Haglund Deformity and Insertional Achilles Correction

Surgical Indications

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 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

Evidence for Non-Operative Treatment

Heel-Lift Orthosis and Shoe Modification

• A heel lift (1-1.5 cm) inside the shoe reduces Achilles tension at the insertion and offloads the retrocalcaneal bursa — this is the first-line conservative measure
• Shoe modification: open-backed shoe or a heel counter with a cut-out at the posterosuperior corner (the Haglund bump area) eliminates direct shoe pressure
• Posterior heel cushioning pads (silicone heel sleeves, felt pads) reduce direct impingement from footwear
• 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

Injections

• Corticosteroid injection into the retrocalcaneal bursa provides short-term pain relief in 50-70% of cases, but carries a risk of Achilles tendon rupture if injected into the tendon substance — image-guided (ultrasound) injection into the bursa is preferred
• Platelet-rich plasma (PRP) injection: limited evidence for insertional tendinopathy; some case series report symptomatic improvement but the evidence is not robust and it is not considered a replacement for structured rehabilitation
• High-volume injection (saline and steroid) has been described for non-insertional Achilles tendinopathy but has no specific evidence for Haglund deformity

Evidence for Surgery

Prominence Resection with Tendon Debridement

• Resection of the posterosuperior calcaneal prominence combined with debridement of the degenerate tendon and retrocalcaneal bursa provides reliable pain relief in 75-90% of patients at medium-term follow-up (2-5 years)
• Anderson et al. reported satisfactory outcomes in 85% of patients at mean 3.4-year follow-up after calcaneal exostectomy with tendon debridement; patients with greater than 50% tendon detachment requiring anchor reattachment had somewhat lower satisfaction
• The most common reason for residual dissatisfaction is incomplete prominence resection — impingement persists if the posterosuperior corner is not fully flattened

Zadek Osteotomy

• The Zadek dorsal closing-wedge osteotomy is indicated for Haglund deformity with a large posterosuperior prominence (greater than 15 mm), a steep calcaneal inclination angle, or failure of isolated prominence resection
• By removing a dorsal wedge and shifting the tuberosity posteriorly, the osteotomy decompresses the Achilles insertion without requiring an extensive tendon detachment for exposure
• Nielson et al. reported 89% good-to-excellent results at mean 4.5-year follow-up after Zadek osteotomy with concurrent Achilles debridement
• Advantages over isolated exostectomy: avoids extensive tendon detachment in selected cases, addresses the biomechanical cause of the prominence, and allows simultaneous correction of calcaneal malalignment
• Disadvantages: requires internal fixation (screws), longer period of protected weight-bearing (6 weeks non-weight-bearing for osteotomy healing), hardware removal in 10-20% of cases if symptomatic

Key Evidence

Posterosuperior Calcaneal Tuberosity

The Haglund Prominence

The posterosuperior calcaneal tuberosity is the bony prominence at the posterosuperior corner of the calcaneus where the Achilles tendon inserts. In Haglund deformity, this prominence is enlarged or abnormally shaped, projecting superiorly and posteriorly to impinge on the overlying Achilles tendon and retrocalcaneal bursa.

The shape of the posterosuperior corner varies widely between individuals. Three morphological types are described:

• Type A: A smooth, rounded posterosuperior corner — normal appearance, least prone to impingement
• Type B: A prominent, squared-off posterosuperior corner — the most common Haglund shape, with a well-defined superior lip that directly impinges on the bursa
• Type C: A separate posterosuperior ossicle or a very prominent superior projection — most severe form

Radiographic Measurements

Achilles Tendon Insertion

Insertion Anatomy

The Achilles tendon is the conjoined tendon of the gastrocnemius and soleus muscles. It is the thickest and strongest tendon in the body, with a peak cross-sectional area of approximately 50-80 square millimetres at its mid-substance. The tendon inserts on the posterior surface of the calcaneal tuberosity.

