Calcaneal prominence resection, insertional tendon debridement and reattachment, Zadek osteotomy · advanced
- Haglund deformity is a prominence of the posterosuperior calcaneal tuberosity that impinges on the retrocalcaneal bursa and the deep surface of the Achilles tendon insertion. The classic radiographic signs are the Fowler-Philip angle (greater than 69 degrees), parallel pitch lines (positive when the superior calcaneal cortex projects above a line drawn along the anterior calcaneal cortex), and the Haglund angle on the lateral heel radiograph. The diagnosis is clinical (posterosuperior heel pain with tenderness at the Achilles insertion, shoe rubbing, positive two-pinch test) supported by these measurements.
- Surgical correction involves three core elements: (1) resection of the posterosuperior calcaneal prominence and inflamed retrocalcaneal bursa, (2) debridement of the degenerate portion of the Achilles tendon insertion with excision of intratendinous calcification, and (3) reattachment of the detached tendon using suture anchors (single-row or double-row) when greater than 50% of the insertion is detached. If the deformity is large or the calcaneal inclination is unfavourable, a Zadek dorsal closing-wedge osteotomy shifts the prominent tuberosity posteriorly and decompresses the insertion.
- The sural nerve runs in the subcutaneous tissue posterolateral to the Achilles tendon and is the structure most at risk during the approach. It courses from mid-calf to the lateral border of the foot, passing approximately 1-2 cm lateral to the tendon at the level of the calcaneal insertion. A paramedial approach (medial or lateral to the tendon) keeps the nerve lateral to the incision if a medial approach is chosen, but careful full-thickness skin-flap elevation is essential regardless of approach to avoid nerve transection or neuropraxia.
- Wound breakdown over the posterior heel is the most feared post-operative complication (reported 5-15% in series), driven by the thin soft-tissue envelope, tension at closure, and postoperative swelling. Periosteal stripping should be minimised, the wound should be closed without tension (relaxing incisions or flap advancement if needed), and the limb elevated strictly for the first 72 hours.
When & Why
Indication. Haglund deformity correction is reserved for symptomatic insertional Achilles tendinopathy with a posterosuperior calcaneal prominence that has failed a structured non-operative programme. Most surgical patients have all three components of the syndrome at once — the bony prominence, retrocalcaneal bursitis, and degenerate insertional tendon — and surgery is planned to address all three. ### Absolute indications - Insertional Achilles tendinopathy with Haglund deformity recalcitrant to at least 3-6 months of structured non-operative treatment (heel-lift orthosis, activity modification, eccentric loading programme, at least one image-guided injection).
- Retrocalcaneal bursitis with posterosuperior calcaneal impingement causing refractory posterior heel pain, confirmed by positive parallel pitch lines and MRI evidence of bursal wall thickening and tendon involvement.
- Partial Achilles tendon avulsion at the insertion (greater than 50% detachment) with an associated Haglund prominence, in an active patient.
- Symptomatic intratendinous calcification at the Achilles insertion with pain on activity and failure of non-operative management. ### Relative indications - Haglund deformity with mild insertional tendinopathy where non-operative treatment has been partially successful but the patient wishes to return to high-impact sport.
- Recurrent symptoms after a previous conservative (partial) bursoscopy or limited bursectomy.
- Prominent Haglund deformity in a patient who cannot accommodate shoe modification due to occupational or sporting requirements.
- Failure of a Zadek osteotomy to resolve symptoms (revision with tendon repair). ### Contraindications Absolute: - Active local infection (cellulitis, ulceration, or deep heel wound infection) — surgery deferred until resolved.
- Severe peripheral vascular disease with critical limb ischaemia — wound healing is unreliable.
- Active inflammatory arthropathy flare at the Achilles insertion — optimise medical management first. Relative: - Poorly controlled diabetes with significant peripheral neuropathy — elevated wound breakdown risk; optimise glycaemic control first.
- Established subtalar arthritis — a Zadek osteotomy may worsen hindfoot pain; consider fusion instead.
- Heavy tobacco use (greater than 20 pack-years) — counsel about wound healing risk; cessation before surgery is advisable.
- Patient unable to comply with 4-6 weeks non-weight-bearing — this is essential for tendon healing; discuss expectations. Non-operative treatment comes first. The first-line measures are a heel lift (1-1.5 cm) inside the shoe to reduce Achilles tension at the insertion and offload the retrocalcaneal bursa, plus shoe modification (an open-backed shoe or a heel counter with a cut-out at the posterosuperior corner) to eliminate direct shoe pressure. Posterior heel cushioning pads (silicone heel sleeves, felt pads) reduce direct impingement. An eccentric loading programme (Alfredson protocol) has moderate evidence for non-insertional Achilles tendinopathy but less evidence specifically for insertional disease — modified protocols that limit dorsiflexion beyond neutral may be needed to avoid exacerbating insertional pain. A corticosteroid injection into the retrocalcaneal bursa gives short-term relief in 50-70% of cases but carries a risk of Achilles rupture if injected into the tendon substance, so an image-guided (ultrasound) bursal injection is preferred. Platelet-rich plasma (PRP) has limited evidence for insertional tendinopathy and is not a replacement for structured rehabilitation.
