Haglund’s deformity, often dubbed “pump bump,” is a common, yet frequently misunderstood, musculoskeletal condition characterized by a bony enlargement on the back of the heel bone (calcaneus). While the bony protrusion itself may be present without symptoms, the real issue arises when this enlargement rubs against the rigid back of a shoe, leading to painful inflammation of the surrounding soft tissues, most notably the retrocalcaneal bursa and the Achilles tendon. This combination of bony abnormality and subsequent soft tissue irritation is sometimes referred to as Haglund’s syndrome. Understanding its underlying causes, recognizing its distinct symptoms, and knowing the available treatment options are crucial for effectively managing this often-painful condition.

The Anatomy and Etiology of a “Pump Bump”

The heel is a complex structure where the powerful Achilles tendon inserts into the posterior part of the calcaneus. A small, fluid-filled sac called the retrocalcaneal bursa sits between the tendon and the bone, acting as a cushion to reduce friction. In Haglund’s deformity, a bony prominence or exostosis forms on the superior aspect of the calcaneus, directly where the Achilles tendon attaches.

This abnormal bone growth can be a result of several factors, often a combination of inherited foot structure and external influences.

Inherited biomechanics play a significant role. Individuals with a high arch (pes cavus) are particularly susceptible. In a high-arched foot, the heel bone is often tilted backward, placing increased pressure on the area where the Achilles tendon attaches. A tight Achilles tendon is another key predisposing factor. When the tendon is taut, it can press the bursa and surrounding tissue more firmly against the bony prominence, intensifying the friction and irritation. Furthermore, a tendency to walk on the outside of the heel can also contribute to the development of the condition.

Beyond inherited factors, external triggers are often what turn a latent deformity into a painful, symptomatic condition. The most notorious of these is footwear. The name “pump bump” is a direct reference to the stiff, rigid heel counters found in dress shoes and high heels that are particularly effective at causing irritation. However, any shoe with a firm back, including ice skates, men’s dress shoes, and even some athletic shoes, can be a culprit. Repetitive strain from activities like running, especially on hard surfaces or uphill, can also exacerbate the condition by increasing the friction between the bony protrusion and the soft tissues.

Symptoms and Diagnosis

The symptoms of Haglund’s deformity are typically localized to the back of the heel and can range from a minor annoyance to severe, debilitating pain. The most characteristic symptom is a noticeable, hard bump on the back of the heel that can be seen and felt. While the bump itself is a hallmark, the pain and inflammation stem from the soft tissue irritation. Patients commonly experience pain at the back of the heel, particularly in the area where the Achilles tendon attaches. This pain is often exacerbated by wearing shoes with a rigid back and may be worse after a period of rest.

Associated symptoms include redness and swelling over the bump, which are signs of the underlying inflammation of the retrocalcaneal bursa (bursitis) and the Achilles tendon (tendinitis). The symptoms can sometimes be confused with other conditions causing heel pain, such as isolated Achilles tendinitis or even a plantar heel spur, which is a bony growth on the bottom of the heel.

Diagnosing Haglund’s deformity involves a thorough physical examination and a review of the patient’s medical history. A healthcare provider will inspect the heel for the tell-tale bump, swelling, and redness. They will also assess the patient’s foot structure and gait. Imaging studies are often used to confirm the diagnosis and rule out other conditions. A lateral X-ray of the foot is the most common diagnostic tool, as it can clearly show the bony prominence of the calcaneus. In some cases, a standing X-ray can also reveal a steep angle of the heel bone, which is characteristic of the condition. In more complex or questionable cases, an ultrasound or MRI may be used to evaluate the extent of soft tissue involvement, such as inflammation in the bursa or damage to the Achilles tendon.

Treatment and Management

The goal of treatment for Haglund’s deformity is to alleviate pain and reduce inflammation. The vast majority of cases can be successfully managed with conservative, non-surgical approaches. The cornerstone of conservative treatment is addressing the friction that causes the symptoms. This involves modifying footwear by avoiding shoes with rigid heel backs and opting for soft-backed or open-backed shoes, such as clogs or sandals.

Other non-surgical treatments include:

• Rest and Ice: Reducing activity and applying ice to the inflamed area for 20-minute intervals can help to decrease swelling and pain.
  
• Oral Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can be effective in managing pain and inflammation.
  
• Heel Lifts or Pads: Placing soft pads or heel lifts inside the shoe can help cushion the area, reduce friction, and, in high-arched individuals, change the angle of the heel to take pressure off the Achilles tendon.
  
• Physical Therapy: Stretching exercises for a tight Achilles tendon and calf muscles can reduce strain on the heel.
  
• Orthotic Devices: Custom orthotics can be prescribed to correct foot biomechanics, such as a high arch or overpronation, which may contribute to the condition.
  
• Immobilization: In severe cases, a walking boot or cast may be used to immobilize the foot and allow the inflamed tissues to heal.
  

While conservative treatment is effective for most, it does not reduce the size of the bony bump. If non-surgical options fail to provide adequate relief after an extended period, typically six months to a year, surgery may be considered. The most common surgical procedure for Haglund’s deformity is a calcaneal ostectomy (removal of a portion of the heel bone). The surgeon makes an incision at the back of the heel, detaches a small portion of the Achilles tendon, and then shaves or removes the bony prominence. In cases where the Achilles tendon has been significantly damaged, a repair or debridement may also be performed.

The prognosis for Haglund’s deformity is generally good, with most patients finding significant relief through conservative measures. However, even with successful treatment, the bony prominence will remain, and there is a risk of symptoms recurring if proper footwear and preventative measures are not maintained. For those who undergo surgery, the outcomes are also highly successful, though recovery can be a lengthy process, often requiring several weeks of limited weight-bearing and physical therapy to regain full function and strength in the foot and ankle. The journey with Haglund’s deformity, from diagnosis to management, underscores the complex interplay between our inherent anatomy and the external forces we place upon it.