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Haglunds in an elite marathon runner

Discussion in 'Foot Surgery' started by Simon Spooner, Jun 14, 2006.


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    All,

    I know little about rearfoot surgical procedures.

    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.
     
  2. 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.
     
  3. Dieter Fellner

    Dieter Fellner Well-Known Member

    Rce

    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.
     
  4. John Spina

    John Spina Active Member

    Try to do or refer this patient to physical therapy.I have gotten good results like this.
     
  5. Asher

    Asher Well-Known Member

    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.

    Thanks

    Rebecca
     
  6. John Spina

    John Spina Active Member

    I am not sure of the difference between Haglunds and pump bump myself,in fact I think that they are one and the same.
     
  7. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    Achilles insertional calcific tendonitis.

    Long slow recovery from surgery - best suited to non-athletic individuals with sedentary occupations and plenty of patience. ;)


    LL
     
  8. John Spina

    John Spina Active Member

    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.
     
  9. Asher

    Asher Well-Known Member

    Hi there ...

    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 ...

    Rebecca
     
  10. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    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
     
  11. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    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
     
  12. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Endoscopic calcaneoplasty (ECP) as a surgical treatment of Haglund's syndrome.
    Knee Surg Sports Traumatol Arthrosc. 2007 Mar 6;
    Jerosch J, Schunck J, Sokkar SH
     
  13. drsarbes

    drsarbes Well-Known Member

    "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
     
  14. 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".
     
    Last edited: May 24, 2007
  15. drsarbes

    drsarbes Well-Known Member

    "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
     
  16. Dr. Steve:

    This wasn't my patient.
     
  17. Freeman

    Freeman Active Member

    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.

    Best wishes,
    Freeman Churchill
     
  18. jensglynne

    jensglynne Member

    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.

    Jens
     
  19. Brandon Maggen

    Brandon Maggen Active Member

    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.

    Regards

    Brandon Maggen
     
  20. moggy

    moggy Active Member

    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)

    Claire
     
  21. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    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.
     
  22. Stanley

    Stanley Well-Known Member

    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.

    Regards,

    Stanley
     
  23. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
  24. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Persistent Haglund’s disease after conventional treatments: the innovative role
    of radiotherapy.

    F. di Chio et al
    source
     
  25. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Haglund’s Syndrome: A Commonly Seen
    Mysterious Condition

    Raju Vaishya , Amit Kumar Agarwal , Ahmad Tariq Azizi , Vipul Vijay
    Cureus 8(10): e820. DOI 10.7759/cureus.820 Full text
     
  26. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    This is well worth watching:

     
  27. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
  28. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Endoscopic Achilles Tendon Augmentation With Suture Anchors After Calcaneal Exostectomy in Haglund Syndrome.
    Vega J et al
    Foot Ankle Int. 2018 Mar 1:1071100717750888. doi: 10.1177/1071100717750888.
     
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