The two-pinch test differentiates insertional Achilles pathology from retrocalcaneal bursitis alone. Pinch the Achilles tendon at its insertion — pain means tendon involvement. Then pinch the bursa lateral to the tendon — pain means bursal involvement. Most surgical patients are positive for both, which is exactly why the operation addresses bone, bursa and tendon together.
Draw a line along the inferior cortex of the calcaneus on a lateral radiograph, then a second line along the superior cortex. If the posterosuperior corner projects above the first (inferior) line, the test is positive for Haglund deformity. The Fowler-Philip angle — measured between the posterior calcaneal tuberosity and the undersurface of the calcaneus — gives a number, with greater than 69 degrees considered abnormal, but parallel pitch lines are easier to communicate and reproduce.
The one decision that matters. Once non-operative care has failed, the core operation is always the same — resect the prominence, excise the bursa, debride the tendon. The real choice is whether to add a calcaneal osteotomy, and whether to do it open or endoscopically:
The default for a moderate prominence with an intact or minimally detached tendon. Reliable pain relief in 75-90% at 2-5 years. Open allows full tendon debridement and anchor reattachment when needed.
For a large prominence (greater than 15 mm), a steep calcaneal inclination, or a failed exostectomy. Decompresses the insertion biomechanically but needs screw fixation, 6 weeks non-weight-bearing, and hardware removal in 10-20%.
Two posterior portals for an intact tendon with predominant bursal pathology. Better cosmesis and faster return to sport, but a steep learning curve and it cannot reliably deliver suture-anchor reattachment.
Consent specifically for sural nerve injury (2-10% transient numbness, 1-3% persistent neuroma), wound breakdown or infection (5-15%), Achilles avulsion or weakness if reattachment fails (less than 5%), the need for hardware removal if a Zadek osteotomy is performed (10-20%), prolonged recovery (3-6 months to full activity), and the possibility of incomplete pain relief (5-10%). Setup. Prone on the operating table with a padded post (or bolster) under the tibia to elevate the calf and foot off the table, giving unrestricted access to the posterior heel; ensure the common peroneal nerve is not compressed at the fibular neck by the bolster. Calf tourniquet (250 mmHg), exsanguinated with an Esmarch bandage, limited to less than 90 minutes. General anaesthesia with a popliteal sciatic nerve block (long-acting local anaesthetic such as bupivacaine 0.25% with dexamethasone) for postoperative analgesia; spinal is an alternative. Image intensifier set for a true lateral view of the calcaneus, confirmed before prepping. A single dose of intravenous cefazolin 2 g at induction (clindamycin 600 mg if penicillin-allergic), repeated if tourniquet time exceeds 4 hours.
The Operation
The goal is to expose the posterosuperior calcaneus through a safe approach, resect the bony prominence and the inflamed retrocalcaneal bursa completely, debride the degenerate tendon (excising any intratendinous calcification), reattach the insertion with suture anchors when greater than 50% is detached, and — when the deformity is large or the inclination unfavourable — decompress the insertion with a Zadek closing-wedge osteotomy. The exposure, with its sural-nerve protection and full-thickness flaps, is laid out in full below.
Operative sequence
- Prone, padded post under the tibia, calf tourniquet (250 mmHg), true lateral fluoroscopy confirmed before prepping.
- Before inflating the tourniquet, mark the posterosuperior calcaneal prominence by palpation, the estimated course of the sural nerve (approximately 1-2 cm lateral to the Achilles tendon), and the proposed incision.
The approach is chosen to match the pathology and the planned fixation: - Central tendon-splitting approach — the best direct access to both the posterosuperior calcaneus and the full tendon insertion; a longitudinal midline incision, then split the Achilles in line with its fibres from the musculotendinous junction to the insertion and retract each half. Avoids the sural nerve entirely if truly midline, but creates a deliberate tendon split that must be repaired.
- Medial paramedial approach — a longitudinal incision 1-1.5 cm medial to the tendon border; preferred when sural nerve protection is the priority and the anticipated detachment is less than 50%. The sural nerve stays lateral to the whole field, with a good cosmetic result and no tendon split, but lateral exposure of the prominence is more limited.