The insertion footprint has a characteristic shape:

• Central portion: broadest area of attachment, highest tensile load-bearing area
• Medial margin: thinner, continuous with the plantar fascia via the paratenon (the plantaris tendon runs here, variably present)
• Lateral margin: thinner, closely applied to the retrocalcaneal bursa

Insertional Achilles Tendinopathy — Pathoanatomy

The degenerative process at the insertion involves:

1. Mucoid degeneration of the tendon substance at the insertion — loss of collagen organisation, increased ground substance
2. Fibrocartilaginous metaplasia at the tendon-bone junction — the enthesis normally contains fibrocartilage; in tendinopathy this becomes disorganised and partially detached
3. Intratendinous calcification: dystrophic calcification within the tendon substance, visible on radiographs. May be located within the tendon or at the tendon-bone interface. Needs surgical excision
4. Partial avulsion: the degenerate tendon partially tears away from its bony insertion. If greater than 50% of the footprint is detached, the remaining tendon is under increased stress and reattachment is recommended
5. Retrocalcaneal bursitis: the bursa between the Achilles tendon and the calcaneus becomes inflamed, thickened, and scarred. Chronic bursitis can cause secondary tendon irritation

Sural Nerve — Detailed Anatomy

Course

The sural nerve is formed in the mid-calf by the union of:

• The medial sural cutaneous nerve (branch of the tibial nerve)
• The peroneal communicating branch (branch of the common peroneal nerve)

The nerve courses distally in the subcutaneous fat of the posterolateral calf, running 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, lateral border of the foot, and the lateral aspect of the fifth toe.

Relationship to the Achilles Tendon and Calcaneus

At the level of the calcaneal insertion (approximately 5-6 cm proximal to the calcaneal tubercle), the sural nerve lies:

• Approximately 1-2 cm lateral to the lateral border of the Achilles tendon
• Superficial to the crural fascia and the peroneal tendon sheath
• At risk during lateral or posterolateral approaches to the calcaneus

Variations

In approximately 15-20% of individuals, the sural nerve runs closer to the Achilles tendon (less than 1 cm) or even crosses the posterior aspect of the tendon. The peroneal communicating branch may join the sural nerve at variable levels, sometimes very distally, producing a thin branch that crosses the surgical field.

Clinical Importance

• The sural nerve is the most commonly injured structure in surgery around the posterior heel
• Injury causes numbness along the lateral heel and lateral foot, and may produce a painful neuroma
• Prevention: identify the nerve proximally before flap elevation, protect it throughout, and avoid excessive lateral retraction

Retrocalcaneal Bursa

Anatomy

The retrocalcaneal (sub-Achilles) bursa is a thin-walled bursa located between the posterior surface of the calcaneus (anterosuperior to the posterosuperior tuberosity) and the anterior surface of the Achilles tendon, just proximal to the tendon insertion. Its roof is formed by the Achilles tendon; its floor is the posterosuperior calcaneal cortex.

In Haglund deformity, the bursa is compressed between the enlarged calcaneal prominence and the tendon. Chronic compression leads to:

• Bursal wall hypertrophy and fibrosis: the bursa becomes thick-walled and scarred
• Inflammatory fluid accumulation: acute or chronic bursitis with effusion
• Adhesions between the bursa, the calcaneus, and the tendon

Operative Importance

Complete excision of the retrocalcaneal bursa (bursoscopy or open bursectomy) is a key step in Haglund surgery. Incomplete bursal excision leaves inflamed tissue that perpetuates symptoms. The bursa is excised sharply and sent for histopathology.

Positioning and Preparation

Patient position: Prone on the operating table with a padded post (or bolster) under the tibia to elevate the calf and foot off the table. This allows unrestricted access to the posterior heel. The foot hangs freely or rests on a padded foot rest. Ensure the peroneal nerve is not compressed at the fibular neck by the bolster.

