Have you been told that you have a Haglund's deformity that is causing pain in your Achilles tendon or at the back of your heel? In this article, Maryke explains why you do not have to pay too much attention to the fact that you have a Haglund's deformity and how the right physiotherapy treatment programme could get you pain-free and up-and-running again without having to go under the knife.
Remember, if you need help with an Achilles injury, you're welcome to consult one of our team via video call.
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In this article:
I've also discussed it in detail here:
Why diagnosing someone's heel pain as Haglund's deformity is not really accurate
In the X-ray image below, the arrow indicates a typical Haglund's deformity.
Each human bone looks very similar to those in other humans, but they are not exactly the same. A Haglund's deformity is a common shape that many people (also those without pain) have in their heel bones.
If you have a Haglund's deformity, it is already present by the time your bones mature (around 18 years old). But most people who are diagnosed with Haglund's deformity only develop heel pain in their late twenties or even into their forties.
Also, people usually have a Haglund's deformity in both feet but often only pain in one. And we've seen many patients recover and get back to full pain-free function despite the Haglund's deformity still being there (because it's not something that goes away).
So, your Haglund's deformity would have been present for a very long time, even before you've ever had any pain. And people recover from heel pain despite the deformity still being present.
If you look at an MRI scan of someone complaining of heel pain and who has been diagnosed with Haglund's deformity, the structures that show up as being injured are:
the Achilles tendon (insertional tendinopathy),
or the bursa between the tendon and the heel bone (heel bursitis)
or both of them.
These injuries are NOT unique to people with Haglund's deformity – they are very common in people who have absolutely "normal" looking heel bones.
Yes, a Haglund's deformity might make it easier to develop an injury in your Achilles tendon or bursa, because it decreases the space between the tendon and bone. This can increase the normal compression forces those areas are subjected to when you walk or play sports, which might make it easier to injure them. But you still need a specific trigger (e.g. ramping up activity or training too quickly, or switching to flat shoes, or over-stretching) to develop these injuries.
A more accurate and useful diagnosis would be Achilles tendonitis or heel bursitis (depending on your scan). One can acknowledge that Haglund's deformity might have made it easier to injure these structures and that it has implications for specific elements of treatment (e.g. shoes) and injury prevention, but focusing treatment on the Haglund's is not the best approach.
The real cause of your heel pain
So, if Haglund’s deformity (if you have it) is not the cause of your heel pain, what is?
👉 It is a classic case of overload.
When you walk or do sport, your Achilles tendon pulls tight over your heel bone as your foot moves into dorsiflexion (toes going closer to shin). The bursa is a little sac of fluid that is meant to decrease the friction between the tendon and the bone. So, as your Achilles tendon pulls tight, it compresses the bursa against the heel bone. This is normal and happens to all of us.
Your Achilles tendon as well as your bursa are used to handling a certain amount of compression load in that area, and the body is good at building these structures up to cope with that for your usual amount of walking, running, and other activities.
However, if for some reason you make a sudden change in your habits and you massively increase the amount of compression, it can overload the tendon and bursa, because you have not given your body time to slowly build up to that point, and that is when it flares up.
What type of activities can overload your insertional Achilles tendon and/or bursa so that they suddenly go, "Whoa! This is much more compression than I'm used to"?
A classic example that I often see with non-runners as well as with runners is when they suddenly change from wearing shoes with a bit of a heel to flat shoes or no shoes.
It can be when you go from winter shoes to summer shoes, like flip-flops, or to walking barefoot a lot. Because of the increased dorsiflexion, with your heel now flat on the ground, the compression of the Achilles tendon and the bursa on the heel bone increases.
With runners, it's often when they change from regular running shoes with quite a bit of a drop from the heel to the toe to, for instance, flat minimalist shoes.
Another common cause could be if you do a lot of walking or running on the flat and then suddenly you add a lot of hill walking or running. When you walk or run uphill, again, you increase the dorsiflexion angle compared to when you walk or run on the flat, and that pulls your Achilles tendon tighter over your heel bone, increasing the compression.
Doing a lot of strong calf stretches, like in yoga, can also cause it to flare up.
So, yes, the Haglund's deformity decreases the space in your heel, and it can make you more sensitive to increased compression over the heel bone, but it is that sudden increase in compression loads that actually causes the injury.
In all the above cases, if you make that switchgradually and you build up to it, your body has time to adapt the structures to cope with the load increase and you likely won't get injured.
