How to treat Haglund’s Deformity

hi guys so have you been told that you’ve got a haglund’s deformity in the back of your heel or a heel spur that’s causing your pain in your chest tendon or at the back of your heel well in this video i’m going to explain why you don’t have to pay too much attention to the fact that you’ve got a haglund’s deformity and why you can absolutely get yourself better and pain-free without doing anything to that bony prominence in the back of the heel so for those of you who don’t know me my name is mareka i’m one of the physiotherapists from where you can get online physiotherapy assessment as well as treatment all via video call so have a look at the description of this video if you want to link to our website okay so what is haglund’s deformity now in this x-ray you’ll notice that on the back of that hill there’s a bony pro pointy bit there and then also some bone at the bottom there now the top arrow is pointing to the haglund’s deformity and that’s quite a small one you can get it a little bit larger than that as well and the bottom one is pointing to calcification in the tendon so just there where the achilles tendon is attaching it started foaming a little forming a little bit of bony bits in there so how does it normally happen that you diagnosed with this what happens is you develop pain in the back of your heel and you go to the doctor the doctor says let’s do an x-ray they do an x-ray comes back like this and the doc says um you’ve got a haglund’s deformity that’s the cause of your pain well not really let me explain to you what is causing your pain so that bony bit on its own is not painful it’s just there it’s the shape of your bone okay so that doesn’t create pain if you look at an mri scan the pain you feel in your back of your heel usually at that point is coming either from the achilles tendon insertional tendinopathy or from the bursa behind the tendon which is called the bursitis when it becomes inflamed and sore and painful you can have either of those or both of them at the same time now why am i saying that the haglund’s deformity is not the cause of back pain so let me explain to you why people tend to think it is the cause of the pain so the theory is you’ve got the bony spur there or the haglund’s deformity there so if you think if you can picture this at the back of my heel if i go over my heel like when i walk can you see that the achilles tendon pulls tight over there and it causes compression and that’s quite normal and happens in all of us and it’s in painful in itself that bursa that’s in there is meant to stop friction between the tendon and the bone and again so that gets compressed every day with every step you give absolutely normal now the idea why people say that haglund’s deformity can cause pain in those structures is because it can decrease the the um space you have in the back of the heel so you’re more likely to compress it in that position then but now here’s why i say and there’s quite a few people who agree with me on this in the research it’s not necessarily the cause of that pain because you can get somebody who’s been diagnosed with a haglund’s deformity if you x-ray both feet have it in both feet they shaped exactly the same but they have pain in one foot and don’t have it in the other foot also that heightens deformity is not something that forms overnight or in a week or in a month even it would be there for years and years and years without causing trouble before one day you now develop heel pain then also you get lots and lots of people with insertional tendinopathy plus bursitis because remember that’s the structures actually causing the pain and they’re not the deformity who doesn’t have a haglund’s deformity so there’s three reasons why i say it’s not necessarily the cause of your pain um so what if i’m saying it’s not why do you then have the heel pain there it’s a classic case of overload so if we think of this your eclipse tendon as well as your bursa is used to receiving a certain amount of compression load and the body is brilliant at building the structures up to cope with that so you’re walking around running around doing your runs and stuff no issue but now if for some reason you make a sudden change in your habits and you massively increase the amount of compression that this part is under over a period of time it will be too much for it because because you haven’t given the time to slowly build up to that point and that’s when it flares up now what type of activities can cause it to suddenly overload and suddenly say whoa this is too much compression to what i’m used to classic one that i see and this is in non-runners as well as runners is when they move from wearing a shoe with a bit of a heel to flat shoes so if we think of regular people non-runners it can be when you go from winter shoes to summer shoes so flip flops or walking barefoot a lot so now your achilles tendon and bursa was in this position the whole time so you can see it’s not going to get that much compression over there because it’s not pulling that tight but now you go to flat shoes or to barefoot can you see that the compression is now going to increase suddenly now if you make that switch slowly and you’ve built up to it absolutely fine because the body then has time to adapt those structures and cope with it for runners it’ll be if you go from a shoe with quite a bit of a heel drop so heel toe drop do minimalist shoes for instance that can make that’s one of the most common reasons why i see in runners um why the insertional achilles can flare up another common cause can be if you do a lot of walking on flat and then suddenly you add in a lot of hill walking because walking up the hill again you’ll pull that tight and you increase the compression there so massive increase in compression forces or in lockdown what we’ve seen a lot is suddenly people are working from home so now you have all this free time because you’re not commuting so you can increase your exercise dramatically and it can be that you walk a lot more than what you used to same distance than what you use the same route but just more often same thing for running you’re used to running three times a week brilliant i’ve got time for five or six times a week now but guess what your structures hasn’t adapted to it so yes the haglund’s deformity decreases the space there and it may predispose you to get being more sensitive to increased compression forces but it’s that sudden increase in load of the compression forces that causes it so how do you get it better um do you need surgery to take that haglund’s away well i hope from the previous bit you would have realized that no you don’t really um because and the reason i say that is one you would have had that haglund’s deformity for years without pain and two i’ve seen plenty of patients get better with the haglund’s deformity back to full sport still have the hygienes there so it obviously wasn’t the main issue there so how do you get it better we treat the bits that’s causing the pain so if we think it’s excessive compression when the foot goes into dorsiflexion that’s causing the irritation in the achilles tendon as well as the bursa we want to take that compression off for a little bit so for a short period of time we may get you to only wear shoes with a heel on it so regular trainers for instance or even put a heel lift in your shoe so that you don’t go into that areas where it compresses and that may mean that you’ve got to wear shoes for a short period of time in in your house until it decides to calm down how long that period of time is will depend