- Lateral paramedial approach — a longitudinal incision 1-1.5 cm lateral to the tendon border; preferred for a Zadek osteotomy (it allows lateral screw placement) and large lateral prominences. The sural nerve must be identified and protected during flap elevation, and the lateral scar is more visible and more prone to shoe irritation.
If a Zadek osteotomy is planned, a lateral approach is most practical because it allows lateral screw insertion. If no osteotomy is needed, a medial paramedial or central tendon-splitting approach keeps the sural nerve out of the wound. The choice of approach matters less than meticulous full-thickness skin-flap elevation and deliberate sural nerve identification.
- Incise skin sharply (number 10 or 15 blade) and elevate full-thickness flaps directly on the periosteum (or on the paratenon for a tendon-splitting approach), keeping the subcutaneous fat attached to the skin flap. Do NOT undermine the skin in the subcutaneous plane — that devascularises the flap and is the single biggest cause of wound breakdown.
- Use a knife and small retractors rather than cautery for flap elevation to minimise thermal injury. With a lateral approach, identify the sural nerve in the proximal wound before any lateral flap elevation and protect it throughout.
- Identify the thickened, inflamed, scarred retrocalcaneal bursa between the Achilles tendon and the posterosuperior calcaneal cortex.
- Excise it completely with scissors and a rongeur, including all fibrotic and inflamed tissue — incomplete bursal excision leaves inflamed tissue that perpetuates symptoms. Send the bursa for histopathology.
- The posterosuperior calcaneal prominence and the deep surface of the Achilles insertion are now fully exposed.
- Identify the posterosuperior corner (a hard bony bump projecting superiorly). Use an oscillating saw to make an oblique osteotomy through the prominence, angled from posterosuperior to anteroinferior and parallel to the orientation of the Achilles fibres, then remove the fragment with a rongeur.
- Contour the remaining surface with a rongeur then a burr until the posterosuperior corner is flush and smooth — nothing palpable when a finger is run over the posterior calcaneus.
- Verify on lateral fluoroscopy that the corner no longer projects above the inferior cortex line (parallel pitch lines now negative) and that no bony spicules remain.
- Inspect the deep surface of the insertion. Excise degenerate, discoloured or friable tendon sharply, leaving healthy, bleeding margins.
- Look for and excise any intratendinous calcification — hard, gritty, white-yellow deposits within the substance — palpating thoroughly so none is missed.
- Assess the percentage of the insertion still attached: less than 50% detached — the remaining tendon is sufficient for healing, close the defect, no anchors; greater than 50% detached — the tendon is functionally compromised, proceed to suture-anchor reattachment.
- Freshen the cortical insertion footprint with a burr or curette to expose bleeding cancellous bone, without over-penetrating into the calcaneal body. Insert anchors into the dense cortical bone of the posterosuperior tuberosity (the strongest bone in the calcaneus), not the cancellous body.
- Single-row: 2-3 anchors (typically 5.0 or 5.5 mm bioabsorbable or metal) along the footprint; pass suture limbs through the tendon in a Krackow or modified Mason-Allen configuration; tie with the foot in maximal plantarflexion to relax the repair.
- Double-row: a medial row of 2 anchors plus a lateral row of 1-2 anchors, with medial-row sutures bridged to the lateral row, creating a wider footprint contact area and higher pull-out strength in biomechanical studies.
Indicated for a large prominence (greater than 15 mm), a steep calcaneal inclination, a failed isolated exostectomy, or combined deformity with hindfoot malalignment. Through a lateral or posterolateral incision, protecting the sural nerve: 1. Palpate the posterior facet of the subtalar joint and mark its posterior margin — the osteotomy must sit entirely posterior to it (typically 1-1.5 cm posterior). Confirm the site on lateral fluoroscopy. 2. With an oscillating saw under fluoroscopy, make a proximal transverse cut from the posterosuperior cortex to the plantar cortex, and a distal angled cut meeting it on the plantar cortex to create a dorsal closing wedge (typically 10-20 degrees). 3. Close the wedge by depressing the tuberosity — the posterosuperior fragment shifts posteriorly and inferiorly, decompressing the insertion. 4. Fix with 1-2 6.5-7.3 mm partially threaded cannulated lag screws placed posterior to anterior, with threads crossing the osteotomy for compression; confirm position and that the cut does not enter the posterior facet on fluoroscopy. 5. Through the same exposure, debride the bursa and degenerate tendon and reattach with anchors if greater than 50% is detached.
- Irrigate thoroughly. If a central tendon-splitting approach was used, repair the split with 0 or 2-0 absorbable sutures.
- Close the paratenon (if preserved) with 2-0 Vicryl, the subcutaneous tissue with 2-0 Vicryl to take tension off the skin, and the skin with 3-0 nylon horizontal mattress or a running non-absorbable suture. If skin tension is a concern, use a V-to-Y advancement or a small relaxing incision.
