Advance of diagnosis and treatment of Haglund syndrome_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WANG Jie ¹ , ZENG Xiantie ¹ ,  MA Xinlong ^1,2

1. Department of Orthopaedics, Tianjin Hospital, Tianjin, 300211, P.R.China;
2. Department of Orthopaedics, Tianjin Medical University General Hospital, Tianjin, 300052, P.R.China;

Corresponding author：

MA Xinlong, Email: maxinlong123@gmail.com

Keywords：

Haglund syndrome; Haglund malformation; image measurement; surgical treatment

DOI：

10.7507/1002-1892.201907130

Video：

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Objective To review the current research on the diagnosis and treatment of Haglund syndrome.Methods The domestic and foreign literature about Haglund syndrome in recent years was extensively reviewed to summarize and analyze the etiology, anatomy, clinical manifestations, diagnosis, and treatment of Haglund syndrome.Results The etiology of Haglund syndrome is not very clear, and it may be related to local friction and high gastrocnemius muscle tension, and there may be a certain genetic tendency. The local anatomy is more complex and there are many adjacent tissue structures. Haglund malformation may cause the impingement of the posterior heel bursa and Achilles tendon insertion, lead to wear of the posterior heel bursa and the Achilles tendon insertion, and finally result in pain. The FPA (Fowler-Philipp angle), CPA (calcaneal pith angle), PPL (parallel pitch lines), CLA (Chauveaux-Liet angle), and X/Y ratios (ratio of total calcaneal length to calcaneal tuberosity length) measured on X-ray film can be used for the diagnostic measurement of Haglund malformation. Treatment includes conservative and surgical treatment (open Haglund ostectomy, dorsal closed wedge osteotomy of the calcaneus, and arthroscopic Haglund osteotomy).Conclusion Both open and arthroscopic Haglund ostectomy and dorsal closed wedge osteotomy of the calcaneus can achieve satisfactory results, but minimally invasive treatment is the current development trend. Surgeons should pay attention to the management of the calcification of Achilles tendon insertion and reconstruction of Achilles tendon insertion.

Citation： WANG Jie, ZENG Xiantie, MA Xinlong. Advance of diagnosis and treatment of Haglund syndrome. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(4): 518-523. doi: 10.7507/1002-1892.201907130 Copy

