Understanding and Managing Heel Pain: Haglund's Deformity and Bursitis Explained | OEP368

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Hello everyone and welcome to episode 368 of the OrthoEvalPal podcast.
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I'm your host, paul Marquis, and today we're going to be talking about Haglund's deformity or subcutaneous calcaneal bursitis.
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We're going to be discussing the anatomy surrounding the posterior heel.
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We're going to talk about how to differentiate between a Haglund's deformity and subcutaneous calcaneal bursitis.
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We're going to be talking about some of the contributing factors.
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We'll go over some tips for treatment and so much more.
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Now on to today's show.
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We are going to be talking about Hagelin's deformity and subcutaneous calcaneal bursitis.
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Now the first thing I want to do is talk about how similar these are and how we do treat them a little bit differently.
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But some of the concepts that we use to treat these kind of overlap, and that is perfectly fine.
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They're very closely associated.
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One will respond a lot better than treating something caused from the other, and I'll explain why that is in just a little bit.
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So the first thing I want to do is just go over some anatomy.
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I want you to envision this we are looking at the back of the heel and I want to work from the skin inward toward the calcaneus.
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So we're going to start at the skin.
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Inside or beneath the skin is a subcutaneous calcaneal bursa.
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That's like a small fluid-filled sac.
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Not everyone has this.
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Some of us just develop these over time as a mechanism to help protect the back of the tendon, the back of the heel, from the skin and the bursa.
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You need to remember a bursa isn't like every picture you see in a magazine, in a book, okay, like it looks like it's a big ball of fluid that's sitting in there.
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It can become a big ball of fluid if it becomes inflamed or swollen, but it really imagine it as this, like a water balloon that you've just taken all of the water out of, and it's really skinny, it's really thin, um, wrinkly, a little bit, all right.
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So that's kind of more like what the bursa is like.
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But when it does get irritated it can start to swell, can become inflamed and can cause pain, all right.
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So then, if we go in to the next structure, then we have the Achilles tendon, which inserts onto the posterior calcaneal tubercle.
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There's two calcaneal tubercles.
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One, the most common one, is the one underneath your foot.
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So people come in and say I have plantar fasciitis and I've got a heel spur.
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Okay, that is the one underneath the heel.
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This one, though, where the Achilles attaches, is that posterior calcaneal tubercle.
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Now there is the retro calcaneal bursa, which we all have at birth, all right, and this one sits between the Achilles tendon and the posterior calcaneus.
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It's just a little bit superior to the subcutaneous calcaneal bursa, all right.
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So that's what we have.
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And then we have our calcaneus.
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All right, so what is the Haglund's deformity?
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Well, it's an overgrowth of that posterior calcaneal tubercle, kind of like an Osgood's slaughters.
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You take your thumb and index finger, grab a little skin on your forearm and pull it away from you, and if you continue to pull that and imagine it becoming bony and hard, it will develop a spur.
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And so this is what happens at the backside of the calcane it will develop a spur.
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Okay, and so this is what happens at the backside of the calcaneus.
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Is we develop this spur?
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Some people develop, maybe because they're super active as kids, and they develop a larger spur.
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Maybe we have a lot of tightness in the calves.
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Our foot posture can make a big difference here.
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An excessive amount of compression to the back of the heel can cause this spur to kind of build up and it becomes this large outgrowth.
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Okay, that sits on the back of the heel.
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Many people have them and they're not all painful, okay.
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A lot of people come into the clinic and it's interesting because I'll say, oh, you've got yourself, you know, quite a spur on the back of your heel there, and most of them will say they were quite active.
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As younger individuals.
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They played sports or maybe they did a lot of hard, aggressive labor where they had to push up off their toes a lot and that could cause a spur, but not everybody has pain with it.
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So, like the calcaneal tubercle and the plantar surface of the foot, they generally disperse Itself, doesn't generate pain, okay, but I think it's something to be aware of that.
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Somebody has it.
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So what happens if there's overuse and or overpressure over the deformity?
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Well, that will cause some inflammation to the Achilles tendon and the surrounding bursae in that region.
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Okay, so you know, imagine you have this nice round posterior heel and you take a couple nickels, you glue them together and you stick them on the bone.
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Now we have this excessive tissue that is now sticking out the back even more.
