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Haglund’s Deformity: The Pump Bump

The most common cause of heel pain, is plantar fasciitis. A distant second-place finisher is insertional Achilles tendonitis. This is where pain and swelling is found in the back of the heel, at the point where the Achilles tendon attaches to the heel bone (calcaneus). 

This irritation is from chronic tightness of the Achilles tendon and muscle complex. The tendon will try to pull the away from the calcaneus. 

Typically, this is a problem that has been brewing for a long time. Damage to the Achilles tendon will slowly develop under excessive force. This area can also be irritated from the back of shoes, in the area known as the heel counter. No matter what causes Achilles irritation, there will be pain and swelling in the back of the heel. 

Fortunately, you can always come see us here at the office of Jeffrie C. Leibovitz, DPM for the effective care and treatment you need.

A Little Greek (maybe Geek) Trivia on the Achilles Tendon

 

The Achilles tendon is the largest tendon in the body. It is attached to the only two muscles below the knee that move us forward. It has to lift over 1 million pounds and absorb over 3-4 million pounds of force in a 5,000 step day for a 150 lb. person! 

The back story of Achilles (the hero) is told by Homer (not Simpson) in The Iliad. If the ancient Greeks knew how strong this tendon is, they may have named it after Hercules.

So What is the Bump? Where Did it Come From?

The damage to the junction of the Achilles and calcaneus is from persistent and repetitive inflammation cycles.  

The incredibly strong fibers of the Achilles will eventually stretch and tear under too much force. Like a strong rope under too much tension, a few small fibers will begin to tear or break. Over time, more and more fibers are damaged and the local irritation increases like a small spark that wants to becomes a bonfire. 

The heel bone (calcaneus) will put up a valiant fight to heal over the injured tendon. The bone’s response is to put more bone around the tendon to increase its hold. The back of the calcaneus will change its shape and become squared off. 

If the tearing force continues, the bone will start to infiltrate and grow into the tendon. This will look like an upside down icicle or spur on X-ray. Bone will change very slowly. It may take 5-10 years of irritation to see significant changes. Unlike the spur associated with plantar fasciitis, this is a spur that can cause a world of problems.

Chronic inflammation can also create a bursa at the back of the heel. The bursa is a fluid filled sack that acts as an airbag to reduce the repetitive impact from a shoe. This may change size on a daily basis.

 

The Achilles tendon is the largest tendon in the body. It is attached to the only two muscles below the knee that move us forward. It has to lift over 1 million pounds and absorb over 3-4 million pounds of force in a 5,000 step day for a 150 lb. person! 

The back story of Achilles (the hero) is told by Homer (not Simpson) in The Iliad. If the ancient Greeks knew how strong this tendon is, they may have named it after Hercules.

So What is the Bump? Where Did it Come From?

The damage to the junction of the Achilles and calcaneus is from persistent and repetitive inflammation cycles.  

The incredibly strong fibers of the Achilles will eventually stretch and tear under too much force. Like a strong rope under too much tension, a few small fibers will begin to tear or break. Over time, more and more fibers are damaged and the local irritation increases like a small spark that wants to becomes a bonfire. 

The heel bone (calcaneus) will put up a valiant fight to heal over the injured tendon. The bone’s response is to put more bone around the tendon to increase its hold. The back of the calcaneus will change its shape and become squared off. 

If the tearing force continues, the bone will start to infiltrate and grow into the tendon. This will look like an upside down icicle or spur on X-ray. Bone will change very slowly. It may take 5-10 years of irritation to see significant changes. Unlike the spur associated with plantar fasciitis, this is a spur that can cause a world of problems.

Chronic inflammation can also create a bursa at the back of the heel. The bursa is a fluid filled sack that acts as an airbag to reduce the repetitive impact from a shoe. This may change size on a daily basis.

A Lump Called Haglund

The lump that develops at the back of the heel is called a Haglund’s deformity or Pump Bump. This area is especially aggravated by women’s closed high-heeled shoes. 

We find that most patients have a gradual onset of both pain and swelling. This develops where the Achilles tendon attaches into the heel bone. 

At first the pain is described as occurring only after activity, but symptoms become constant over time. The pain worsens during high-impact activities. This include running, jumping, and other athletic activities. Symptoms will also flare after wearing a shoe with a curved or rigid heel counter. The big offenders are penny loafer and women’s high heel dress shoes.

There is an increased risk for Achilles damage for those who have inflammatory soft tissue diseases, use medications like antibiotics in the fluoroquinolone family (e.g. Cipro) or use corticosteroids. These meds can weaken the connective tissue that makes up tendons.

To properly diagnose the condition, we may need to use X-rays. This will reveal how much calcification deposits are in the tendon. This problem is much easier to treat if the changes are limited to soft tissue. Ultrasound imaging can be used instead of MRI to see the extent of the tendon’s degeneration. It may also show other factors contributing to the posterior heel pain like bursitis.

Can I blame it on high heels?

The answer is Yes and No.

The majority of the population have a short Achilles. This is from wearing shoes with an elevated heel.

The majority of shoes have a 15mm or greater lift. The problem is that the Achilles will get accustomed to this position and gradually tighten. It will also tighten from exercise and walking.
Typically, high-heeled shoes have a curved back or strap that will also insult the heel. This is a very tough 1-2 combination.

If the Achilles never tightens up there is no problem. So the moral of the insertion Achilles tendonitis story is that we need to compensate for an elevated shoe with a stretching program.

We Can Do This the Easy Way or the Hard Way

Conservative treatment is quite effective for the majority of patients. The key is addressing it in the early stages. The treatment that will provide the greatest improvement is a stretching program link to stretching video and a shoe that does not place pressure on the heel area.  

Other options may include anti-inflammatory medication, orthotics, and heel lifts. In the event that symptoms linger, we may prescribe a stretching splint, and physical therapy. (NOTE: It is important that the stretching splint go above the knee to be effective). 

We should see improvement in 3-4 weeks from the stretching program. It may take several months to achieve complete relief. As a last resort we may need to immobilize the leg with a removable brace or cast. 

About 80% of people respond very well to conservative treatment. I would like these odds when I go to Vegas. 

If conservative care does not provide adequate relief, surgery can be considered. Surgery will remove the degenerative portions of the Achilles tendon and enlarged bone. The bursa will also be removed if present. The Achilles complex will be lengthened to reduce the chance of re-occurrence. 

There is not an “overnight” recovery for this surgery. Tendon and bone have a white appearance because there is little blood supply. This means healing takes a long time. There is 4 weeks where the foot will not touch the ground after the surgery. That should be some significant incentive to do the stretching program!

For more information on insertional Achilles tendinitis, or to schedule an appointment for treatment to take away that pain in the back of the heel, simply give our Indianapolis, IN office a call at (317) 545-0505.

 

Get the care you need today!

When you have pain in the back of your heel, come see your go-to foot doc. Dr. Leibovitz will diagnose the problem and create a treatment plan to resolve it – all so you can find relief from painful symptoms!

Follow the lead of your neighbors who already make our office their first choice for foot and ankle care and contact us today. Schedule your appointment by calling (317) 545-0505.

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9505 E. 59th St., Suite A
Indianapolis, IN 46216

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(317) 545-0505

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