risk. (“Study on surgical outcomes of Haglund’s deformity excision – see PubMed.”)
Who Performs This Treatment? (Specialists and Team Involved)
Haglund’s deformity is treated by an orthopedic foot and ankle surgeon or a podiatric foot and ankle surgeon. The team may include an anesthesiologist, radiologist, and physical therapist to assist with diagnosis, surgery, and rehabilitation.
When to See a Specialist?
See a specialist if you have heel pain that persists despite rest, orthotics, or footwear changes, or if swelling and tenderness worsen with activity.
When to Go to the Emergency Room?
Seek immediate care if you experience sudden severe pain, inability to walk, signs of infection (fever, redness, drainage), or a suspected Achilles tendon tear.
What Recovery Really Looks Like?
Mild swelling and soreness are common in the first few weeks. Gradual improvement continues with physical therapy, and most patients regain full mobility within 3–6 months.
What Happens If You Ignore It?
Untreated Haglund’s deformity can cause chronic heel pain, Achilles tendinosis, and bursitis, eventually leading to degenerative changes in the tendon and reduced mobility.
How to Prevent It?
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Wear shoes with soft or open heels.
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Perform regular calf and Achilles stretches.
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Use orthotics to maintain alignment and reduce friction.
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Avoid prolonged walking or running in rigid-backed footwear.
Nutrition and Bone or Joint Health
A diet rich in calcium, vitamin D, and protein supports tendon and bone healing. Staying hydrated and maintaining a healthy weight reduce stress on the heel and Achilles tendon.
Activity and Lifestyle Modifications
Choose low-impact exercises such as swimming or cycling during recovery. Avoid running uphill or wearing high-heeled or tight shoes. Continue stretching and use supportive footwear to prevent recurrence.
Dr. Mo Athar
