The Haglund heel

Synonyms

Haglundferse, Haglund exostosis, Haglundexostose, Calcaneus altus et latus

definition

It is in the Haglundferse a form variant of the heel bone body, which is prominently formed in its lateral and rear portion and thereby can lead to pressure soreness in the shoe. The Haglundferse often occurs in connection with a Heersensporn.

Anatomy / Structure

The heel bone (calcaneus) is part of the foot and involved in shaping the lower ankle. Numerous ligaments, tendons and muscles attach to it. The Achilles tendon attaches to its posterior (dorsal) portion. By pulling the Achilles tendon, the foot can be lowered and the toe level can be taken. At the lower part of the heel bone some small foot muscles as well as the Plantarfaszie (Plantaraponeurose) responsible for the longitudinal arch tension of the foot originated. To the front, the heel bone is connected to the tarsal bones, upwards over the lower ankle joint with the anklebone (talus).

Cause and genesis = Ethiopathogenesis

In Haglund Exostosis (also called Haglund heel) there is an increased ossification of the approach of the Achilles tendon on the heel, causing those affected especially when wearing shoes pressure pain in this area feel.
The cause of the ossification is not completely clear so far. First, there is the theory that Haglund exostosis is innate, other experts suspect that the disease can also be secondary secondary to overloading the Achilles tendon with the following Achilles tendon or even bad-fitting footwear can be caused. It is being discussed whether a combination of these factors may be responsible for the fact that Haglund exostosis is in part congenital and may be impaired by heel deformity.
This theory is supported by the fact that the Haglund Exostose occurs very frequently in young, physically active people. The pressure of the palate on the calcified sinew approaches provokes the pain and secondary bursitis often develops in this area. These are manifested by severe discomfort when walking, pronounced pressure pain and in many cases by swelling, redness and overheating of the tissue.

Symptoms / complaints

Patients with a painful ( symptomatic ) Haglund heel report a load-dependent pain in the area of ​​the back heel (hindfoot). Ready-to-wear shoes are only badly tolerated. Patients often wear footwear without a heel counter. In the middle Achilles tendon attachment, the heel becomes red, swollen and sensitive to pressure. The Achilles tendon may be flabby distended. Lifting the foot with a pull on the Achilles tendon causes a violent pain.

diagnostics

The medical history ( patient history ) of patients combined with the local pressure pain and the external aspect of the skin are the decisive indication of the underlying disease of Haglund's heel.

The suspected diagnosis thus confirmed is confirmed in the X-ray of the lateral heel bone. To recognize here is a withdrawal of the upper Kalkaneusrandes.

The ultrasound examination may reveal a fluid-filled bursa and tendon distension of the Achilles tendon.

therapy

The therapy of the Haglund heel consists in various measures, which are combined or used individually. Basically, a distinction is made between conservative and operative therapy measures. Conservative therapy is always used first. If this is no longer sufficient, an operative attempt can be made to remove the aching heel spur.

Conservative therapy

The primary goal of all therapeutic measures are the inflammation and pain relief, as well as the relief of heel spurs through deposits or padding. The conservative therapy consists of medical, physical or physiotherapeutic measures and the right footwear.

Medical therapy

Medication pain medications are used, which simultaneously show an anti-inflammatory effect (non-steroidal anti-inflammatory drugs "NSAIDs"). Since these strongly attack the stomach, a stomach protection should be taken in addition. Similarly, locally different drugs can be injected.

For example, local cortisone infiltration is strongly anti-inflammatory. Local injection of botulinum toxin damages neighboring nerves and prevents pain transmission. Since an injection in the area of ​​the heel is very painful, this therapy is not recommended permanently. In addition, the cortisone can attack the tendons of the muscles and make them porous.

Physical therapy and physiotherapy

In addition to the drug therapy can be tried by physiotherapeutic exercises to relieve the heel and strengthen the corresponding muscles. Here, local cold therapies are performed in the form of an ice massage and stretching exercises of the muscles and tendons. The general measures also include the right footwear and, in case of overweight, the weight reduction.

Physiotherapy at the Haglundferse

Physiotherapy and stretching exercises can relieve the complaints in the Haglundferse and are among the first conservative measures that should be taken. It mainly plays an important role in the strengthening and stretching of the foot and calf muscles.
The foot and calf muscles are overloaded in the Haglundferse, it comes to irritation of the tissue, which in turn triggers pain. Overuse of the muscles can be treated with loosening exercises.
The calf muscles usually undergo a shortening due to a Haglund heel, which can be perceived as painful. With physiotherapy and targeted massages you can relax the shortened ligaments and tendons. In addition, special exercises for stretching the calf muscles can be performed. For example, while sitting, a towel may be wrapped around the foot and both ends of the towel held with both hands and pulled toward the body until there is a stretch in the calf. If the exercise is performed with the knee bent, the Achilles tendon is also stretched. See also: Elongation of the Achilles tendon

Especially in the Achilles tendon, Haglund's heel often results in tendon shortening, which can be very painful.
Again, physiotherapy is a good way to relieve acute discomfort with stretching exercises. For example, with a single lunge forward, stretching of the Achilles tendon and calf muscles can be achieved when the leg of the affected side is at the back. To do this, straighten your upper body and bend the front leg, the back leg is firmly on the ground and the heel is pressed down.
In everyday life, stairs are suitable for stretching the Achilles tendon by only standing on the step with the forefoot and slowly letting the affected heel hang down over the edge.
If pain occurs during stretching, discontinue stretching immediately and consult with the physiotherapist.

