What is the diagnosis?

This is a case of a Haglund Syndrome (retrocalcaneal exostosis). Haglund syndrome is a bony enlargement (mostly due to an osteophyte or bone spur) of the retrocalcaneal tuberosity where the Achilles tendon is inserted that contributes to irritation of the soft tissue near the back of the heel [1].

Image 2. Lateral radiograph of the left foot with annotation by author. There is a bony prominence seen on the postero-superior aspect of the calcaneal tuberosity (red circle). Notably, there is also a calcaneal spur in the inferior aspect of the calcaneal tuberosity which is a separate condition (red square). Annotations courtesy of the author. Image courtesy of Mohammadtaghi Niknejad, Radiopaedia.org, rID:61628

• Pearl: Haglund Syndrome can cause chronic inflammation and degeneration of the Achilles tendon, eventually leading to rupture [2].

What is the mechanism of injury?

The exact etiology is not well known. A Haglund deformity is often idiopathic with a hereditary cause as a presumed factor but is also associated with a tight Achilles tendon ora high arch of the foot. Excess friction caused by the calcaneus rubbing against rigid shoes can also predispose or exacerbate a deformity [1].

What physical exam findings are expected?

Patients often present with pain at the posterior heel on the affected side, worse after wearing rigid shoes and walking long distances. It does not improve with rest [1]. Patients may also concurrently have an Achilles tendon rupture [2]. 

• Pearl: Patients will commonly present with a visible and palpable  bump on the posterior aspect of the heel around the insertion of the Achilles tendon called a Haglund deformity.

Which imaging modalities can be used?

Plain radiographs are sufficient to visualize bony prominences on the calcaneal tuberosity (see Figure 1) as well as soft tissue swelling. MRI is helpful to detect degenerative changes within the Achilles tendon (see Image 3 below).

Image3. MRI Sagittal T1 view of the right foot. There is significant thinning of the insertional portion of the Achilles tendon (red arrow) with adjacent edema. There is also fluid collection in the retrocalcaneal bursa (blue arrow). Annotations courtesy of the author. Image courtesy of Roberto Schubert, Radiopaedia.org, rID: 15781

What is the management in the ED and when do you consult orthopedics?

Initial conservative management is encouraged with anti-inflammatory medications. In the outpatient setting, patients may also consider orthopedic shoes, heel lifts, and physiotherapy [1].When initial conservative management fails, an outpatient surgical consult is warranted to consider excision of the bony exostosis of the calcaneus [1].