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I have a patient, female elite marathon runner- National standard, who is considering surgery for her Haglunds/ pump bumps. I have a number of questions on her behalf:
1. Successful outcome rates?
2. Recovery time?
3. Post op complications?
4. Are there a choice of procedures?
5. Who's the best surgeon in the UK to perform this and where are they?
6. Is it wise for an athlete to consider this type of surgery at all?
Thanks in advance for your help.
__________________ Science is the antidote to the poison of enthusiasm and superstition
I have a patient, female elite marathon runner- National standard, who is considering surgery for her Haglunds/ pump bumps. I have a number of questions on her behalf:
1. Successful outcome rates?
2. Recovery time?
3. Post op complications?
4. Are there a choice of procedures?
5. Who's the best surgeon in the UK to perform this and where are they?
6. Is it wise for an athlete to consider this type of surgery at all?
Thanks in advance for your help.
Simon:
Avoid this surgery if possible since a poor or fair surgical result will end her running career. I would try, instead accommodating the posterior-lateral heel in the running shoe to avoid compression/friction irritation and would try using heel lifts. Sometimes simply doing a little shoe surgery is in order where the plastic heel counter plate inside the heel counter of the shoe is trimmed where the osseous prominence of her "pump bump" hits the shoe. Many runners simply need to have their shoes accommodated in this fashion to become asymptomatic and avoid a potentially problematic surgery.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I have a patient, female elite marathon runner- National standard, who is considering surgery for her Haglunds/ pump bumps. I have a number of questions on her behalf:
1. Successful outcome rates?
2. Recovery time?
3. Post op complications?
4. Are there a choice of procedures?
5. Who's the best surgeon in the UK to perform this and where are they?
6. Is it wise for an athlete to consider this type of surgery at all?
Thanks in advance for your help.
Simon, I agree with Kevin.
A good deal depends on the diagnosis: haglund's, pump bump or AICT i.e. the precise location and size of the heel bump, symptoms shod / unshod etc. This will dictate the surgical treatment, extent of exposure, degree of AT involvement, and influence surgical choice in regard to the need for tendon debulking and any additional steps required to correct this problem. Recovery is quicker and less problematic when the achilles tendon can be left relatively undisturbed.
Regradless, recovery is almost always slow and can / does extend over many months. NWB / crutches for up to 8 weeks, aircast for up to 4 weeks, physical therapy.....
It can take up to one year for a patient to perform 10 single heel raises.
Unless essential this surgery is best avoided in the high demand patient, and / or if the patient cannot accept the athletic career may come to an end if the outcome is suboptimal.
I'm becoming frustrated with cases of posterior heel irritation in sports shoes with mild to moderate Haglunds deformities.
I note that Kevin mentions cutting an aperture in the plastic heel counter of the shoe, sounds tricky but I'll give it a go. Can others tell me what they do.
I have tried lining the heel counter with 3mm PPT and Silipos sheeting but both wear pretty quickly. Have also had the local shoe repairer glue foam under a pigskin / felt type material, to no long term avail.
Dieter, excuse my ignorance but what's the difference between Haglunds and pump bump and what's AICT.
I have a lady,early 60s who is seeking non surgical management of this.I injected-NOT IN ACHILLES TENDON,OF COURSE,only in Haglund's and it gave her relief,but for obvious reasons,I do not want to overdo it.Any other suggestions?I am starting her on PT and will see if it works.
I would really like to find out what others recommend for posterior heel irritation from shoes. I have tried silipos sheeting and PPT. And I have recently cut out a section of heel counter as per Kevin Kirby's earlier post and covered with silipos, so will see how it goes. Is there a better friction-absorbing material to use?
I agree I don't know the first thing about the making of sports shoes but I would love to see better material used in front of the heel counter to take the friction / pressure of the posterior calc. I have only seen thin flimsy foam used in even the best sports shoes.
In thinking, I tend to use pretty high arch heights in the orthotics I prescribe but I wouldn't think this would cause more frontal plane calcaneal motion and therefore friction to make this a common problem in my practice. Any thoughts ...