How to treat heel pain associated with Haglund's deformity
Is surgery to remove that Haglund's deformity the solution? If you have read up to here, I hope you will realise that the answer is mostly “no”. The best approach is to focus treatment on the bits that are actually causing the pain (the Achilles tendon and bursa).
First, offload
Because it is excessive compression when the foot goes into dorsiflexion that is causing the irritation in the Achilles tendon as well as in the bursa, we want to offload it – decrease that compression for a while.
So, for a short time, we may get you to wear only shoes with a bit of a heel on it, such as most types of regular trainers/sneakers, to decrease the dorsiflexion of the feet. An alternative is putting a heel lifting wedge into your shoes to reduce the strain.
Or if you can't stand any pressure on the back of your heel, wearing sandals with heels and a strap that goes above the back of your heel may be a good option.
👉 This may mean that, for a while, you avoid walking barefoot and wear shoes even around the house until the pain has calmed down.
If you are into exercises such as doing squats in the gym, which increases the dorsiflexion, we would get you to raise your heels by, for example, putting a plate under them.
Offloading also involves not stretching your calf and your Achilles into dorsiflexion. I was really shocked when I searched online for Haglund's deformity to search for pictures for this article and found many articles by people who claim to know how to treat this telling their readers to do calf stretches or to put a band around their foot to pull it towards them into dorsiflexion.
If you are going to stretch your foot like that, it will only increase the compression, increase the load on those structures that are sensitive, and it will be like poking a bruise repeatedly. Your pain will just escalate.
🙏 So please, if you are doing calf stretches for an insertional tendinopathy or bursitis or Haglund's deformity, just stop. It is one of the best things you can do.
Medication?
If there is a bursitis involved, then using a short course – no more than five to ten days – of anti-inflammatories may be useful to calm it down quicker. Please check with your doctor before taking any medication; there may be reasons why you should not take them.
Anti-inflammatories do not help for tendinopathies. We know from the research that tendinopathies do not really have a massive inflammatory component to them, and taking this type of medication does not help them heal.
Usually, we find that anti-inflammatories aren't necessary if we can offload the compression of the tendon with the shoe/orthotic treatment that I described above.
Then, rehab
Once the acute pain has settled down, we need to start loading things up gently to strengthen your Achilles tendon (if your heel pain is associated with a tendinopathy) and get your heel used to normal movement.
But the exercises have to be done in a way that they initially don't cause too much compression around the heel. We may opt for something like isometrics, where you just hold the heel raise in one position, or doing your heel raises from floor level rather than over the side of a step.
Only once your heel has calmed down significantly should you start introducing exercises that involve more dorsiflexion, e.g. heel raises over the side of a step.
If your heel pain was caused by bursitis only, then you may not have to do any specific exercises. You can find more advice about exercises for bursitis here.
Other treatments
There are also other treatments like shockwave or injections that might be useful. We've previously discussed the best treatments for tendinopathy and for bursitis.
Surgery for Haglund's deformity?
Of course, the treatment discussed above will not work for 100% of people, and there are some cases that eventually go on to surgery and do well with surgery.
It could be that your Haglund's deformity is just so big that it does poke directly on that tendon, and because of the shape of your foot it just does not get to a position where this does not happen. In those cases, it may be useful to have that piece of bone removed.
Sometimes the bursa or tendon may just be so irritated that, despite doing all the correct treatments, the pain just doesn't want to settle. In those cases surgery might also be an option.
However, I often find that people do not offload the tendon for long enough and do not give it enough time to recover and calm down. Insertional Achilles tendinopathy is not a situation where you can go, "Oh I offloaded it for a week or two and now it's still not getting better."
Achilles tendinopathy and bursitis take at least three months to show good improvement. And then it can take several more months to get back to where you want to be. It is not unusual to take 6 to 12 months to achieve full recovery.
Now, that may sound long, but recovery from surgery is going to take just as long and is not always guaranteed . So please do not see surgery as a short-term solution.
I have worked with patients who, a year after surgery for this, are still not much better than before the surgery. Then again, I have had other patients who were much better after surgery.
So, do not take this as, "Surgery is always a bad thing". It is just about making sure that you try all other treatments and give it enough time before you decide to go on to surgery.
How we can help
Need more help with your Achilles injury? You’re welcome to consult one of the team at TMA online via video call for an assessment of your injury and a tailored treatment plan.
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Treat My Achilles we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.
About the Author
Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn, ResearchGate, Facebook, Twitter, and Instagram.