- Apply a well-padded below-knee posterior splint or cast with the foot in approximately 20-30 degrees of plantarflexion (neutral is acceptable for anchor repairs; slight plantarflexion relaxes the repair).
The sural nerve runs in the subcutaneous fat posterolateral to the Achilles tendon, approximately 1-2 cm lateral to it at the level of the calcaneal insertion, and in 15-20% of people runs closer (less than 1 cm) or crosses the tendon. It is the most commonly injured structure in posterior heel surgery, causing lateral heel numbness or a painful neuroma. Identify it proximally before flap elevation, protect it throughout, prefer a medial paramedial approach when no osteotomy is needed, and elevate full-thickness flaps sharply on the periosteum to keep the nerve safe in the subcutaneous layer.
The posterior facet of the subtalar joint lies just anterior to the posterosuperior tuberosity. A Zadek osteotomy that violates the posterior facet produces subtalar arthritis, pain and loss of hindfoot motion. Palpate the facet, mark its posterior margin, make the osteotomy at least 1-1.5 cm posterior to it, and confirm on fluoroscopy before and after cutting that the osteotomy does not enter the facet.
After contouring the prominence, palpate the posterosuperior corner (it should be flush), confirm on lateral fluoroscopy that parallel pitch lines are now negative, then passively dorsiflex the ankle. No soft-tissue impingement should be palpable between the Achilles and the calcaneus. If impingement or a residual bump persists, take the burr back until clearance is achieved — incomplete resection is the most common cause of recurrent symptoms.
Place anchors in the dense cortical bone of the posterosuperior tuberosity, not the weak cancellous body, and confirm each is fully seated with secure purchase by pulling on the suture limbs before passing them through the tendon. Debride to healthy tissue so sutures do not cut through degenerate tendon, and tie with the foot held in maximal plantarflexion so the repair is not under tension.
Aftercare & Complications
Rehabilitation. Strict elevation above heart level for the first 72 hours is the single most important wound-protective measure. | Phase | Timing | Immobilisation & weight-bearing | Therapy focus | |-------|--------|----------------------------------|---------------| | 1 | 0-6 weeks | Below-knee cast or CAM boot; strict non-weight-bearing (4 weeks for isolated exostectomy with intact tendon; 6 weeks if anchors or a Zadek osteotomy); foot in slight plantarflexion or neutral; strict elevation first 72 hours | Wound check at 7-10 days; toe active motion only | | 2 | 6-12 weeks | Progressive weight-bearing in CAM boot with heel wedges (wean over 2-3 weeks); boot removed by 10-12 weeks | Gentle active ROM; proprioception; wean into a cushioned shoe with a 1-1.5 cm heel lift | | 3 | 12-24 weeks | Supportive shoe with heel lift | Eccentric loading (modified Alfredson, limiting dorsiflexion); bilateral then single-leg heel raises; cycling and swimming | | 4 | 3-9 months | — | Gradual return to running and sport (3-6 months isolated exostectomy; 6-9 months anchors or Zadek) | Multimodal analgesia (regular paracetamol, short NSAID course, 5-7 days opioid, gabapentinoid for nerve irritation) covers the early phase. Mechanical DVT prophylaxis is used for the first 2 weeks, with chemical prophylaxis added for additional risk factors (previous VTE, BMI greater than 40, immobility). Return-to-sport criteria are full pain-free range of motion, single-leg heel-raise strength at least 80% of the contralateral side, and pain-free hopping and sport-specific movement. Complications. The posterior heel soft-tissue envelope is thin, relatively avascular and subject to shoe shear — so wound problems dominate. Meticulous full-thickness flaps, haemostasis, layered tension-free closure and strict elevation are the preventive pillars.