Angle analysis of haglund syndrome and its relationship with osseous variations and achilles tendon calcification. Foot Ankle Int. 2007 Feb;28(2):181-5
Lu CC, Cheng YM, Fu YC, Tien YC, Chen SK, Huang PJ
Quote:
BACKGROUND: Haglund syndrome is a cause of posterior heel pain. The prominent posterosuperior projection into the retrocalcaneal bursa is thought to be a major etiology. Many methods have been proposed to measure the posterosuperior projection of the tuberosity into this bursa. The Fowler angle and the parallel pitch lines are the most frequently used. However, the relation between symptomatic Haglund syndrome and the measuring methods, especially the Fowler angle and parallel pitch lines, is not clear. The purposes of this paper were to study the predictive value of the most frequently used measurement methods to evaluate bursal impingement and to determine if other osseous variations and Achilles tendon calcification are associated with the development of Haglund syndrome.
METHODS: From October, 1996, to March, 2003, we evaluated 37 heels in 31 patients with symptomatic Haglund syndrome, and 40 heels in 27 individuals without posterior heel pain. On a lateral view radiograph, the Fowler angle, and the parallel pitch lines were measured, in addition to Achilles tendon calcification and the osseous variations, such as a posterior calcaneal step spur or plantar osseous projection.
RESULTS: The average Fowler angles in the control group and study group were 62.31 +/- 7.79 degrees and 60.14 +/- 7.01 degrees, respectively. There was no statistically significant difference (p = 0.490). The positive parallel pitch lines in the symptomatic group were 56.8% and in the control group 42.5%. There was no statistically significant difference (p = 0.474) between the groups.
CONCLUSIONS: No statistically significant differences were noted between the groups concerning the Fowler angle and parallel pitch lines. The posterior calcaneal step spur and Achilles tendon calcification were statistically significant between these two groups. The Fowler angle and parallel pitch lines were of little predictive value for the Haglund syndrome.
Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for the treatment of haglund deformity and retrocalcaneal bursitis. Foot Ankle Int. 2007 Feb;28(2):149-53
Ortmann FW, McBryde AM
Quote:
BACKGROUND: The traditional operative management of Haglund deformity and retrocalcaneal bursitis consists of an open excision of the inflamed bursa, resection of the posterosuperior calcaneal tuberosity, and debridement of the Achilles tendinopathy. In an effort to reduce morbidity and recovery time, an endoscopic technique was used for the management of this condition.
METHODS: Thirty consecutive patients (32 heels) who had retrocalcaneal bursitis unrelieved by nonoperative measures were treated with the endoscopic technique. Two portals were created, one laterally and one medially, over the posterosuperior portion of the calcaneus to gain access to the retrocalcaneal space. The inflamed bursal tissue was removed, and the prominent bone was resected. Patients were evaluated preoperatively and postoperatively with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale.
RESULTS: The mean followup was 35 months. Twenty-eight patients (30 heels) were available for followup. The AOFAS scores averaged 62 preoperatively and 97 postoperatively. There were 26 excellent results, three good results and one poor result. One major and one minor complication occurred: an Achilles tendon rupture three weeks after surgery and residual pain and swelling that required reoperation through an open procedure. There were no wound complications or postoperative infections.
CONCLUSIONS: The endoscopic technique can be done outpatient and has a low morbidity and high patient satisfaction. The time to return to normal activity level is short. Sufficient exposure of the Achilles tendon and removal of the calcaneal prominence and retrocalcaneal bursa can be done effectively using an endoscopic technique.
Posterior calcaneal exostosis treatment modalities showed many controversial opinions. After failure of the conservative treatment, surgical bursectomy and resection of the calcaneal exostosis are indicated by many authors. But clinical studies also show a high rate of unsatisfactory results with a relative high incidence of complications. The minimal surgical invasive technique by an endoscopic calcaneoplasty (ECP) could be an option to overcome some of these problems. We operated on 81 patients with an age range between 25 and 55 years, 40 males and 41 females. The radiologic examination prior to surgery documented in all cases a posterior superior calcaneal exostosis that showed friction to the Achilles tendon. All patients included in the study had neither clinical varus of the hind foot nor cavus deformities. All patients had undergone a trial of conservative treatment for at least 6 months and did not show a positive response. The average follow-up was 35.3 months (12-72). According to the Ogilvie-Harris-Score, 34 patients presented good and 41 patients excellent results, while three patients showed fair results, and three patients only poor results. All the post-operative radiographs showed sufficient resection of the calcaneal spur. Only minor postoperative complications were observed. ECP is an effective and of minimal-invasive procedure for the treatment of patients with calcaneal exostosis. After a short learning curve, the endoscopic exposure is superior to the open technique has less morbidity, less operating time, and nearly no complications; moreover, the pathology can better be differentiated.