Tourniquet: Calf tourniquet (250 mmHg). Exsanguinate the limb with an Esmarch bandage before inflating. Limit tourniquet time to less than 90 minutes — the Achilles repair requires meticulous suturing and prolonged tourniquet time increases postoperative stiffness.

Anaesthesia: General anaesthesia with a popliteal sciatic nerve block (long-acting local anaesthetic such as bupivacaine 0.25% with dexamethasone) for postoperative pain control. Spinal anaesthesia is an alternative. Local infiltration at the wound edges before closure provides additional analgesia.

Fluoroscopy: Image intensifier positioned for a true lateral view of the calcaneus. Confirm the lateral view before prepping — the calcaneus should be clearly visualised. Fluoroscopy is used to verify complete prominence resection and, if performing a Zadek osteotomy, to confirm osteotomy position and screw placement.

Markings: Before inflating the tourniquet, mark the posterosuperior calcaneal prominence by palpation. Mark the course of the sural nerve (estimated 1-2 cm lateral to the Achilles tendon). Mark the proposed incision.

Antibiotic prophylaxis: A single dose of intravenous cefazolin 2 g at induction (or clindamycin 600 mg if penicillin-allergic), repeated if tourniquet time exceeds 4 hours.

Consent: Specifically counsel regarding: sural nerve injury (2-10% numbness, 1-3% neuroma), wound breakdown or infection (5-15%), Achilles avulsion or weakness if reattachment fails (less than 5%), need for hardware removal if Zadek osteotomy performed (10-20%), prolonged recovery (3-6 months to full activity), and the possibility of incomplete pain relief (5-10%).

Approach Selection

Central Tendon-Splitting Approach

• Indications: Most Haglund deformities where extensive tendon debridement is required; provides the best direct access to both the posterosuperior calcaneus and the full tendon insertion
• Technique: A longitudinal skin incision in the midline, then split the Achilles tendon longitudinally in line with its fibres from the musculotendinous junction to the insertion. Each half is retracted to expose the calcaneal prominence and bursa
• Advantages: Excellent exposure of the prominence, bursa, and tendon; avoids sural nerve entirely if incision is truly midline
• Disadvantages: Creates a deliberate tendon split that must be repaired; theoretically weaker during early rehabilitation

Medial Paramedial Approach

• Indications: Preferred when sural nerve protection is the priority; smaller prominences; cases where tendon detachment is anticipated to be less than 50%
• Technique: Longitudinal incision 1-1.5 cm medial to the Achilles tendon border. Develop full-thickness skin flaps laterally to expose the tendon, calcaneus, and bursa. The sural nerve remains lateral to the entire operative field
• Advantages: Sural nerve is outside the wound; good cosmetic result; no deliberate tendon splitting
• Disadvantages: Lateral exposure of the prominence is more limited; may require more extensive lateral flap dissection

Lateral Paramedial Approach

• Indications: Zadek osteotomy (allows lateral screw placement); large lateral prominences; surgeon preference
• Technique: Longitudinal incision 1-1.5 cm lateral to the Achilles tendon border. The sural nerve must be identified and protected during flap elevation
• Advantages: Direct access for lateral screw placement during Zadek osteotomy
• Disadvantages: Sural nerve dissection adds time and risk; lateral scar is more visible and more prone to shoe irritation

Isolated Exostectomy with Tendon Debridement — Step-by-Step

Step 1: Incision and Exposure

Make a longitudinal incision (approximately 6-8 cm) centred on the posterosuperior calcaneal prominence. For a central tendon-splitting approach, place the incision in the midline posterior to the Achilles tendon. For a medial paramedial approach, place it 1-1.5 cm medial to the tendon border.

Incise skin sharply with a number 10 or 15 blade. Develop full-thickness skin flaps by dissecting sharply on the periosteum (or on the paratenon, if using a central tendon-splitting approach). Do not undermine the skin in the subcutaneous plane — this devascularises the flap and increases wound breakdown risk.