- Incidence
- 2-10% transient numbness; 1-3% persistent neuroma
- Recognition
- Numbness, tingling or burning along the lateral heel and lateral foot; positive Tinel at the surgical site
- Prevention and management
- Prevention: identify the nerve before flap elevation; prefer a medial paramedial approach; full-thickness periosteal flaps; protect with a vessel loop. Management: most neurapraxia resolves in 3-6 months; persistent neuroma — desensitisation, gabapentin or pregabalin; neurolysis or neuroma excision with transposition for refractory cases
- Incidence
- 5-15%
- Recognition
- Skin-edge necrosis, dehiscence or full-thickness loss at the posterior heel 1-3 weeks post-op; exposed tendon or bone in severe cases
- Prevention and management
- Prevention: full-thickness periosteal flaps, meticulous haemostasis, layered closure without tension, relaxing incision or V-to-Y if needed, strict elevation for 72 hours, no early weight-bearing. Management: superficial — saline dressings, antibiotics if infected, elevation; deep with exposed tendon or bone — negative-pressure therapy then secondary closure or skin graft; flap coverage if extensive
- Incidence
- Less than 5%
- Recognition
- Loss of plantarflexion power versus the other side; inability to single heel-raise; palpable gap at the insertion; pain on resisted plantarflexion
- Prevention and management
- Prevention: adequate anchor purchase in cortical bone; confirm fixation before tying; repair with foot in plantarflexion; protect non-weight-bearing 4-6 weeks. Management: partial — boot, extend protected loading, physiotherapy; complete — revision anchor repair, possible FHL transfer for chronic irreparable tears
- Incidence
- 3-8%
- Recognition
- Erythema, warmth, swelling and increasing pain at the wound 5-14 days post-op; purulent discharge from suture sites
- Prevention and management
- Prevention: perioperative antibiotic prophylaxis, meticulous skin preparation, haemostasis, layered closure. Management: wound swab; oral antibiotics guided by culture (flucloxacillin or cephalexin first-line); remove affected sutures; local care; return to theatre for washout if deep infection suspected
- Incidence
- 5-10%
- Recognition
- Return of posterolateral heel pain after initial resolution; tenderness at the posterosuperior calcaneus or insertion; shoe impingement returning
- Prevention and management
- Prevention: complete prominence resection verified on fluoroscopy; complete bursal excision; thorough tendon debridement; no residual bony spicules. Management: lateral radiographs and MRI to rule out incomplete resection; repeat injection for mild symptoms; revision exostectomy with tendon repair, or a Zadek osteotomy if not previously performed, for refractory cases
- Incidence
- 1-3% non-union; 2-5% malunion
- Recognition
- Persistent osteotomy-site pain beyond 3 months; loss of hindfoot alignment; hardware failure on radiographs; no bridging trabeculae on CT
- Prevention and management
- Prevention: accurate congruent cuts; compression with lag screws; strict non-weight-bearing 6 weeks. Management: non-union — revision fixation with bone grafting; malunion — corrective osteotomy if symptomatic hindfoot malalignment
- Incidence
- 10-20% (screws after Zadek)
- Recognition
- Pain or skin irritation over the screw heads at the posterosuperior calcaneus; shoe rubbing over hardware
- Prevention and management
- Prevention: countersink screws adequately; confirm hardware is not prominent on fluoroscopy. Management: hardware removal once the osteotomy is united (typically 6-12 months); removal is usually curative
Viva & Exam Focus
HAGLUNDHAGLUND — Diagnosis and pre-operative planning
SURGEONSURGEON — Operative technique steps
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 42-year-old recreational runner presents with a 12-month history of posterolateral right heel pain. She has tried heel lifts, activity modification, a structured eccentric loading programme, and a single ultrasound-guided corticosteroid injection into the retrocalcaneal bursa with temporary relief. Her lateral heel radiograph shows a positive parallel pitch lines test and a Fowler-Philip angle of 74 degrees. MRI shows thickening of the retrocalcaneal bursa, intratendinous calcification at the Achilles insertion, and approximately 60% detachment of the tendon from the calcaneal tuberosity. How do you manage her?”
“A 55-year-old man with a long-standing Haglund deformity underwent an isolated calcaneal exostectomy 18 months ago at another hospital. His initial pain relief lasted 6 months but he has had recurrence of posterolateral heel pain, which is now worse than before surgery. Examination reveals tenderness at the posterosuperior calcaneus, a positive two-pinch test, and pain on full dorsiflexion. Radiographs show a residual posterosuperior prominence. MRI shows recurrent retrocalcaneal bursitis and a new area of intratendinous calcification at the Achilles insertion. How do you proceed?”
“A 35-year-old woman is being counselled for Haglund deformity correction. She asks you about the differences between open and endoscopic surgery. How do you explain the options?”