"To a man with a hammer all things look like a nail"
Being a surgeon, I of course will argue in favor of the surgical procedures. I admit I have not had time to read all the reponses.
First, there is a need to be more specific with the diagnosis; i.e., lateral "pump bump" vs centrally located retrocalcaneal exostoses vs achilles tendinitis vs mucinous degeneration, intra-achilles calcification; and also underlying etiology - equinus, rearfoot varus, etc.......
The simple Haglunds (lateral exostosis with no tendon involvement) is a very successful and quick healing procedure, even on those where the superior angle of the OS CALCIS is removed.
The retrocalcaneal exostoses (medial to lateral) which requires partial achilles resection with or without debridement of achilles or grafting, are also quite successful when surgical indications are followed although very slow healing. When the posterior aspect of the os calcis is debrided along with the achilles and commonly graft, I inform patients that the healing is approximately 6-8 months.
Hope this helps
s. arbes
"To a man with a hammer all things look like a nail"
Being a surgeon, I of course will argue in favor of the surgical procedures. I admit I have not had time to read all the reponses.
First, there is a need to be more specific with the diagnosis; i.e., lateral "pump bump" vs centrally located retrocalcaneal exostoses vs achilles tendinitis vs mucinous degeneration, intra-achilles calcification; and also underlying etiology - equinus, rearfoot varus, etc.......
The simple Haglunds (lateral exostosis with no tendon involvement) is a very successful and quick healing procedure, even on those where the superior angle of the OS CALCIS is removed.
The retrocalcaneal exostoses (medial to lateral) which requires partial achilles resection with or without debridement of achilles or grafting, are also quite successful when surgical indications are followed although very slow healing. When the posterior aspect of the os calcis is debrided along with the achilles and commonly graft, I inform patients that the healing is approximately 6-8 months.
Hope this helps
s. arbes
Steve:
"To a man with a hammer all things look like a nail." And, to a surgeon, every patient looks like a potential surgery.
All who have been around podiatric surgeons or orthopedic surgeons for as long as I have know this to be the case. Since I am also a surgeon, I am respectful of surgeons who are well-trained and with good technical skills. However, I become a little wary when these same medical professionals start talking about all their successes, but never mention or even acknowledge any of their failures. I have experienced that even the best trained surgeons, those that often tell their patients and others that their surgeries nearly always work well and their patients don't have problems with their surgeries, have plenty of their patients who do not come back to them. These patients complain that the doctor's surgery not only did not relieve their pain but the surgery made their pain worse. For the surgeon with selective memory of their less-than-perfect results or for the surgeon who blames all their less-than-perfect results on the patient but not on themselves, the apparent lack of objectivity by the doctor is normally manifest by them proclaiming high cure rates, when few others can match their reported surgical success. If you have been around surgeons as long as I have, you should know very well what I am talking about. By the way, I have been practicing in a group practice with orthopedic surgeons for the past 22 years and have been attending podiatric surgical seminars for nearly a quarter of a century.
The bottom line of this message is that an elite marathon runner deserves conservative care first before surgery. One should attempt every conservative method that I have mentioned in my earlier postings on this subject so that, if the unexpected surgical failure or surgical complication occurs, the patient doesn't become a surgical cripple and the surgeon won't need to again selectively erase that surgical failure from their mind so that they can continue to say that all of their surgeries are "very successful".
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
"The bottom line of this message is that an elite marathon runner deserves conservative care first before surgery."
As do all your patients, elite or not.
Good luck and let us know how it turns out.
Dr. Steve
"The bottom line of this message is that an elite marathon runner deserves conservative care first before surgery."
As do all your patients, elite or not.
Good luck and let us know how it turns out.
Dr. Steve
Dr. Steve:
This wasn't my patient.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I have had fairly good results by placing a spacer at the back end of the orthotic to actually push it forward roughly 4-6 mm. This reduces the aspect of reducing friction.
From a tension point of view, heel raise to tolerance.
Lastly, and certainly not least, reduce excessive frontal plane motion which may be a factor in torsion on the Achilles. It will feel different to the runner, and they may also balk at how it feels.
I have a couple of high mileage runners, whose very sigificantly red, swollen and painful "bumps" have settled down to almost normal with virtually no pain..Shoe surgery by popping out the heel conter with heat and cutting out a hole is very effective.