1.	Lawrence DA, Rolen MF, Morshed KA, et al. MRI of heel pain. AJR Am J Roentgenol, 2013, 200(4): 845-855.
2.	Ippolito E, Ricciardi-Pollini PT. Invasive retrocalcaneal bursitis: a report of three cases. Foot Ankle, 1984, 4(4): 204-208.
3.	Kraemer R, Wuerfel W, Lorenzen J, et al. Analysis of hereditary and medical risk factors in Achilles tendinopathy and Achilles tendon ruptures: a matched pair analysis. Arch Orthop Trauma Surg, 2012, 132(6): 847-853.
4.	Irwin TA. Current concepts review: insertional Achilles tendinopathy. Foot Ankle Int, 2010, 31(10): 933-939.
5.	Abate M, Schiavone C, Salini V, et al. Occurrence of tendon pathologies in metabolic disorders. Rheumatology (Oxford), 2013, 52(4): 599-608.
6.	Kucuksen S, Karahan AY, Erol K. Haglund syndrome with pump bump. Med Arch, 2012, 66(6): 425-427.
7.	Gerster JC. Plantar fasciitis and Achilles tendinitis among 150 cases of seronegative spondarthritis. Rheumatol Rehabil, 1980, 19(4): 218-222.
8.	Moll JM. Seronegative arthropathies in the foot. Baillieres Clin Rheumatol, 1987, 1(2): 289-314.
9.	Rees JD, Maffulli N, Cook J. Management of tendinopathy. Am J Sports Med, 2009, 37(9): 1855-1867.
10.	Zhou B, Zhou Y, Tang K. An overview of structure, mechanical properties, and treatment for age-related tendinopathy. J Nutr Health Aging, 2014, 18(4): 441-448.
11.	Lui TH. Endoscopic Achilles tenolysis for management of heel cord pain after repair of acute rupture of Achilles tendon. J Foot Ankle Surg, 2013, 52(1): 125-127.
12.	Owens BD, Wolf JM, Seelig AD, et al. Risk factors for lower extremity tendinopathies in military personnel. Orthop J Sports Med, 2013, 1(1): 2325967113492707.
13.	Gaida JE, Cook JL, Bass SL. Adiposity and tendinopathy. Disabil Rehabil, 2008, 30(20-22): 1555-1562.
14.	Myerson MS, McGarvey W. Disorders of the Achilles tendon insertion and Achilles tendinitis. Instr Course Lect, 1999, 48: 211-218.
15.	Fridrich F. Tendon-splitting approach for the surgical treatment of Haglund’s deformity and associated condition. Evaluation and results. Acta Chir Orthop Traumatol Cech, 2009, 76(3): 212-217.
16.	Kang S, Thordarson DB, Charlton TP. Insertional Achilles tendinitis and Haglund’s deformity. Foot Ankle Int, 2012, 33(6): 487-491.
17.	van Dijk CN, van Sterkenburg MN, Wiegerinck JI, et al. Terminology for Achilles tendon related disorders. Knee Surg Sports Traumatol Arthrosc, 2011, 19(5): 835-841.
18.	Maffulli N, Reaper J, Ewen SW, et al. Chondral metaplasia in calcific insertional tendinopathy of the Achilles tendon. Clin J Sport Med, 2006, 16(4): 329-334.
19.	Vogel KG, Ordög A, Pogány G, et al. Proteoglycans in the compressed region of human tibialis posterior tendon and in ligaments. J Orthop Res, 1993, 11(1): 68-77.
20.	Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J Bone Joint Surg (Am), 2005, 87(1): 187-202.
21.	Syed TA, Perera A. A proposed staging classification for minimally invasive management of Haglund’s syndrome with percutaneous and endoscopic surgery. Foot Ankle Clin, 2016, 21(3): 641-664.
22.	Ballal MS, Walker CR, Molloy AP. The anatomical footprint of the Achilles tendon: a cadaveric study. Bone Joint J, 2014, 96-B(10): 1344-1348.
23.	Stephens MM. Haglund’s deformity and retrocalcaneal bursitis. Orthop Clin North Am, 1994, 25(1): 41-46.
24.	Pavlov H, Heneghan MA, Hersh A, et al. The Haglund syndrome: initial and differential diagnosis. Radiology, 1982, 144(1): 83-88.
25.	Fowler A, Phillip J. Abnormality of the calcaneus as acause of painful heel: its diagnosis and operative treatment. Br J Surg, 1945, 132: 494-498.
26.	Lu CC, Cheng YM, Fu YC, et al. Angle analysis of Haglund syndrome and its relationship with osseous variations and Achilles tendon calcification. Foot Ankle Int, 2007, 28(2): 181-185.