Diagnosis
- Haglund deformity = posterosuperior calcaneal prominence impinging on the retrocalcaneal bursa and Achilles insertion
- Clinical: posterolateral heel pain, shoe rubbing, tenderness at the insertion and posterosuperior calcaneus, positive two-pinch test
- Radiographic: Fowler-Philip angle greater than 69 degrees, positive parallel pitch lines, Haglund angle greater than 65-70 degrees
- Three components: bony prominence, retrocalcaneal bursitis, insertional tendinopathy — most patients have all three
- MRI: bursal wall thickening, tendon degeneration, partial tearing, intratendinous calcification, percentage of insertion detached
Non-operative first (minimum 3-6 months)
- Heel lift (1-1.5 cm) and open-backed shoes or a heel-counter cut-out
- Eccentric loading (modified Alfredson) — limit dorsiflexion to avoid exacerbating insertional pain
- Image-guided corticosteroid injection into the bursa (NOT the tendon) — 50-70% short-term relief
- Activity modification and gastrocnemius-soleus flexibility work
- PRP: limited evidence; not a replacement for structured rehabilitation
Surgical anatomy
- Sural nerve: 1-2 cm lateral to the Achilles at the insertion; from the medial sural cutaneous nerve plus the peroneal communicating branch; supplies the lateral heel and fifth toe
- Achilles insertion: posterior third of the calcaneal tuberosity; central third bears the highest load; medial and lateral margins thinner
- Retrocalcaneal bursa: between the Achilles and the posterosuperior calcaneal cortex; hypertrophied and fibrotic in Haglund syndrome
- Posterior facet of the subtalar joint: just anterior to the posterosuperior tuberosity — must not be violated by a Zadek osteotomy
Operative technique — key steps
- Prone, calf tourniquet (250 mmHg), lateral fluoroscopy, mark the sural nerve and the prominence
- Approach: central tendon-splitting (best exposure), medial paramedial (protects the sural nerve), or lateral (for a Zadek osteotomy)
- Full-thickness periosteal flaps — the most important step to prevent wound breakdown
- Excise the retrocalcaneal bursa completely
- Resect the prominence with an oscillating saw; contour with a burr; verify on fluoroscopy (parallel pitch lines negative)
- Debride degenerate Achilles and excise intratendinous calcification
- If more than 50% detached: reattach with suture anchors (double-row preferred); place anchors in the cortical bone of the posterosuperior tuberosity
- Layered closure without tension; relaxing incision or V-to-Y if skin deficit anticipated
Zadek osteotomy
- Indications: large prominence (greater than 15 mm), steep calcaneal inclination, failed isolated exostectomy
- Dorsal closing wedge posterior to the subtalar joint — shifts the tuberosity posteriorly and inferiorly, decompressing the insertion
- Fix with 1-2 6.5-7.3 mm cannulated lag screws (posterior to anterior)
- Must be entirely posterior to the posterior facet — confirm on fluoroscopy
- 6 weeks strict non-weight-bearing; 10-20% require hardware removal
Danger zones
- Sural nerve: identify before flap elevation; protect with a vessel loop; a medial approach keeps it out of the wound
- Wound breakdown: full-thickness periosteal flaps, layered closure without tension, strict elevation for 72 hours
- Incomplete prominence resection: most common cause of failure; verify on fluoroscopy; palpate for a residual bump; check dorsiflexion clearance
- Subtalar joint: a Zadek osteotomy must not violate the posterior facet; palpate and fluoroscope before cutting
Complications
- Sural nerve injury: 2-10% transient, 1-3% neuroma; identify and protect; manage neurapraxia conservatively, neuroma with neurolysis or excision
- Wound breakdown: 5-15%; the most common and troublesome complication; prevent with periosteal flaps, no tension, elevation; manage with local care, VAC, or flap coverage
- Achilles avulsion: less than 5%; ensure adequate anchor purchase; protect non-weight-bearing 4-6 weeks; revision repair or FHL transfer for chronic failure
- Recurrence: 5-10%; usually incomplete resection; revision with a Zadek osteotomy and repeat debridement
- Hardware prominence after Zadek: 10-20%; removal once united (6-12 months)
Rehabilitation
- Weeks 0-6: non-weight-bearing in a CAM boot; strict elevation for the first 72 hours; wound check at 10 days
- Weeks 6-12: progressive weight-bearing in the boot with heel wedges (wean over 2-3 weeks); begin ROM exercises
- Weeks 12-24: eccentric loading programme; bilateral then single-leg heel raises; proprioception; cycling and swimming
- Return to running: 3-6 months (isolated exostectomy); 6-9 months (anchor repair or Zadek osteotomy)
- Return-to-sport criteria: full pain-free ROM, single-leg heel-raise strength 80% of the contralateral side, pain-free hopping
Background & Evidence
Epidemiology. Haglund deformity (the "pump bump") is classically associated with rigid-backed footwear and repetitive posterior heel impingement, and so is over-represented in runners and in women wearing pump-style shoes; it is frequently bilateral. Most surgical patients are in the fourth to sixth decade and have failed a prolonged non-operative programme. Pathoanatomy — three interlocking problems. - The bony prominence. The posterosuperior calcaneal tuberosity is enlarged or abnormally shaped, projecting superiorly and posteriorly to impinge on the overlying tendon and bursa. Three morphological types are described: Type A — a smooth, rounded posterosuperior corner (normal, least prone to impingement); Type B — a prominent, squared-off corner with a well-defined superior lip that directly impinges on the bursa (the most common Haglund shape); Type C — a separate posterosuperior ossicle or a very prominent superior projection (the most severe form).