As a physiotherapeutic measure with the Haglundferse relaxation techniques of the musculature are to be recommended. With the help of certain physiotherapy techniques, cold or heat treatments or relaxing medications or yoga, the stressed muscles can be relaxed and the complaints and pain of the Haglundferse can be alleviated.

If the physiotherapy is not successful to relieve the symptoms, further measures and possibly also surgery should be considered.

Shock Wave Therapy

The shockwave therapy uses high energy sound waves that strike the bone and excess bone material as it hits the bone, gradually reducing the ossification of the tendon insertion.

Through a special device, it is possible to apply the waves directly in the area of ​​discomfort, this applicator is called Transducer. In general, this application of radiation is not perceived as really painful. A single application would not be sufficient to damage the unwanted bone, so multiple sessions must be scheduled in this procedure. Gradually, the excess bone tissue loses its texture and hardness, crumbling from outside to inside, and the body is then able to break down the tissue that is created by the external energy. Furthermore, the waves also stimulate the renewal of the tissue in this area. This is possible through small micro-injuries that are placed in the surrounding tissue, which stimulates the body to become active in this area and form new, healthy tissue. The blood circulation in the irradiated area is increased and waste products and also inflammatory substances can be transported away well - the tissue is "detoxified".

The sound waves lead to an anesthesia of the nerve fibers, which in turn has a positive effect on the reduction of the sensed pain.

The costs of this treatment are not borne by the health insurance companies, so that the patient has to reckon with incurring costs. The reformation of increased bone growth after completion of the shockwave therapy is sometimes dependent on the behavior of the patient. Because such malignant, protruding bony prominences have their cause mostly in faulty loading and poor posture of the foot, so that regular physiotherapy should be performed. Care should also be taken to maintain a good posture and normal walking movement, and if in doubt, use orthopedic insoles. Side effects or risks associated with this method of treatment are unlikely to occur, there may be temporary skin irritation in the irradiated area.

X-ray irradiation stimulus

In this form of treatment, the affected bone area is treated with X-rays. The main goal, however, is not healing, but the rays primarily have a pain-relieving effect. This means that the actual underlying disease, the excess bone growth at this point only diminished, but not completely eliminated. Normally, therapy is given in 3 consecutive cycles. A cycle consists of 6 individual dates. It is irradiated twice within one week, so that a period of 3 weeks is counted for one cycle. The second cycle follows after about 2 months and the 3rd cycle then takes 3 months.

This treatment can be repeated several times and is also used in the treatment of heel spurs, tennis elbow or arthritis. The advantage of this method is the locally very limited application of radiation, which makes it possible to protect the surrounding tissue and overlying tissues such as muscles and skin, because this radiation passes unhindered through soft tissue and then strikes the bone.

Strict application to the patient group must be ensured in advance. Patients must be 50 years old, and alternative treatments (such as surgery) must be discussed with a physician beforehand and well balanced. The background of using individual cycles is to minimize the side effects. Excessive use in the affected area in the long term would do more harm than good, because X-radiation is itself cell damaging. This should primarily be the case in the area of ​​excess bone tissue on the Haglund heel. However, surrounding tissue must be spared. Therefore, the allocation of radiation provides good protection for the surrounding tissue. The main focus here is placed on the vascular and nerve conservation.

Skin irritations can be prevented by cooling ointments. Care should be taken to ensure that the irradiated tissue is preserved during the period of irradiation. That is, avoidance of massages, no mechanical overload, but also the introduction of cortisone in this area should be avoided so as not to cause any damage.

Further information can be found under our topic: Haglundferse Irradiation.

Insole and upholstery

A therapy option of the Haglundferse is the conservative treatment by means of insole. In the best case, the insert cushions the heel, or the bony prominence, towards the back, thus preventing further inflammation.

Furthermore, running shoes with a high shoe edge are recommended, as this stabilizes the heel, and less scrubs. In addition, the heel is slightly raised by the insert, to shift the pressure forward, to the toes. Insoles of this shape are available in every orthopedic shoe store. They should be specially adapted to the foot, as each Haglundferse occurs individually differently.

An alternative is "taping" or connecting the heel with Leukoplast or bandage. This is probably the most cost-effective and uncomplicated option, however, care should be taken that the dressing does not slip during jogging, and from time to time for hygienic reasons is changed.

