Haglund Syndrome and Insertional Achilles Tendinopathy

Haglund syndrome and insertional Achilles tendinopathy are taught together because they coexist in 60-70 percent of posterior heel pain presentations. Insertional tendinopathy accounts for 20-25 percent of all Achilles tendon pain. Distinguishing pure Haglund, which is bone and bursa, from insertional tendinopathy, which is tendon-driven, changes both the conservative algorithm and the surgical plan.

Who. The peak is at 30-50 years, with a second, smaller peak in active adolescents of the Sever type. Women are more often affected, the pump bump coming from rigid heel counters. Runners tend to present with insertional tendinopathy, and walkers in tight dress shoes with Haglund.

Which feet. A cavus foot, a varus heel and a Haglund-shaped calcaneus predispose, and gastrocnemius-soleus equinus increases the impingement.

Burden. 25 percent are chronic after first-line conservative care, and conservative care fails in roughly 25-50 percent of insertional cases; these are the patients who present for a surgical opinion, and 5-10 percent eventually undergo surgery. VISA-A scores are commonly 50-60 out of 100 at presentation.

The anatomy. The Haglund deformity is a posterosuperior prominence of the calcaneus at the Achilles insertion. Two bursae lie beside it: the retrocalcaneal bursa between the anterior distal Achilles and the calcaneus, and the subcutaneous bursa between the tendon and the skin.

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Each component has its own driver, its own histology and its own place on imaging.

Why the tendon fails. The zone 2-7 cm above the insertion is a watershed area, and the insertional fibres have a separate, poorer blood supply of their own. Under repetitive load, collagen microfailure outstrips repair. Abnormal vessels then grow in with accompanying nerves, which are substance P positive, and these neovessels are the target of sclerosing injections. Calcification is the end-stage finding, often with intratendinous bone formation.

Why the bone impinges. In dorsiflexion the prominent calcaneal corner drives into the anterior Achilles; with equinus, limited dorsiflexion means more impingement per step. A rigid shoe counter compresses the skin and the superficial bursa. Cavus and varus matter because hindfoot varus loads the lateral insertion more.

The classification that earns its place is by which components are present, because that is what drives the choice between simple ostectomy and combined tendon reconstruction. Retrocalcaneal bursitis can occur without a Haglund prominence, and the tendon can be diseased without a prominent bone.

History. The pain sits at the posterior heel, at or just above the Achilles insertion. It is aggravated by dorsiflexion (stairs, hills), rigid shoe backs and prolonged standing, and relieved by open-back shoes, heel lifts, rest and NSAIDs. Morning stiffness is classic for insertional tendinopathy and not for pure bursitis. Ask about shoe wear (tight dress shoes, ice skates, ski boots) and activity (running mileage, hill work, a sudden spike in load).

Inspection. Look for the posterosuperior bump, erythema, swelling, callus and the pump-bump sign.

Palpation stages the pathology. Where the heel is tender tells you which component is driving it, and the findings are not exclusive, but they help stage the pathology and tailor the imaging:

• Single-finger tenderness at the posterosuperior bony corner suggests Haglund
• Two-finger mediolateral pinch tenderness anterior to the tendon, just above the insertion, suggests retrocalcaneal bursitis; the two-finger squeeze gives a pincer-like tenderness of bursa and tendon
• A tender, thickened tendon, pain on compressing the tendon with the ankle plantarflexed, morning stiffness and a painful heel raise point to insertional tendinopathy

Movement and strength. Measure dorsiflexion and perform the Silfverskiöld test for gastrocnemius equinus. The single-leg heel raise is often weak and painful in chronic tendinopathy.

Nerves. Palpate the sural nerve and Baxter's nerve at the medial heel.

The lateral radiograph comes first. A weight-bearing lateral of the ankle or calcaneus. Look for the posterosuperior bony prominence, the parallel pitch lines, the Fowler-Philip angle, intratendinous calcification and a posterior calcaneal cyst. It defines the bone component and guides the ostectomy, and most Haglund decisions can be made on a good weight-bearing lateral with the parallel pitch lines drawn.

Drawing the lines. The parallel pitch lines (Pavlov) are a plantar tangent along the inferior calcaneus and a second line parallel to it through the posterior lip of the talar facet. A posterosuperior corner that projects above the upper line is abnormally prominent, a positive sign: the calcaneus is too tall. The Fowler-Philip angle, between the plantar surface and the posterior surface of the tuberosity, supports a Haglund deformity when it exceeds about 75 degrees, though its sensitivity is limited. A calcaneal pitch over 30 degrees marks a cavus predisposition, so watch for varus overload.

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Shape is not the diagnosis. The lines and the angle measure the shape of the heel, and Haglund morphology is common and frequently asymptomatic. In the Fiamengo case-control series in the evidence section, the Fowler-Philip angle did not differ between symptomatic heels and 104 controls; what separated them was the calcaneal step, tendon calcification and calcaneal length. The pitch lines define Haglund and the bone an ostectomy would remove; they do not decide whether to remove it. Use the angles to describe the heel, then let focal tenderness, imaging-confirmed bursitis or insertional tendinopathy, and failure of loading decide whether to operate on it.

Ultrasound. A dynamic assessment of the retrocalcaneal bursa, tendon thickening and neovessels: a bursal fluid crescent, tendon thickening greater than 6 mm, hypoechoic areas and neovascularisation on Doppler. It is operator dependent, but cheap and readily repeatable.

MRI. Reserved for when tendon quality is unclear (chronic cases, failed conservative care, suspected partial tear), for surgical planning, or when the diagnosis is in doubt. Do not MRI every patient with posterior heel pain. It is the best test for tendon quality and partial tears, and shows intrasubstance signal, calcification, partial tear, retrocalcaneal fluid and Kager fat pad oedema.

What each finding changes. Imaging guides the surgical plan more than the clinical examination alone:

• Increased intrasubstance signal at the insertion means tendinopathy or partial tear, and indicates tendon work
• A crescent of retrocalcaneal fluid anterior to the tendon is retrocalcaneal bursitis, and responds to bursectomy
• Intratendinous calcification, bone within the tendon on X-ray, is end-stage tendinopathy and must be debrided

The Zadek osteotomy: the tendon-sparing alternative

What it is. A dorsal closing-wedge calcaneal osteotomy (Zadek, also credited to Keck and Kelly), the emerging option that treats the bony geometry without touching the Achilles insertion at all. Removing a dorsally based wedge from the tuberosity reduces the calcaneal pitch and rotates the posterosuperior prominence away from the tendon, so the impinging corner no longer abuts the Achilles, rather than debriding the tendon and its footprint.

Why it appeals. It avoids detaching any part of the insertion, so the question of how much of the footprint can be taken down does not arise, and it needs no anchor reattachment or augmentation.