Step 2: Retrocalcaneal Bursa Excision

Identify the retrocalcaneal bursa between the Achilles tendon and the posterosuperior calcaneal cortex. The bursa is thickened, inflamed, and scarred in surgical patients. Excise it completely with scissors and a rongeur, including all fibrotic and inflamed tissue. The bursa should be sent for histopathology.

After bursa excision, the posterosuperior calcaneal prominence and the deep surface of the Achilles insertion are fully exposed.

Step 3: Posterosuperior Prominence Resection

Identify the posterosuperior corner of the calcaneus. The prominence is palpable as a hard bony bump projecting superiorly. Use an oscillating saw to make an oblique osteotomy cut through the prominence, angled from posterosuperior to anteroinferior, parallel to the orientation of the Achilles tendon fibres. Remove the bone fragment with a rongeur.

Contour the remaining calcaneal surface with a rongeur and then a burr until the posterosuperior corner is flush and smooth. There should be no residual prominence palpable when the surgeon runs a finger over the posterior calcaneal surface.

Step 4: Achilles Tendon Debridement

Inspect the deep surface of the Achilles tendon insertion. Identify areas of degenerate, discoloured, or friable tendon tissue. Excise these areas sharply with a scalpel, leaving healthy, bleeding tendon margins.

Look for and excise any intratendinous calcification — these appear as hard, gritty, white-yellow deposits within the tendon substance. Remove them completely.

After debridement, assess the percentage of the Achilles insertion that remains attached to the calcaneus:

• Less than 50% detached: the remaining attached tendon is sufficient for direct healing; no anchors needed. Close the tendon defect if possible
• Greater than 50% detached: the tendon is functionally compromised; proceed to suture anchor reattachment

Step 5: Suture Anchor Reattachment (if indicated)

Prepare the calcaneal insertion footprint by freshening the cortical bone with a burr or curette to expose bleeding cancellous bone. Do not over-penetrate into the calcaneal body.

Single-row repair: Insert 2-3 suture anchors (typically 5.0 or 5.5 mm bioabsorbable or metal anchors) into the posterosuperior calcaneal tuberosity along the insertion footprint. Pass the suture limbs through the detached tendon in a Krackow or modified Mason-Allen configuration. Tie sutures with the foot in maximal plantarflexion (this relaxes the repair).

Double-row repair: Insert a medial row of 2 anchors into the medial aspect of the footprint. Pass sutures through the tendon. Insert a lateral row of 1-2 anchors. Pass the medial-row suture limbs through the lateral-row anchors (or use bridging sutures between rows) to create a wider footprint contact. This technique covers a broader area of the calcaneal insertion and has higher pull-out strength in biomechanical studies.

Step 6: Wound Closure

Irrigate the wound thoroughly with normal saline. If a central tendon-splitting approach was used, repair the tendon split with 0 or 2-0 absorbable sutures in a running or interrupted fashion.

Close the paratenon (if preserved) with 2-0 Vicryl. Close the subcutaneous tissue with 2-0 Vicryl to reduce tension on the skin closure. Close the skin with 3-0 nylon horizontal mattress sutures or a running non-absorbable suture. If there is any concern about skin tension, consider a V-to-Y advancement closure or a small relaxing incision.

Apply a well-padded below-knee posterior splint or a below-knee cast with the foot in approximately 20-30 degrees of plantarflexion (neutral is acceptable for anchor repairs; slight plantarflexion relaxes the repair).

Zadek Osteotomy — Technique (When Indicated)

Indications

• Large posterosuperior calcaneal prominence (greater than 15 mm projection above parallel pitch lines)
• Steep calcaneal inclination angle contributing to impingement
• Failed isolated exostectomy with persistent symptoms
• Combined Haglund deformity with hindfoot malalignment

Step 1: Approach

Use a lateral or posterolateral longitudinal incision (approximately 8-10 cm) centred on the posterosuperior calcaneus. Identify and protect the sural nerve. Elevate full-thickness skin flaps on the periosteum.