27.	Chauveaux D, Liet P, Le Huec JC, et al. A new radiologic measurement for the diagnosis of Haglund’s deformity. Surg Radiol Anat, 1991, 13(1): 39-44.
28.	Fiamengo SA, Warren RF, Marshall JL, et al. Posterior heel pain associated with a calcaneal step and Achilles tendon calcification. Clin Orthop Relat Res, 1982, (167): 203-211.
29.	Bulstra GH, van Rheenen TA, Scholtes VA. Can we measure the heel bump? Radiographic evaluation of Haglund’s deformity. J Foot Ankle Surg, 2015, 54(3): 338-340.
30.	Tourné Y, Baray AL, Barthélémy R, et al. Contribution of a new radiologic calcaneal measurement to the treatment decision tree in Haglund syndrome. Orthop Traumatol Surg Res, 2018, 104(8): 1215-1219.
31.	Sofka CM, Adler RS, Positano R, et al. Haglund’s syndrome: diagnosis and treatment using sonography. HSS J, 2006, 2(1): 27-29.
32.	Sella EJ, Caminear DS, McLarney EA. Haglund’s syndrome. J Foot Ankle Surg, 1998, 37(2): 110-114.
33.	Sammarco GJ, Taylor AL. Operative management of Haglund’s deformity in the nonathlete: a retrospective study. Foot Ankle Int, 1998, 19(11): 724-729.
34.	Lohrer H, Arentz S. Impingement lesion of the distal anterior Achilles tendon in sub-Achilles bursitis and Haglund-pseudoexostosis—a therapeutic challenge. Sportverletz Sportschaden, 2003, 17(4): 181-188.
35.	Paavola M, Orava S, Leppilahti J, et al. Chronic Achilles tendon overuse injury: complications after surgical treatment. An analysis of 432 consecutive patients. Am J Sports Med, 2000, 28(1): 77-82.
36.	Natarajan S, Narayanan VL. Haglund deformity-surgical resection by the lateral approach. Malays Orthop J, 2015, 9(1): 1-3.
37.	Anderson JA, Suero E, O’Loughlin PF, et al. Surgery for retrocalcaneal bursitis: a tendon-splitting versus a lateral approach. Clin Orthop Relat Res, 2008, 466(7): 1678-1682.
38.	Ahn JH, Ahn CY, Byun CH, et al. Operative treatment of Haglund syndrome with central Achilles tendon-splitting approach. J Foot Ankle Surg, 2015, 54(6): 1053-1056.
39.	Zadek I. An operation for the cure of achillobursitis. Am J Surg, 1939, 43(2): 542-546.
40.	Keck SW, Kelly PJ. Bursitis of the posterior part of the heel; evaluation of surgical treatment of eighteen patients. J Bone Joint Surg (Am), 1965, 47: 267-273.
41.	Miller AE, Vogel TA. Haglund’s deformity and the Keck and Kelly osteotomy: a retrospective analysis. J Foot Surg, 1989, 28(1): 23-29.
42.	林灿, 马林, 陈万, 等. 跟骨后上结节切除与跟骨体闭合楔形截骨治疗 Haglund 综合征疗效的对比分析. 中华医学杂志, 2017, 97(35): 2733-2736.
43.	van Dijk CN, van Dyk GE, Scholten PE, et al. Endoscopic calcaneoplasty. Am J Sports Med, 2001, 29(2): 185-189.
44.	Jerosch J. Endoscopic calcaneoplasty. Foot Ankle Clin, 2015, 20(1): 149-165.
45.	Jerosch J, Nasef NM. Endoscopic calcaneoplasty—rationale, surgical technique, and early results: a preliminary report. Knee Surg Sports Traumatol Arthrosc, 2003, 11(3): 190-195.
46.	Kondreddi V, Gopal RK, Yalamanchili RK. Outcome of endoscopic decompression of retrocalcaneal bursitis. Indian J Orthop, 2012, 46(6): 659-663.
47.	Ortmann FW, McBryde AM. Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis. Foot Ankle Int, 2007, 28(2): 149-153.
48.	van Dijk CN, de Leeuw PAJ, Scholten PE. Hindfoot endoscopy for posterior ankle impingement: surgical technique. J Bone Joint Surg (Am), 2009, 91(Suppl 2): 287-298.
49.	彭旭, 段小军, 杨柳. 关节镜辅助 Haglund 畸形矫正术. 中华骨科杂志, 2013, 33(3): 285-288.
50.	Lohrer H, Nauck T, Dorn NV, et al. Comparison of endoscopic and open resection for Haglund tuberosity in a cadaver study. Foot Ankle Int, 2006, 27(6): 445-450.
51.	Madarevic T, Rakovac I, Ruzic L, et al. Ultrasound-assisted calcaneoplasty. Knee Surg Sports Traumatol Arthrosc, 2014, 22(9): 2250-2253.
52.	Rakovac I, Madarevic T, Tudor A, et al. The “cello technique”: a new technique for ultrasound-assisted calcaneoplasty. Arthrosc Tech, 2012, 1(1): e91-e94.

