Treatment of Haglund’s Deformity of the Heel Bone

Haglund’s deformity, colloquially known as “pump bump,” is a bony
enlargement of the posterior-superior aspect of the calcaneus — the heel
bone. First described by Swedish surgeon Patrik Haglund in 1928, the
condition presents as a prominent bony protrusion at the back of the heel that
can cause significant pain, inflammation, and functional impairment. The
deformity frequently irritates the overlying soft tissues, particularly the
retrocalcaneal bursa and the Achilles tendon, leading to bursitis and, in
chronic cases, tendinopathy. Understanding the full spectrum of treatment
options — from conservative management to surgical intervention — is
essential for clinicians and patients navigating this often-frustrating condition.

Understanding the Pathology
Before exploring treatment, it is important to understand why Haglund’s
deformity develops. The condition arises from a combination of structural
and biomechanical factors. An abnormally high pitch of the calcaneus,
excessive heel varus, a tight Achilles tendon, and high-arched (cavus) foot
posture can all contribute to increased mechanical stress at the posterior heel.
Repetitive friction — often exacerbated by rigid-backed footwear such as
dress shoes and high heels — inflames the retrocalcaneal bursa, which sits
between the calcaneus and the Achilles tendon. Over time, chronic irritation
can lead to calcification and further bony hypertrophy, worsening the
deformity and creating a painful cycle of inflammation and structural change.

Conservative Treatment
Footwear Modification is often the simplest and most immediately effective
intervention. Patients are advised to avoid rigid, enclosed-back footwear and
transition to open-back shoes, sandals, or soft-backed athletic footwear.
Reducing direct mechanical pressure on the bony prominence can
substantially decrease bursal inflammation and pain.

Orthotic Devices play a significant role in addressing the underlying
biomechanical contributors to the deformity. Heel lifts alter the angle of the
calcaneus and reduce tension in the Achilles tendon, thereby decreasing the
compressive force on the retrocalcaneal bursa. Custom foot orthotics can
correct pronation or supination imbalances, redistributing load across the foot
and reducing focal stress at the posterior heel.
Physical Therapy is a cornerstone of conservative management. A structured
rehabilitation programme focuses on stretching the Achilles tendon and calf
musculature to reduce tendon tension, as well as eccentric strengthening
exercises that promote tendon remodelling and pain reduction. Manual
therapy, ultrasound, and laser therapy may be employed adjunctively to
manage soft-tissue inflammation and accelerate healing.
Pharmacological Management includes the use of non-steroidal
anti-inflammatory drugs (NSAIDs) to reduce pain and swelling during acute
flare-ups. Topical anti-inflammatory gels may offer localised relief with a
lower systemic side-effect profile. Corticosteroid injections into the
retrocalcaneal bursa can provide dramatic short-term relief, though clinicians
must exercise caution: repeated injections carry the risk of Achilles tendon
weakening and potential rupture, and should therefore be used judiciously.
Activity Modification and Rest are critical during symptomatic periods.
Reducing or temporarily ceasing high-impact activities such as running or
prolonged walking allows the inflamed tissues to recover. Ice therapy applied
to the posterior heel for 15-20 minutes several times daily helps to manage
acute swelling and discomfort.

Emerging and Minimally Invasive Treatments
When conservative measures fail to provide adequate relief, several
minimally invasive options occupy a middle ground between conservative
care and open surgery.
Extracorporeal Shock Wave Therapy (ESWT) has gained growing
acceptance in the management of insertional Achilles tendinopathy and
associated Haglund’s deformity. High-energy acoustic waves are directed at
the affected tissue, stimulating neovascularisation, promoting collagen
synthesis, and disrupting pain signal pathways. Clinical studies report
meaningful pain reduction and functional improvement in a significant
proportion of patients, making ESWT an appealing option for those wishing
to avoid surgery.

Ultrasound-guided percutaneous needling and platelet-rich plasma (PRP)
injections are being explored as adjuncts to tendon rehabilitation. PRP,
derived from the patient’s own blood, delivers concentrated growth factors to
degenerated tendon tissue, potentially accelerating regeneration. While
evidence continues to mature, these biological therapies represent a
promising frontier in managing chronic tendinopathy associated with
Haglund’s deformity.

Surgical Treatment
Surgical intervention is reserved for patients who have failed a thorough
course of conservative treatment, typically spanning at least three to six
months. The primary goal of surgery is to remove the bony prominence and
decompress the Achilles tendon and retrocalcaneal bursa.
Open Calcaneal Osteotomy remains the traditional gold-standard surgical
approach. The surgeon resects the posterosuperior prominence of the
calcaneus, excises any inflamed or degenerated bursae, and, where necessary,
debrides the Achilles tendon insertion. Recovery following open surgery can
be protracted, often requiring immobilisation in a cast or boot for several
weeks, followed by a structured physiotherapy programme extending over
several months.
Endoscopic Calcaneoplasty has emerged as a minimally invasive alternative
that offers comparable outcomes to open surgery with the advantages of
smaller incisions, reduced wound complications, faster rehabilitation, and
shorter time to return to footwear and activity. Using small portals and an
arthroscopic camera, the surgeon visualises and resects the bony exostosis
under direct vision. Patient satisfaction and complication rates compare
favourably with open techniques in skilled hands.
Regardless of the surgical approach, risks include wound healing
complications, infection, inadvertent damage to the Achilles tendon, sural
nerve injury, and the possibility of incomplete resection necessitating revision
surgery. Careful patient selection and meticulous surgical technique are
paramount.

Haglund’s deformity, while a seemingly straightforward bony condition, can
have a significant and lasting impact on quality of life, particularly in active
individuals. Treatment follows a logical, stepwise progression — from
footwear changes and physiotherapy through to shock wave therapy and, ultimately, surgery. The vast majority of patients achieve satisfactory reliefhe vast majority of patients achieve satisfactory relief
with conservative measures, and surgical outcomes, particularly with
endoscopic techniques, continue to improve. Early intervention, patient
education, and addressing the underlying biomechanical causes of the
deformity are the keys to achieving lasting resolution and a return to
pain-free activity.