Step 2: Osteotomy Planning

Palpate the posterior facet of the subtalar joint and mark its posterior margin. The osteotomy must be made entirely posterior to the posterior facet — typically 1-1.5 cm posterior to the facet margin.

Confirm the planned osteotomy site on lateral fluoroscopy. The osteotomy is a dorsal closing wedge, oriented in the sagittal plane, removing a wedge of bone from the dorsum of the calcaneus posterior to the facet.

Step 3: Osteotomy Execution

Using an oscillating saw, make the osteotomy cuts under fluoroscopic guidance:

• Proximal cut: transverse, from the posterosuperior cortex to the plantar cortex
• Distal cut: angled from the posterosuperior cortex to meet the proximal cut on the plantar cortex, creating a closing wedge

The wedge angle is typically 10-20 degrees depending on the size of the prominence. Close the wedge by depressing the calcaneal tuberosity (the posterosuperior fragment shifts posteriorly and inferiorly).

Step 4: Fixation

Fix the osteotomy with 1-2 6.5-7.3 mm partially threaded cannulated lag screws placed from posterior to anterior, across the osteotomy site, under fluoroscopic guidance. Ensure screw threads cross the osteotomy line for compression.

Confirm screw position and osteotomy closure on lateral fluoroscopy. Verify that the osteotomy does not extend into the posterior facet of the subtalar joint.

Step 5: Concurrent Achilles Debridement

Through the same exposure, debride the retrocalcaneal bursa and the degenerate portion of the Achilles insertion as described in steps 2-5 above. Reattach with suture anchors if more than 50% of the insertion is detached.

Post-operative Protocol

Protected Weight-Bearing Phase (Weeks 0-6)

• Immobilisation: Below-knee cast or controlled ankle motion (CAM) boot with the foot in neutral or slight plantarflexion. The foot is pointed slightly down (approximately 20 degrees plantarflexion) for the first 2 weeks if no anchors were used; neutral position is acceptable for anchor repairs
• Weight-bearing status: STRICT non-weight-bearing on the operated side for 4-6 weeks (4 weeks for isolated exostectomy with intact tendon; 6 weeks if suture anchors or Zadek osteotomy were performed). Use crutches or a knee scooter
• Elevation: Elevate the limb above heart level continuously for the first 72 hours, then as much as possible for the first 2 weeks — this is the single most important measure to prevent wound breakdown
• Dressings: Keep the wound dry and inspect at 7-10 days for suture removal (or wound check if absorbable subcuticular closure was used). Replace the cast or boot at this visit
• Analgesia: Multimodal — regular paracetamol, NSAID (if not contraindicated), short course of opioid (5-7 days). Gabapentin or pregabalin if nerve irritation is present. Codeine or tramadol as rescue for breakthrough pain
• DVT prophylaxis: Mechanical (intermittent pneumatic compression device or TED stockings) for the first 2 weeks; chemical prophylaxis (low-molecular-weight heparin) if additional risk factors are present (previous VTE, BMI greater than 40, immobility)

Early Rehabilitation Phase (Weeks 6-12)

• Week 6: Begin progressive weight-bearing in a CAM boot with heel wedges (initially 1-2 heel wedges, reduced over 2-3 weeks)
• Week 6-8: Gentle active range-of-motion exercises — dorsiflexion and plantarflexion within the boot; gentle hindfoot stretching
• Week 8-10: Remove heel wedges; walk in the boot with full weight-bearing; begin proprioception exercises (single-leg balance, wobble board)
• Week 10-12: Begin weaning from the boot to a supportive shoe (cushioned trainer with a 1-1.5 cm heel lift). Begin gentle eccentric loading programme (modified Alfredson protocol — limited dorsiflexion to avoid stressing the repair)

Intermediate Rehabilitation Phase (Weeks 12-24)