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Okay, and so we see this with the use of new footwear.
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Or if people have this increased calf tightness, which, when you have a tight calf, the heel is more likely to pull up out of the shoe a micro amount, okay, millimeters and piston up and down in the shoe, well, if it continues to do that, the back of the heel will rub on the inside part of the shoe or the boot usually a new leather boot that hasn't been broken in yet.
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It will cause these, and so that will cause some irritation to the surrounding structures, because there's just more stuff in there, okay, which is the spur.
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Now, how does this differ from a subcutaneous calcaneal bursitis?
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Now, we've probably heard more of a retrocalcaneal bursitis and that's probably what you're thinking here.
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But the most outer bursitis, closest to the skin, is the subcutaneous calcaneal bursitis.
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The retrocalcaneal bursitis sits behind the calcaneus but just anterior to the Achilles tendon, a little bit smaller, but can become quite inflamed and irritated.
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So we talked about the Haglund's deformity as not being a big pain generator, but the bursitis okay, the bursa can be a very big pain generator.
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It can be very easy to inflame.
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People who have this bursitis will generally be tender to touch.
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It can be a little bit warm.
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What I find is that the way to differentiate between one and the other is that the bursitis will be very puffy, fluid filled, kind of like a sack, and it's kind of squishy a little bit, and so that would be more of an inflamed bursa rather than a bone spur back there, where the bone spur is going to be really hard and it's not going to be forgiving at all and, like I said, if it's a bursitis it could be a little red, could be a little swollen.
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Now we see this a lot in people who don't unlace their shoes to take them off or to put them on.
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They just kind of slide in the shoe and they take maybe the ball of the foot on the opposite foot and they slide the shoe off and they're just really compressing that bursa on the back of the heel.
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So it just causes this repetitive, cumulative trauma to the back of the heel.
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Now think about this If you're wearing a tall boot and you're sliding your foot into that boot, you're just grinding that bursa on the way in and then when you pull it out, same thing, you're grinding it on the way out.
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So just that alone can cause some of this, okay, so what do we do with these?
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Well, for both of them and I'm going to talk about how you would treat them a little bit differently, but really a majority of the treatment is pretty much the same.
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Number one you want to remove the trauma to the direct contact to the back of the heel.
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Okay, so maybe a larger shoe, or what I like to do is, if somebody is wearing a leather boot or a shoe that has material that can be kind of tight, but not just like a soft material, but something that's a little bit harder.
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You can go to a cobbler.
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They have this nice little device that has a ring and a ball and what you do is you put the ring on the outside of the back of the um of the heel of the shoe and then you put the ball on the inside and you squeeze them together.
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You might wet that down, use a leather softener, and basically it just does a little punch out the back of the shoe.
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It doesn't open it up completely, but it just makes an out dent, not an indent, but an out dent on the back of the heel.
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And people love this.
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Ok, they get into their boots or their shoes and there's this immediate relief.
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You can use this for both of those diagnoses.
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Ok, and it's hard to find a cobbler these days, but if you can, this is a great way to do that.
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Some people will get shoe stretchers where you can stretch the front to the back a little bit, so to give yourself a little bit more room or just go up in size.
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Look at the materials back there.
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Make sure those materials are not driving into the heel and that they're kind of flared outward away from the heel.
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Some shoes have a very slippery surface back there and that can be helpful.
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Sliding the foot in and out cause less trauma.
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You need to unlace the boot or the shoe to prevent the rubbing on the way into and out of the footwear.
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Okay, I just say it blows me away at how many people just jump into their shoes.
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They're all tied up and they just jam their feet in there.
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Number one it just wrecks the retrocalcaneal bursa, that subcutaneous calcaneal bursa.
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It irritates all the structures over the Hagelin's deformity and it ruins your shoes Like in no time the back of the shoe is gone.
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So I really instill in people that they need to unlace their shoes when they put their shoes on and take their shoes off, all right.
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Next, I like to gain dorsiflexion range of motion.
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I like to stretch that calf a little bit.
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I only do this on a slant board and I'm very cautious with these.
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Usually I'm a pretty aggressive stretcher, um, depending on what the issue is.
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But if we have a retrocalcaneal bursitis, a distal Achilles insertional tendonitis, too much stretch into dorsiflexion can cause a little impingement down there.