1. Lawrence DA, Rolen MF, Morshed KA, et al. MRI of heel pain. AJR Am J Roentgenol, 2013, 200(4): 845-855.
2. Ippolito E, Ricciardi-Pollini PT. Invasive retrocalcaneal bursitis: a report of three cases. Foot Ankle, 1984, 4(4): 204-208.
3. Kraemer R, Wuerfel W, Lorenzen J, et al. Analysis of hereditary and medical risk factors in Achilles tendinopathy and Achilles tendon ruptures: a matched pair analysis. Arch Orthop Trauma Surg, 2012, 132(6): 847-853.
4. Irwin TA. Current concepts review: insertional Achilles tendinopathy. Foot Ankle Int, 2010, 31(10): 933-939.
5. Abate M, Schiavone C, Salini V, et al. Occurrence of tendon pathologies in metabolic disorders. Rheumatology (Oxford), 2013, 52(4): 599-608.
6. Kucuksen S, Karahan AY, Erol K. Haglund syndrome with pump bump. Med Arch, 2012, 66(6): 425-427.
7. Gerster JC. Plantar fasciitis and Achilles tendinitis among 150 cases of seronegative spondarthritis. Rheumatol Rehabil, 1980, 19(4): 218-222.
8. Moll JM. Seronegative arthropathies in the foot. Baillieres Clin Rheumatol, 1987, 1(2): 289-314.
9. Rees JD, Maffulli N, Cook J. Management of tendinopathy. Am J Sports Med, 2009, 37(9): 1855-1867.
10. Zhou B, Zhou Y, Tang K. An overview of structure, mechanical properties, and treatment for age-related tendinopathy. J Nutr Health Aging, 2014, 18(4): 441-448.
11. Lui TH. Endoscopic Achilles tenolysis for management of heel cord pain after repair of acute rupture of Achilles tendon. J Foot Ankle Surg, 2013, 52(1): 125-127.
12. Owens BD, Wolf JM, Seelig AD, et al. Risk factors for lower extremity tendinopathies in military personnel. Orthop J Sports Med, 2013, 1(1): 2325967113492707.
13. Gaida JE, Cook JL, Bass SL. Adiposity and tendinopathy. Disabil Rehabil, 2008, 30(20-22): 1555-1562.
14. Myerson MS, McGarvey W. Disorders of the Achilles tendon insertion and Achilles tendinitis. Instr Course Lect, 1999, 48: 211-218.
15. Fridrich F. Tendon-splitting approach for the surgical treatment of Haglund’s deformity and associated condition. Evaluation and results. Acta Chir Orthop Traumatol Cech, 2009, 76(3): 212-217.
16. Kang S, Thordarson DB, Charlton TP. Insertional Achilles tendinitis and Haglund’s deformity. Foot Ankle Int, 2012, 33(6): 487-491.
17. van Dijk CN, van Sterkenburg MN, Wiegerinck JI, et al. Terminology for Achilles tendon related disorders. Knee Surg Sports Traumatol Arthrosc, 2011, 19(5): 835-841.
18. Maffulli N, Reaper J, Ewen SW, et al. Chondral metaplasia in calcific insertional tendinopathy of the Achilles tendon. Clin J Sport Med, 2006, 16(4): 329-334.
19. Vogel KG, Ordög A, Pogány G, et al. Proteoglycans in the compressed region of human tibialis posterior tendon and in ligaments. J Orthop Res, 1993, 11(1): 68-77.
20. Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J Bone Joint Surg (Am), 2005, 87(1): 187-202.
21. Syed TA, Perera A. A proposed staging classification for minimally invasive management of Haglund’s syndrome with percutaneous and endoscopic surgery. Foot Ankle Clin, 2016, 21(3): 641-664.
22. Ballal MS, Walker CR, Molloy AP. The anatomical footprint of the Achilles tendon: a cadaveric study. Bone Joint J, 2014, 96-B(10): 1344-1348.
23. Stephens MM. Haglund’s deformity and retrocalcaneal bursitis. Orthop Clin North Am, 1994, 25(1): 41-46.
24. Pavlov H, Heneghan MA, Hersh A, et al. The Haglund syndrome: initial and differential diagnosis. Radiology, 1982, 144(1): 83-88.
25. Fowler A, Phillip J. Abnormality of the calcaneus as acause of painful heel: its diagnosis and operative treatment. Br J Surg, 1945, 132: 494-498.
26. Lu CC, Cheng YM, Fu YC, et al. Angle analysis of Haglund syndrome and its relationship with osseous variations and Achilles tendon calcification. Foot Ankle Int, 2007, 28(2): 181-185.
27. Chauveaux D, Liet P, Le Huec JC, et al. A new radiologic measurement for the diagnosis of Haglund’s deformity. Surg Radiol Anat, 1991, 13(1): 39-44.