• Progressive strengthening: bilateral heel raises, then single-leg heel raises as tolerated
• Eccentric loading programme: slow eccentric lowering from a step (full weight on the forefoot, slowly lower the heel). Limit dorsiflexion to neutral or slightly beyond neutral (do not force full dorsiflexion)
• Proprioception and balance training: single-leg standing on uneven surfaces, wobble board
• Stationary cycling and swimming (flutter kick, no push-off) as aerobic conditioning
• Gradual return to walking distances and light jogging from 3-4 months if pain-free and strength is improving

Return to Sport and Full Activity

• 3-6 months (isolated exostectomy with intact tendon): return to low-impact activities (walking, cycling, swimming); gradual return to running from 4 months
• 6-9 months (anchor reattachment or Zadek osteotomy): return to sport-specific training; full return to high-impact sport (running, jumping, pivoting) from 6-9 months depending on progress
• Criteria for return to sport: full pain-free range of motion, single-leg heel raise strength at least 80% of contralateral side, pain-free hopping and sport-specific movements, completion of eccentric loading programme

Special Case: Combined Insertional and Non-Insertional Achilles Tendinopathy

Presentation

Some patients present with insertional tendinopathy and Haglund deformity (posterosuperior heel pain) alongside a separate area of non-insertional mid-substance Achilles tendinopathy (pain 2-6 cm proximal to the insertion). Both contribute to pain and functional limitation.

Surgical Strategy

• Address the insertional component first (prominence resection, tendon debridement, anchor reattachment as needed)
• Inspect the mid-substance Achilles through the same exposure or through a separate proximal incision
• For mid-substance tendinosis: perform a longitudinal tenotomy (multiple percutaneous or open stab incisions) with debridement of the degenerate core if extensive
• If the mid-substance component is severe (greater than 50% of tendon cross-section involved), consider flexor hallucis longus (FHL) tendon transfer as an augmentation — this provides an active plantarflexion power source and improves outcomes in chronic irreparable Achilles tendinopathy
• The two pathologies are addressed in a single stage when possible; staged surgery is rarely needed

Special Case: Revision Surgery After Failed Haglund Correction

Causes of Failure

• Incomplete posterosuperior prominence resection — the most common cause (50-60% of failures)
• Inadequate tendon debridement with residual degenerate tendon
• Failure to recognise and repair a greater than 50% detachment (tendon heals in an attenuated, lengthened position)
• Wound complications preventing adequate rehabilitation
• Sural nerve injury or neuroma causing pain disproportionate to the heel pathology

Revision Strategy

• Full reassessment with MRI: assess the current state of the calcaneal contour, tendon integrity, bursa, and sural nerve
• For incomplete resection: repeat exostectomy with thorough recontouring of the posterosuperior corner; consider Zadek osteotomy if not previously performed
• For failed tendon repair: revision debridement and reattachment with double-row anchors; consider FHL transfer if the tendon is irreparably degenerate
• For sural nerve neuroma: surgical neurolysis, excision of the neuroma, and transposition of the nerve stump into muscle or bone
• Warn patients that revision surgery has lower success rates (60-75% satisfaction) and higher complication rates than primary surgery

Special Case: Endoscopic Calcaneal Exostectomy

Technique Overview

Endoscopic Haglund correction is performed through two posterior portals (medial and lateral to the Achilles tendon). A 4.0 mm arthroscope is introduced, and the retrocalcaneal bursa is visualised and excised. The posterosuperior calcaneal prominence is identified and resected with an arthroscopic burr.

Indications and Limitations

• Suitable for Haglund deformity with predominantly bursal pathology and an intact or minimally detached tendon insertion
• Limited ability to perform extensive tendon debridement or anchor reattachment through the endoscope
• Steeper learning curve; requires specialised equipment and experience
• Evidence (level III comparative studies) shows comparable pain outcomes to open surgery at 2-year follow-up, with better cosmetic results and faster return to work, but higher operative times and a learning curve for complications