Haglund deformity (pump bump) and back-of-heel pain

What is a Haglund deformity?

Haglund deformity is a bony enlargement at the back of the heel bone, at the top corner near where the Achilles tendon attaches. It is also called a retrocalcaneal exostosis or “pump bump,” because the rigid back of a pump-style shoe can press on it.^[1,2] The prominent bone can irritate the small fluid-filled sac between the tendon and the heel bone (the retrocalcaneal bursa), causing bursitis, which is a significant cause of pain at the back of the heel.^[2] The Achilles tendon just above its attachment can also become painful. See Achilles tendon injuries.

Pain at the back of the heel is common and occurs in many foot types, and a Haglund deformity is only one of several possible causes.^[3]

Symptoms

• a bump on the back of the heel that you can see or feel
• pain where the Achilles tendon meets the heel, often worse after rest and when the shoe presses on it
• swelling and redness in the area^[1]

What causes a Haglund deformity?

Shoes with a rigid back irritate the area, which is why the condition is linked to pumps, dress shoes and ice skates. Inherited foot features also contribute: a high arch, a tight Achilles tendon, and a walking pattern that puts weight on the heels.^[1] For related conditions, see cavus foot and gastrocnemius recession, which addresses a tight calf.

How it’s evaluated

The diagnosis rests on the examination and X-rays, which show the shape of the heel bone.^[1] Because the bump sits next to the tendon, the examination also checks the tendon itself, the calf tightness and the shoes you wear. X-ray and ultrasound are available on site at our practice; see foot and ankle imaging.

Non-surgical care

Non-surgical treatment is the first step, and it includes:

• anti-inflammatory medicine and ice
• stretching exercises and physical therapy
• heel lifts or pads that lift the heel away from the shoe
• shoes with a soft or open back
• custom arch supports, and sometimes a short period in a cast^[1]

A review of posterior heel pain notes that these measures have shown mixed results, so treatment is adjusted to how you respond.^[3] They can settle the inflammation, but they don’t remove the bone, so some people continue to have symptoms in tight shoes.^[1]

When surgery is considered

Surgery is considered for people whose pain persists after a period of non-surgical care that includes pain relief, physical therapy, activity changes and changes of footwear.^[2,1] The operation typically removes the bursa, shaves down the bony prominence and cleans up the diseased part of the Achilles tendon. It can be done through an open incision or with an endoscope through small incisions.^[2]

• A systematic review of 35 studies (1,260 ankles) found good results and high satisfaction. Compared with open surgery, endoscopic surgery had higher average function scores, fewer complications (about 4% versus 15%) and a faster return to daily activities.^[4]
• A later meta-analysis of 39 studies of insertional Achilles tendinopathy, a closely related heel problem, found function scores improved to a similar degree with either approach, and again a lower complication rate and faster recovery with the endoscopic approach.^[5]
• When the problem is more than a bump, a bone cut that tilts the heel bone (a Zadek osteotomy) is another option. In a review of eight case series, function scores improved and complications were mostly minor.^[6]

These are comparisons across studies rather than head-to-head trials, and the authors call for further research.^[2] For the operations, recovery and risks, see Haglund deformity surgery.

When to seek care

Consider an evaluation if a bump on the back of the heel keeps hurting despite changes of footwear and stretching, or if the area becomes red, swollen or warm.