Hi Kevin,
Just after a quick insight.
What is your understanding of the difference between:
Haglunds Syndrome , Haglunds deformity, Pump Bump, and retrocalcaneal bursitis?
are these interchangable or are there significant differences. The literature seems to be quite hazy on this.
Many Thanks.
Hi
I have had previous success, although not in all Haglunds cases, where by chance the runner was due for a new pair of shoes. I asked he get one size larger into which I stuck an EVA apertured heel counter covered with a PPT/ durahyde/ similar material, taking care to use enough material to avoid rolling. The EVA took up the necessary space to accomodate the longer shoe and changing his lacing to 'loop' in the last hole, accomodated for width.
Please don't quote me on this but I remember having convesation with a surgeon about this and we were discussing outcomes - he didn't like doing them as the prognosis was poor and regrowth of bone was a real issue - he did, however say that there was a new proceedure thtat rmonved the bump and then they drilled very small holes into the calc - this , apparently meant that less ostreophytic growth was produced as the body filled in the holes rather than creating another bump - he also mentioned they were doing this on teh 1st mpj - I didn't get a referrance unfortunately but it sort of made sense? has anyone else heard of this??? (must sort out my typos)
Surgical correction of Haglund's triad using complete detachment and reattachment of the Achilles tendon.
DeVries JG, Summerhays B, Guehlstorf DW. J Foot Ankle Surg. 2009 Jul-Aug;48(4):447-51.
Quote:
Haglund's triad consists of the simultaneous presentation of the following clinical entities: Achilles tendinosis, Haglund's deformity, and retrocalcaneal bursitis. In this retrospective study, we review outcomes following the surgical treatment of Haglund's triad by means of complete detachment and reattachment of the Achilles tendon, removal of the retrocalcaneal exostosis, and excision of the retrocalcaneal bursa through a medial J-shaped approach. Patients were identified via chart review, and sent consent forms and a questionnaire consisting of a visual analog scale (VAS), a satisfaction survey, and the Maryland Foot Score. Seventeen patients (22 feet) met the inclusion criteria and returned the consent and questionnaires. Their mean age was 51.6 +/- 11.6 years, and the mean duration of postoperative follow-up was 40.1 +/- 27.0 months. The mean preoperative VAS was 7.9 +/- 2.3, and the postoperative VAS was 1.6 +/- 1.3 (P < .001). The mean postoperative Maryland Foot Score was 91.5 +/- 9.1, with 16 good to excellent results. Of the 17 patients, 16 were satisfied and only 1 was somewhat unsatisfied. Four complications were observed, and 1 of these required further surgical intervention. The outcome of this study demonstrated that surgical correction of Haglund's triad using a medial "J" approach, complete detachment and reattachment of the Achilles tendon, exostectomy, and retrocalcaneal bursectomy provided patient satisfaction with limited complications
I have had fairly good results by placing a spacer at the back end of the orthotic to actually push it forward roughly 4-6 mm. This reduces the aspect of reducing friction.
Freeman,
I agree with what you wrote. In 1984, when I coordinated the curriculum for the American Academy of Podiatric Sports Medicine, I obtained the curriculums from all the colleges of Podiatric Medicine. The California College had exactly what you wrote for Haglund's deformity. I have been using it ever since. I will use either 1/8" (3mm) or 1/4" (6mm) depending on the severity. Prior to this I performed surgery,with only about 33% of the patients truly happy. Looking back, I think the reason was that I didn’t provide enough immobilization for the patient post surgically.
My definition of Haglund's deformity is the enlargement of the posterior superior part of the calcaneus. My radiographic examination is performed on the lateral view by drawing a line parallel with the superior posterior half of the calcaneus, and dropping a perpendicular. Normal is 10 degrees, as this is the angulation of the superior counter of the shoe. Less than this can cause irritation. Most of the symptomatic cases have an angle of 0 degrees.
A pump bump is an enlargement of the middle of the calcaneus, and this is caused by a smaller angle (the exact mumber I can't tell you, as I haven't seen enough of these over the years), so the middle of the calcaneus protrudes.
Other conditions to be wary of are the two bursitises that can occur (one anterior and one posterior to the Achilles tendon), calcification of the Achilles tendon, and enthesiopathy of the Achilles tendon.
Haglunds in an elite marathon runner
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