- Retrocalcaneal bursitis. The sub-Achilles bursa — roofed by the tendon and floored by the posterosuperior cortex — is compressed between the enlarged prominence and the tendon. Chronic compression produces bursal wall hypertrophy and fibrosis, inflammatory fluid, and adhesions between the bursa, calcaneus and tendon.
- Insertional Achilles tendinopathy. The degenerative process at the insertion proceeds through mucoid degeneration of the tendon substance, fibrocartilaginous metaplasia at the enthesis, dystrophic intratendinous calcification (visible on radiographs and needing surgical excision), partial avulsion (reattach if greater than 50% of the footprint is detached), and secondary tendon irritation from the chronic bursitis.
- How to measure
- Angle between the posterior calcaneal tuberosity and a line along the undersurface of the calcaneus
- Normal
- Less than 69 degrees
- Pathological
- Greater than 69 degrees
- How to measure
- A line along the inferior cortex and a second along the superior cortex; positive when the posterosuperior corner projects above the inferior line
- Normal
- Lines parallel or the corner within the lines
- Pathological
- Corner projects above the inferior cortex line
- How to measure
- Angle from the intersection of a line along the posterior cortex and a line along the anterior cortex
- Normal
- Less than 60-65 degrees
- Pathological
- Greater than 65-70 degrees
- How to measure
- Angle between the inferior calcaneal cortex and the horizontal plane
- Normal
- 15-30 degrees
- Pathological
- Variable — a steep angle contributes to impingement
Distinguishing the three overlapping diagnoses. A Haglund deformity is a bony prominence of the posterosuperior tuberosity — a radiographic diagnosis (Fowler-Philip angle, parallel pitch lines) that may be asymptomatic until footwear or activity irritates the bursa and tendon. Retrocalcaneal bursitis is inflammation of the bursa between the tendon and the prominence — posterolateral pain, worse with shoe wear, tender lateral to the tendon. Insertional Achilles tendinopathy is degeneration and often partial tearing of the tendon at its calcaneal insertion — pain directly at the insertion with possible swelling and calcification. Combined pathology is the rule in surgical patients: the prominence irritates the bursa, chronic bursitis drives tendon degeneration, and the degenerate tendon loses its load-absorbing capacity — which is why surgery addresses all three components. Sural nerve — detailed anatomy. Formed in the mid-calf by the union of the medial sural cutaneous nerve (from the tibial nerve) and the peroneal communicating branch (from the common peroneal nerve), it runs distally in the subcutaneous fat of the posterolateral calf, posterior to the lateral malleolus (approximately 1-1.5 cm posterior to it), then along the lateral border of the foot to supply the lateral heel, the lateral foot, and the lateral fifth toe. At the level of the calcaneal insertion (approximately 5-6 cm proximal to the calcaneal tubercle) it lies approximately 1-2 cm lateral to the Achilles tendon, superficial to the crural fascia and the peroneal tendon sheath. In approximately 15-20% of individuals it runs closer to the tendon (less than 1 cm) or crosses its posterior aspect — the basis for identifying it before any lateral flap elevation.
- Isolated exostectomy + debridement
- Moderate Haglund deformity, intact or minimally detached tendon
- Zadek osteotomy + debridement
- Large deformity (greater than 15 mm), unfavourable calcaneal inclination, or failed exostectomy
- Isolated exostectomy + debridement
- Paramedial (medial or lateral) or central tendon-splitting
- Zadek osteotomy + debridement
- Lateral approach to allow osteotomy and screw insertion
- Isolated exostectomy + debridement
- Yes — for exposure and debridement; reattach if more than 50% detached
- Zadek osteotomy + debridement
- Less detachment; tendon debrided in-situ through the exposure gained by the osteotomy
- Isolated exostectomy + debridement
- Suture anchors (if reattachment needed)
- Zadek osteotomy + debridement
- Suture anchors (if reattachment) plus 1-2 6.5-7.3 mm cannulated lag screws for the osteotomy
- Isolated exostectomy + debridement
- 4-6 weeks (tendon healing)
- Zadek osteotomy + debridement
- 6 weeks (osteotomy healing, longer than isolated exostectomy)
- Isolated exostectomy + debridement
- Rare (anchor only)
- Zadek osteotomy + debridement
- 10-20% for symptomatic screw removal
- Isolated exostectomy + debridement
- 3-6 months
- Zadek osteotomy + debridement
- 4-8 months
- Isolated exostectomy + debridement
- 75-90% at 2-5 years
- Zadek osteotomy + debridement
- 85-95% at 2-5 years in selected cases