on how sensitive yours is how long it’s been irritated for um and a lot of other factors around that so that’s the first step is offload it get it out of that position um second bit on that as well you’ll often find that then other activities like squats and stuff in the gym can flare it up as well because it causes that dorsiflexion so lifting your heels without so putting a plate under your heels when you squat brilliant way of continuing squatting then then the second bit will depend on whether it’s a bursitis or tendinopathy or the combination if there’s a bursitis involved then using a short course of anti-inflammatories may be useful for it to calm down more quickly but remember to check with your doc because you may not be okay with taking anti-inflammatories there may be a reason why you shouldn’t take them anti-inflammatories doesn’t help for tendinopathies what we know from the research is that tendinopathies don’t really have a massive inflammatory component to them so don’t take it just for healing for tendinopathy it’s only if there’s a bursitis that you could try a short course but when i say short course five to ten days but check with your gp um then also if a business is really really really persistent and does not want to calm down there are certain injections that can be useful for it but those are only as a last resort because usually for business they will inject corticosteroid into the bursa not the tendon but the bursa is really close to the tendon and we know that corticosteroids is not good for the tendon and you can’t keep it to just the bursa there will be a little bit that spreads to the tendon as well so it’s a last resort if the bursa doesn’t want to calm down usually what we find is for our patients if we can offload it okay with the shoes they don’t need any of that the next bit with offloading is to stop stretching your calf and your achilles and into dorsiflexion so i was really shocked once again when i googled haglund’s deformity to see if i could get nice pictures for this talk um to find how many articles of people who claim to know how to treat this tell them to stretch so that typical calf stretch for the runners or put a band around it pull your foot towards you now can you see that if you’re going to stretch your foot like that all it’s going to do is increase the compression increase the load on those structures that’s sensitive and doesn’t like compression and it’s going to be like poking a bruise so your pain is just going to escalate and it’s just going to get worse so please if you’re doing calf stretches for an insertional tendinopathy or bursitis or haggling deformity that you’ve been told for is causing the pain stop stretching that’s one of the best things you can do is just to stop stretching and get yourself into a shoe that doesn’t cause that drop and you’ll be amazed after a couple of weeks how much your pain decreases now we do need once that acute pain is settled down we do need to start loading it up gently but when it comes to this condition it’s not the first thing you need to rush into you need to get it to calm down a little bit first okay so when we do start loading it it’s going to be with heel raise type things where you go up in your toes but it’s going to be different from your mid portion at least tendinopathy you’re not going to load it over the side of a step because can you see if you drop your heel over the side of a step you’re going to get that compression again and it won’t be ready for it so we may opt for things like isometrics where you just hold it or doing your heel raises but doing it to floor level sometimes i get my patients who are really sensitive to start going up and down but with a shoe with a heel on so we’re really limiting that range of motion where we we strengthen it through and then as you get stronger as it calms down as it starts to accept more compression we bring it into more positions where it’s more compressed but it’s really useful working with a physio to to know and understand when to make those transitions because if you do it too quickly then you’ll just flare it up so these things are not stuff that needs to be thrown at it all at once it’s a stage by stage process of okay it’s calmed down for this now let’s add that so that’s how i get my patients back from an insertional tendinopathy anabasis with or without a haglund’s deformity now yes of course it won’t ever treat 100 of people and there are some cases that eventually go on to surgery and does well with surgery but why is it that some people don’t get better so one is that it could be that your haglund’s deformity or bone spur or stuff is just so severe and so big that it does poke directly on that tendon and because of the shape of your foot and everything else it just doesn’t get to a position that we can get it to not do that so in those cases it may be useful to shave that piece of bone off second what i often find is that people just don’t offload it for long enough so they don’t give it enough time to recover and calm down this is not something that you can say oh i offloaded it for a week or two and now it’s it’s still not getting better achilles tendinopathy and bursitis takes at least three months 12 weeks to show good good improvement and then it can take up to six months to get back to where you want to be now that may sound long but listen recovery from surgery isn’t any shorter so please don’t see re surgery as a short term solution um if you’re going to have surgery depending on what they do you can have long standing recovery after that i’m working with people who still a year later after surgery for this type of thing is not much better than what they were before the surgery so but then i do have other people who is massively better so don’t take it as surgery is always a bad thing it’s just about make sure you really follow the guidelines properly before you decide to go on to surgery also i would go for other things first before surgery so if rehab and offloading loading’s not worked consider shockwave especially if it’s an insertional tendinopathy i’ve had good results with patients with that when it’s not wanted to react to the treatments the other types of treatments we’ve tried another one that could be useful is if you try different types of injections there are different things that clinicians can do so prp doesn’t seem to work that well at the moment i don’t think they figured it out properly beside this seems to react well to corticosteroid but like i said not the first instance to decide to do that i wouldn’t go for steroids into the egres tendon that is in my books a little bit irresponsible because it does predispose you to achilles stairs but there are there are high volume injection type injections and there are other injections that’s experimental that’s coming onto the market and if the risk is low with an injection i would always try that first before you go on to surgery okay oh yes and then the other thing is again why it may not work conservative treatment is if you’ve just neglected it for too long so you’ve taken months and months and months that you’ve just kept on annoying it didn’t follow the right treatment device so that the bursa may be a bit thickened and there’s just no way that it can be offloaded um or that it becomes happy to carry loads so in those cases taking the bursa out can be a solution for it as well so let me know if you’ve got any questions and if you need more help with your injury you’re welcome to consult one of us via video call the link is top of this video but also in the bottom in the description take care