28. Fiamengo SA, Warren RF, Marshall JL, et al. Posterior heel pain associated with a calcaneal step and Achilles tendon calcification. Clin Orthop Relat Res, 1982, (167): 203-211.
29. Bulstra GH, van Rheenen TA, Scholtes VA. Can we measure the heel bump? Radiographic evaluation of Haglund’s deformity. J Foot Ankle Surg, 2015, 54(3): 338-340.
30. Tourné Y, Baray AL, Barthélémy R, et al. Contribution of a new radiologic calcaneal measurement to the treatment decision tree in Haglund syndrome. Orthop Traumatol Surg Res, 2018, 104(8): 1215-1219.
31. Sofka CM, Adler RS, Positano R, et al. Haglund’s syndrome: diagnosis and treatment using sonography. HSS J, 2006, 2(1): 27-29.
32. Sella EJ, Caminear DS, McLarney EA. Haglund’s syndrome. J Foot Ankle Surg, 1998, 37(2): 110-114.
33. Sammarco GJ, Taylor AL. Operative management of Haglund’s deformity in the nonathlete: a retrospective study. Foot Ankle Int, 1998, 19(11): 724-729.
34. Lohrer H, Arentz S. Impingement lesion of the distal anterior Achilles tendon in sub-Achilles bursitis and Haglund-pseudoexostosis—a therapeutic challenge. Sportverletz Sportschaden, 2003, 17(4): 181-188.
35. Paavola M, Orava S, Leppilahti J, et al. Chronic Achilles tendon overuse injury: complications after surgical treatment. An analysis of 432 consecutive patients. Am J Sports Med, 2000, 28(1): 77-82.
36. Natarajan S, Narayanan VL. Haglund deformity-surgical resection by the lateral approach. Malays Orthop J, 2015, 9(1): 1-3.
37. Anderson JA, Suero E, O’Loughlin PF, et al. Surgery for retrocalcaneal bursitis: a tendon-splitting versus a lateral approach. Clin Orthop Relat Res, 2008, 466(7): 1678-1682.
38. Ahn JH, Ahn CY, Byun CH, et al. Operative treatment of Haglund syndrome with central Achilles tendon-splitting approach. J Foot Ankle Surg, 2015, 54(6): 1053-1056.
39. Zadek I. An operation for the cure of achillobursitis. Am J Surg, 1939, 43(2): 542-546.
40. Keck SW, Kelly PJ. Bursitis of the posterior part of the heel; evaluation of surgical treatment of eighteen patients. J Bone Joint Surg (Am), 1965, 47: 267-273.
41. Miller AE, Vogel TA. Haglund’s deformity and the Keck and Kelly osteotomy: a retrospective analysis. J Foot Surg, 1989, 28(1): 23-29.
42. 林灿, 马林, 陈万, 等. 跟骨后上结节切除与跟骨体闭合楔形截骨治疗 Haglund 综合征疗效的对比分析. 中华医学杂志, 2017, 97(35): 2733-2736.
43. van Dijk CN, van Dyk GE, Scholten PE, et al. Endoscopic calcaneoplasty. Am J Sports Med, 2001, 29(2): 185-189.
44. Jerosch J. Endoscopic calcaneoplasty. Foot Ankle Clin, 2015, 20(1): 149-165.
45. Jerosch J, Nasef NM. Endoscopic calcaneoplasty—rationale, surgical technique, and early results: a preliminary report. Knee Surg Sports Traumatol Arthrosc, 2003, 11(3): 190-195.
46. Kondreddi V, Gopal RK, Yalamanchili RK. Outcome of endoscopic decompression of retrocalcaneal bursitis. Indian J Orthop, 2012, 46(6): 659-663.
47. Ortmann FW, McBryde AM. Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis. Foot Ankle Int, 2007, 28(2): 149-153.
48. van Dijk CN, de Leeuw PAJ, Scholten PE. Hindfoot endoscopy for posterior ankle impingement: surgical technique. J Bone Joint Surg (Am), 2009, 91(Suppl 2): 287-298.
49. 彭旭, 段小军, 杨柳. 关节镜辅助 Haglund 畸形矫正术. 中华骨科杂志, 2013, 33(3): 285-288.
50. Lohrer H, Nauck T, Dorn NV, et al. Comparison of endoscopic and open resection for Haglund tuberosity in a cadaver study. Foot Ankle Int, 2006, 27(6): 445-450.
51. Madarevic T, Rakovac I, Ruzic L, et al. Ultrasound-assisted calcaneoplasty. Knee Surg Sports Traumatol Arthrosc, 2014, 22(9): 2250-2253.
52. Rakovac I, Madarevic T, Tudor A, et al. The “cello technique”: a new technique for ultrasound-assisted calcaneoplasty. Arthrosc Tech, 2012, 1(1): e91-e94.

Chinese Journal of Reparative and Reconstructive Surgery

Advance of diagnosis and treatment of Haglund syndrome

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