The easiest - but unfortunately only in the warm summer months feasible - is of course a running shoe with a free heel. So you can do without an insole right away. In the case of overweight patients, a nutritional plan for weight loss also helps: the less weight the heel has, the less it is mechanically stressed.

Operative therapy

Despite the various conservative options, conservative measures are often only temporary helpful. To permanently eliminate the pain and inflammation, the root cause must be removed. This can be done as part of an operation.

Surgical intervention

If the heel bone is severely deformed, it often has to be surgically reduced in size. Here, the heel bone body is narrowed and the bone protrusion are removed. Simultaneously with the Haglundferse an inflamed bursa can be removed. A minimally invasive method is the endoscopic removal of heel spurs. Due to the small access path, healing usually proceeds without complications. Since the Achilles tendon insertion and the plantar tendon are in close proximity to the surgical site, the surgery is very demanding and should only be performed by experienced surgeons.

Aftercare - what to look for?

insole

There are several shoe inserts that can relieve the heel and so relieve the pain. There are basically two types of deposits:

  • Shoe inserts with a recess in the heel area to reduce pressure on the heel. They prevent rubbing or pressure on the back of the shoe.
  • Insoles to support the Fußlängsgewölbe serve mainly to support the foot while walking and prevent the formation of a flat foot. This is one of the most common reasons for the development of a Haglundferse and can thus avoid a worsening of the symptoms.

However, both forms of shoe inserts can not reduce the heel spur, but only slightly improve the pain symptoms and the inflammatory situation. In any case, a Haglundferse should wear soft and spacious shoes so as not to strain the heel too much. Also, a heel increase of about 1cm can help to relieve the Achilles tendon on the heel and relieve the pain.

pad

In the case of an upper heel spur, there are special pads, the so-called " Haglund pads ", which especially protect the area of ​​the heel and reduce the inflammation. The padding protects the heel from pressure marks that can occur through the shoe. The cushion protects the heel from the upper edge of the shoe and reduces the pain. In addition, the friction of the heel is avoided on the shoe. This friction is an important cause of the development of inflammation on the heel.

Through the pad, the inflammation can decay somewhat and there is no renewed friction. In addition, the pad can reduce the load on the Achilles tendon and thereby also relieve the pain and inflammation. For the cushion to be of real use, it is important to wear it in every shoe.

forecast

The prognosis for successful treatment of the Haglund heel is good.

The treatment can last for many weeks. Relapsing symptoms after conservative treatment are common. Even after surgical treatment of the Haglund heel recurrences may occur, especially if the posterior bone protrusion is not completely removed.

cure

First, the care of the foot is important.

A spontaneous healing of a Haglundferse in the advanced stage is rather not to be expected, since it concerns a bony malformation, which does not disappear without further. Cause is in addition to congenital malformation too much stress on the heel for a long time.

This can be done on the one hand by too intense running training, on the other hand by badly fitting footwear. Therefore, in acute pain symptoms should be dispensed with running training, and the heel cooled and stored up. Also, other footwear and possibly an insert is advisable (see topic "insert").
Further supportive are cooling quark envelopes and shockwave therapy as well as power and ultrasound treatment. In 1-3 sessions, the bone is smashed from the outside by strong energetic waves, the small pieces of bone then automatically absorbed by the body.

The "ultima ratio" (ie the last option) represents an operative correction. Under anesthesia, a piece of the protruding heel bone is chiseled away and the skin is closed again over it. Such an operation is possible only in the abschwenen state and also requires a several weeks of pausing until complete healing. In order to prevent a re-germination of the complaints, the running training should be started again slowly and gently.

In the acute case, of course, painkillers can be used to treat pain. It should be noted, however, that in case of prolonged ingestion, a stomach protection such as pantoprazole should also be taken, as the freely available painkillers of the NSAID class permanently damage the gastric mucosa. For this, however, a clarification with your family doctor or orthopedist is advisable.

Summary

The complete healing of the Haglund heel takes a relatively long time. If the conservative measures are carried out consistently, it takes about 6 months for the Haglundferse to heal completely. However, it is also important to pay attention to comfortable footwear with appropriate inserts so that the Haglundferse does not develop again.

After a shock wave therapy, the heel heals much faster. After about 6 weeks the symptoms and the heel spur should be eliminated. In addition, as a rule, no aftercare is necessary. On the other hand, after the endoscopic, minimally invasive surgery, the heel needs to be relieved and spared for about 6 weeks. This can be achieved by special shoes with heel lift and a Spitzfußstellung. The long follow-up time helps to avoid possible complications after the operation.

In general, the prospects for successful conservative treatment are relatively good. However, even after the long treatment period, relapses may occur, so the possibility of surgical therapy should be considered. Nevertheless, even after the operation, new complaints are possible. In particular, when the posterior bone protrusion has not been completely removed.

The Haglundferse occurs more often than average with a heel spur. The cause is not completely clear.
A heel spur is a painful osseous retraction on the inner calcaneal body under the heel. The heel spur represents an ossification of a tendon plate (plantar fascia) in the neck area.


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