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So if you're getting a nice comfortable stretch in the calf muscle, the musculotendinous junction maybe behind the knee a little bit bonus, okay.
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But you don't want it to be hurting in that retrocalcaneal region.
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So just kind of find that happy medium.
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A light stretch for a long time is way better than aggressive short stretch.
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Okay, remember, the Haglund's deformity will not change, okay, the only thing that can change that is surgery.
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So manage the inflammation in the surrounding tissues around it, okay.
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So prevent the irritation to that spur around that spur and decrease that inflammation around that area.
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Now I really like it I know if you've been listening to me for a while to that spur around that spur and decrease that inflammation around that area.
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Now I really like it.
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I know if you've been listening to me for a while, you know that I like iontophoresis with dexamethasone, sodium phosphate over that area.
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That bursa sits right below the skin, okay, so that medication can get in there a lot easier.
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It's not like doing a deep periformis muscle.
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You can't iontophoresis that.
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Don't try an upper trap, don't do anything that isn't close to the surface, okay, you'll have very low success with that and I know there's a lot of you out there saying, well, insurance doesn't really pay for this very well and my employer tells me I really shouldn't use it because we're not getting well reimbursed for it.
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Well, you know, it's one of those things where I've had great success using it.
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So we might take a little financial hit on it.
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But when your patient gets better, you explain to them how it works and why it works and why it's more successful in that area.
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Then they're more likely to come back to you for more treatment to manage their situations in the future.
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All right, now here's the other thing and I really like to use to use compression.
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Now, I know what you're thinking.
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I just said don't compress it, don't irritate it, don't do anything like that.
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But what I like to do is I like to co-flex the foot and ankle and when I come around the back of that heel, I pull the co-flex nice and tight so that there's a compression that goes in toward the heel.
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What it does is it pulls the bursa away from the back of the shoe and it brings the friction to the shoe and coflex rather than the shoe and skin, all right.
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So there's just a little bit less friction and shearing that happens at the bursa and at the retrocalcaneal region where that hygolens deformity is.
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So I really like to use coflex.
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If you don't have coflex, then utilize something like you know, like kinesio tape or something like that.
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I'm not a big kinesio taper, but it's very smooth, it slides, slides nicely.
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So you should get into and out of the shoe better and it's comfortable, you can leave it on for several days and just you know, take a piece, pull some pretty good tension on it, hit the center of that retrocalcaneal bursa region and then come around toward the medial and lateral side of the foot and anchor it there.
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And people usually like that.
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If they like that, it's obviously tough for them to wrap themselves, so they can get into like a pull on silicone heel protector.
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That can help in that area.
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Now, if you don't have access to these things, you know, like iontophoresis or something like that, maybe you want to try something like Voltaren.
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It's got a little anti-inflammatory.
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Again, I'm not big on creams, but because it's close to the skin you might have some anti-inflammatory effect that could be helpful there, all right.
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So once that inflammation starts to settle down, gait is improving.
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We've got good shoes, maybe orthotics to prevent lateral rocking of the heel, you know, and they're doing better.
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Then we want to start loading that calf a little bit.
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We want to start with some you know isometric loading and a little bit of plantar flexion, kind of in a neutral position, maybe on a slant board, and you're holding that for 20-30 seconds and you build that up ultimately to doing, you know, double legged 45 seconds and then single legged 45 seconds, then increase a load and hold on to 10 to 20 pounds while doing that for 45 seconds and start to increase tension, because sometimes you're going to have this inflammation at the insertion of the Achilles.
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That also contributes to a lot of this.
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So you want to manage that better, get that tissue, you know, put a little tension on it so it heals itself up some.
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Now, if conservative measures don't work, then you might want to refer to orthopedics.
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Sometimes an injection can be helpful in that region.
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I know we get all panicky about injecting around the Achilles tendon, but I think getting it more near the bursa is helpful and sometimes these folks just need surgery.
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Sometimes the spur is just sticking out so much you can't get around it and then that just becomes so inflamed and irritated it just chronically causes all kinds of problems with gait and how you function.
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So there you have it, folks Hagelin's deformity and subcutaneous calcaneal bursitis all in one show.
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All in a nutshell.
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I hope you enjoyed the show.
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So thank you all.
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So much for listening.
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Be kind to each other and take care.