Haglund Syndrome – A Case of Bilateral Involvement

Haglund syndrome is a cause of posterior heel pain and was first
described by Patrick Haglund, in 1928, to occur in patients who had
a prominence of the posterosuperior surface of the calcaneus.


Introduction
Haglund syndrome is a cause of posterior heel pain and was first described by Patrick Haglund, in 1928, to occur in patients who had a prominence of the posterosuperior surface of the calcaneus [1]. It occurs commonly in adolescent girls who wear high heels with restrictive heel counters and may occur in people with rheumatoid arthritis [1]. Haglund syndrome has also been termed "pump bump," "winter heel," "knobby heels," "calcaneal altus," "highbrow heels," and "cucumber heels" [1]. Haglund syndrome is characterized clinically by thickening of the soft tissues at the Achilles tendon insertion or a painful "pump bump" and retrocalcaneal bursitis, Achilles tendinitis, and a prominent posterosuperior calcaneal border or bursal projection [1][2][3][4].

Abstract
Haglund syndrome is a cause of posterior heel pain and occurs commonly in adolescent girls who wear high heels with restrictive heel counters and may occur in people with rheumatoid arthritis. Is characterized clinically by thickening of the soft tissues at the Achilles tendon insertion or a painful "pump bump" and retrocalcaneal bursitis, Achilles tendinitis, and a prominent posterosuperior calcaneal border or bursal projection. We report a case of a 59 years-old woman with bilateral Haglund syndrome which did not needed surgical treatment, being the conservative treatment enough to improve the patient's quality of life.

Case Presentation
59 years-old woman with pain and swelling in both feet for four months that get worse when use slippers and when she wake up and put her feet in the floor for the first time in the day. The patient denies other complaints and surgeries. At physical examination refers pain at the palpation of in the posterior and inferior regions of the ankle. The Magnetic Resonance Imaging (MRI) demonstrates posterior and plantar calcaneal spurs, liquid in retrocalcaneal and subcutaneous calcaneous bursa, and calcaneal tendon with heterogeneous signal and thickened (1.4cm at left and 1.2cm at right), markedly in their insertion with adjacent bone edema (Figures 1 & 2). The set of findings are compatible with Haglund syndrome. The patient started conservative treatment with non-steroidal anti-inflammatories, change of footwear and physiotherapy, presenting a good response, not requiring surgery.

Discussion
Haglund syndrome is caused by mechanically induced inflammation of the Achilles tendon and its bursa, from abnormally high pressure between the bursal projection of the calcaneus, the Achilles tendon, and the bursa [1,5]. Patients with bursitis have erythema and swelling over the bursa and tenderness to direct palpation [2] besides pain with dorsiflexion of the foot [6]. Clinically, by physical examination alone, it may be difficult to distinguish Haglund's syndrome from other causes of hindfoot pain such as Reiter's disease, rheumatoid arthritis, or isolated local conditions such as superficial tendon Achilles bursitis secondary to poor shoe fit [7]. Plain radiograph in a lateral standing position is useful to assess the presence of a prominent bursal projection of the calcaneum, the Haglund deformity [3]. Loss of a lucent retrocalcaneal recess is an important indication of underlying retrocalcaneal bursitis [3]. The Achilles tendon is swollen, and dystrophic calcifications may also be seen [3].
MRI may be required for ambiguous or clinically equivocal cases [3]. The cardinal soft tissue abnormalities, namely Achilles tendinopathy, and retrocalcaneal and retroachilles bursitis are more easily and directly depicted by MRI [3]. The detection of marrow oedema within the prominent bursal projection is likely to support the repetitive mechanical compression and inflammation as the pathological mechanism in this condition [3]. Treatment of Haglund deformity, with or without bursitis, targets decreasing the pressure and inflammation with openheeled shoes, anti-inflammatory or analgesic medications, and corticosteroid injections [2]. Physical therapy may also help reduce pain. In recalcitrant cases, surgery to remove the Haglund deformity may be necessary [2].
The nonsurgical treatment, combined with modifications in daily shoe wear, is an appropriate initial treatment for pain relief of Haglund's syndrome [7]. Using ultrasound guidance to inject the retrocalcaneal bursa is a simple, reliable method of ensuring accurate delivery of medication into the bursa and avoiding intratendinous injection [7].