Haglund's syndrome was described for the first time in 1928 by Patrick Haglund. It is a cause of tendino-bursitis entrapment of the heel, produced by a posterosuperior exostosis of the calcaneus (Haglund's deformity), accompanied by Achilles tendinitis and retrocalcaneal bursitis.1–3

Although its pathogenesis is unknown, there have been reports proposing predisposing mechanical factors such as shoes that are too tight, high heels worn by women, an increased plantar arch, Achilles tendon too tense and situations that increase friction between the tendon and the bone.2

The differential diagnosis should include xanthomatosis, seronegative spondyloarthropathies and gouty and rheumatoid arthritis.2,3

Haglund's syndrome is a cause for mechanical pain in the hindfoot. There are several theories about its pathogenesis, although some authors point out the continuous contraction of the sural triceps, which produces an entrapment of the Achilles tendon and the retrocalcaneal bursa against the posterosuperior calcaneal exostosis.4 Other authors propose that the process begins with an external compression on the heel, which applies pressure to the retrocalcaneal bursa, which then presses on the outer part of the calcaneus. Thus, the calcaneal tuberosity increases in size in response to this chronic irritation, and the tuberosity, in turn, compresses the bursa and the Achilles tendon, provoking a vicious circle.2,5

The diagnosis is reached on the basis of the clinical signs and radiological images using the measurement of the parallel pitch lines (PPL) in a lateral radiograph of the ankle. This method consists in tracing a line tangent to the lower margin of the calcaneus, and another parallel to the first on the upper margin, at the height of the highest point of the posterior margin of the subtalar joint surface. If the tuberosity exceeds this line, the cause is considered to be Haglund's deformity (Fig. 1).2,5 In some cases, the diagnosis can be completed using ultrasound or magnetic resonance imaging.2,6

Fig. 1.

Lateral radiograph of ankle. The arrow signals the posterosuperior exostosis of the calcaneus, which exceeds the upper line in the parallel pitch line method and, thus, the cause is considered to be Haglund's deformity.

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The initial treatment should be conservative, with the avoidance of shoes that are too tight or have a high heel, using foot orthoses, oral anti-inflammatory drugs, local corticosteroid injection and physiotherapy.3,7 If there is no response to conservative treatment, surgery would be indicated. The technique most frequently used is retrocalcaneal bursectomy with osteotomy of Haglund's deformity, as the central approach to the tendon has been found to be safe and effective.7–10

Haglund's syndrome is a cause of pain in the hindfoot that should be taken into account in the differential diagnosis. It should be suspected in the light of the clinical characteristic finding, and be confirmed by radiological studies to ensure a correct diagnosis. Conservative treatment involving medical and physical therapy should be the first option before surgery.

The authors declare they have no conflicts of interest.