Special situations. When insertional disease coexists with separate non-insertional (mid-substance) tendinopathy, address the insertional component first, then inspect the mid-substance through the same or a proximal incision — a longitudinal tenotomy with core debridement for tendinosis, and a flexor hallucis longus (FHL) transfer to augment if more than 50% of the cross-section is involved. For failed primary surgery, incomplete prominence resection accounts for 50-60% of failures; reassess with MRI, repeat the exostectomy with thorough recontouring (or add a Zadek osteotomy), revise the tendon repair with double-row anchors (or an FHL transfer if irreparably degenerate), and warn that revision satisfaction is only 60-75%. Endoscopic calcaneoplasty — two posterior portals, a 4.0 mm arthroscope, shaver bursectomy and burring of the prominence — suits a moderate prominence with an intact tendon and predominant bursal pathology; it cannot reliably deliver anchor reattachment and has a steep learning curve. Key evidence. Yodlowski (Level IV, 35 patients) established that prominence resection with complete bursectomy and paratenon excision gives complete or significant relief in around 90% failing non-operative care — the foundation of modern Haglund surgery. Kiriluk (Level III, 77 patients) showed a percutaneous Zadek osteotomy gives comparable early patient-reported outcomes to open resection with acceptable complications, avoiding tendon splitting. Thiounn (Level III, 85 patients) found endoscopic calcaneoplasty allowed a significantly faster return to sport (41.6% versus 20.6% at 3 months) with comparable longer-term functional outcomes. Ramelli (Level I systematic review) confirmed double-row repair is biomechanically superior in footprint contact and pull-out strength, though single-row and double-row achieve comparable clinical outcomes. Morrissette (Level III, 370 patients) identified higher BMI — obesity (BMI greater than 30) in particular — as a significant modifiable risk factor for wound breakdown, supporting preoperative weight optimisation and counselling.
References
Surgical treatment of Achilles tendinitis by decompression of the retrocalcaneal bursa and the superior calcaneal tuberosity
- Retrospective cohort of 35 patients (41 feet) with insertional Achilles tendinopathy refractory to 6 months of non-operative treatment, treated with calcaneal exostectomy, complete retrocalcaneal bursectomy, and paratenon excision
- Pain scores improved from 4.7 to 1.5 (0-6 scale) at mean 39-month follow-up; 90% had complete or significant relief, 10% improved, none unchanged or worse
- Surgical resection of the prominent tuberosity, complete bursa debridement, and excision of thickened paratenon provided reliable pain relief in patients failing non-operative management
Percutaneous Zadek Osteotomy vs Open Haglund Resection for Insertional Achilles Tendinopathy: Early Outcomes and Complication Rates
- Retrospective comparative study of 77 patients: 43 open midline Achilles tendon-splitting Haglund resection versus 34 percutaneous Zadek osteotomy for insertional Achilles tendinopathy with Haglund deformity
- Both groups showed significant improvement in PROMIS function, pain, and mobility scores at minimum 12-month follow-up
- Percutaneous Zadek osteotomy offers a less invasive alternative to open resection with comparable early patient-reported outcomes and acceptable complication rates
Comparison of open and endoscopic techniques of isolated calcaneoplasty in the surgical treatment of insertional tendinopathy of the Achilles tendon
- Multicentre prospective comparative study of 85 patients: 51 endoscopic and 34 open calcaneoplasty for insertional Achilles tendinopathy refractory to medical treatment
- At 3 months postoperatively, significantly more patients had returned to sports in the endoscopic group (41.6% vs 20.6% in the open group)
- Both groups showed significant improvement in EFAS daily living, EFAS sports, and VISA-AF scores; endoscopic approach allowed faster return to sport without difference in overall functional outcome at longer follow-up
Single-Row Repair Versus Double-Row Repair in the Surgical Management of Achilles Insertional Tendinopathy: A Systematic Review
- Systematic review of biomechanical and clinical studies comparing single-row and double-row repair for Achilles insertional tendinopathy, following PRISMA guidelines
- Double-row repair demonstrated biomechanically superior footprint contact area and pull-out strength in cadaveric studies compared with single-row repair
- Clinical outcomes (return to activity, pain scores, reoperation rates) were comparable between single-row and double-row techniques, though biomechanical advantages of double-row may be relevant for extensive detachment
Higher BMI Is Associated With Wound Breakdown Following Resection of Haglund Deformity
- Retrospective review of 370 patients undergoing Haglund deformity resection at a single academic centre, stratified by BMI (normal, overweight, obese)
- Wound breakdown was the most common complication; higher BMI was significantly associated with increased wound complication rates following Haglund resection
- Obesity (BMI greater than 30) is a modifiable risk factor for postoperative wound complications; patients should be counselled preoperatively and optimised before surgery