Haglund’s Deformity and Other Causes of Heel Pain in Runners

Runners, is your ‘Achilles heel’ your Achilles heel? Achilles-related pain is estimated to occur in nearly 10% of recreational runners every year (10) and over half of former elite male runners will experience it in their lifetime (23). Overuse injuries of the Achilles tendon are the most common reason for dropouts in athletic careers, especially in track and field (9). Loading of this tendon can reach up to 12.5 times a person’s body weight during running (6, 7) and the Achilles has a notoriously poor blood supply, so its ability to recover from injury is poor (1).

In this article, we discuss the most common types of heel pain, including Achilles tendonitis and plantar fasciopathy. However, we pay special attention to what has been termed a ‘mysterious’ yet ‘common’ heel-pain cause: Haglund’s deformity (20). Haglund’s deformity is where bone grows on the heel bone (calcaneus). This growth can cause pain and irritate the surrounding Achilles tendon and bursae (protective sacs). Together this collection of problems is called Haglund’s syndrome. We focus on Haglund’s deformity because:

  1. It seems to be diagnosed more and more often in the running community, but no studies have yet determined its prevalence;
  2. It closely mimics classic Achilles tendonitis but does not fully respond to/may get worse with the same treatments; and
  3. Why it develops and how to best treat it are still poorly understood.

As we await the study of Haglund’s deformity by the scientific community, we use this article to gather and organize runners’ anecdotal experiences to inform and perhaps benefit others with this injury.

An image showing Haglund’s syndrome in the right heel of Søren Rasmussen, a coach and 2:18 marathoner. Haglund’s syndrome is a bony growth that develops on the heel bone and creates bursitis and Achilles tendonitis. Image: Søren Rasmussen

The Basics of Heel Pain in Runners

The heel is fairly complex in its anatomy and determining the actual source of your pain can be quite challenging but necessary to start the right treatment.

Causes of Pain in the Back Portion of the Heel in Runners

  • Achilles tendonitis in the middle of the tendon or where the tendon attaches to the calcaneus – This is the chronic inflammation of the Achilles tendon where the load on the tendon exceeds the tendon’s ability to heal. Repeat micro-tears and swelling develop within the tendon and the more inflamed the tendon becomes, the worse the blood supply to it is and the harder it is to heal. It is ‘easier’ for the body to create new bone than new tendon, so often little areas of calcium develop in the tendon. This is called calcific tendonitis and usually occurs where the tendon attaches to the calcaneus.
  • Haglund’s deformity and/or syndrome – Haglund’s deformity is a bony growth/bone spur that develops on the calcaneus which can become painful when the bone rubs against a hard surface or when Haglund’s syndrome develops and there is associated inflammation of the bursae and Achilles tendon.
  • Stress fracture –A stress fracture occurs due to repetitive load on the calcaneus, which may cause pain in the back or bottom of the heel.
  • Achilles tendon tear/rupture – It is rare for a large Achilles tendon tear or rupture to develop in runners, but it can occur in a high-velocity injury. When a runner tells me they have an ‘Achilles tear,’ I usually figure it is a small tear that was identified and is a result of chronic Achilles tendonitis.

An illustration of heel anatomy showing the Achilles tendon, which is attached to the muscles of the calf above (gastrocnemius and soleus) and the calcaneus below. At the insertion of the Achilles on the calcaneus, there are two protective pads called bursae. Image: Webmd.com/fitness-exercise/picture-of-the-achilles-tendon#1

Causes of Pain in the Bottom Portion of the Heel in Runners

  • Plantar fasciitis/fasciopathy – Plantar fasciitis, now called plantar fasciopoathy, is the most common cause of pain in this portion of the heel and is due to the same type of problem that leads to Achilles tendonitis. The load on the fascia exceeds its ability to heal and chronic inflammation develops. In fact, the plantar fascia is actually connected to the Achilles and is very similar structurally. This is why the treatments for Achilles tendonitis and plantar fasciopathy are similar.
  • Fat pad atrophy – Fat pad atrophy is the second most common cause of heel pain on the bottom of the foot. It generally occurs in patients over the age of 40 and due to thinning of the fat pad on the bottom of the heel.
  • Stress fracture – Again, a calcaneus stress fracture occurs due to repetitive load, and pain from it can manifest in the bottom or back of the heel.

An illustration showing the plantar fascia (labeled ‘Plantar apon,’ short for plantar aponeurosis) which includes all of the visible white connective tissue. The left bottom line points to the heel’s fat pad. Image: Moore, 1999 (12)

There are other causes of heel pain not listed here, but these are the most common in runners. Let’s explore these specific conditions in more depth.

Achilles Tendonitis/Tendinosis in the Middle of the Tendon

Achilles tendonitis can occur in the middle of the Achilles tendon unrelated to any bony abnormality. This is called mid-substance Achilles tendonitis. Tendinosis is a term used to highlight the fact that it is a chronic condition. When the amount of load is too great and/or the blood supply insufficient for healing, micro-injuries accrue and lead to a chronic state of inflammation or tendonitis. The pain may be at its worst when getting out of bed in the morning, at the beginning or end of a run, or following a run. The pain does tend to ‘warm up’ in the middle of a run, unlike a stress fracture. Stretching also tends to relieve pain.

Strengthening the calf muscles, especially the soleus, increases the resilience and blood supply of the tendon and can be used to treat and prevent mid-substance Achilles tendonitis (2, 13). Heel lifts can also help in reducing pain due to tendonitis, but may put a runner at risk of shortening the tendon and potentially causing it to lose some of its elasticity. Chronic tendonitis may lead to bony enlargement/abnormalities on the calcaneus (5). Full-thickness tears can occur in the Achilles tendons of runners, but chronic tendonitis is much more common.

Insertional Achilles Tendonitis

This is tendonitis where the Achilles tendon attaches to the calcaneus and may include not only tendon swelling but also micro-tears and calcifications at the insertion site. Calcification can occur in a tendon as the body is attempting to heal it. Treatment may be the same as for mid-substance tendonitis, but if it is the calcification causing pain, then strength training will be less helpful and treatment should either focus on removing whatever is rubbing on the calcification (for example, the heel of running shoes) or removing the calcification through a needle or surgically.

Plantar Fasciopathy

Plantar fasciopathy, similarly to Achilles tendonitis, is due to damage of the plantar fascia at its origin on the calcaneus from the load on the fascia superseding its ability to heal. This typically causes pain in the sole of the heel and is at its worst in the morning when getting up from sleeping. The pain typically improves with running until it worsens at the end of and following a run. Ten percent of all people will have plantar fasciopathy in their lifetime (11) and running is a known risk factor (17).

Plantar fasciopathy can also be treated with high-load strength training of the soleus and gastrocnemius muscles in the calf (15, 13). There is also growing evidence for the use of platelet rich plasma (PRP) to treat Achilles tendonitis (3), plantar fasciopathy (8, 14), and tendonitis in general. The theory behind its efficacy is that it both improves the blood flow to areas that classically have poor blood flow for the amount of work that is required of them and that it may have a direct analgesic effect. However, it’s not expected that PRP could remove calcification.

Calcaneal Stress Fracture

A calcaneal stress fracture should also be considered with heel pain. A stress fracture typically does not hurt after sleeping and worsens with running or weight-bearing activities. The risk factors and treatment for stress fractures have been discussed previously in our bone-health article.

Fat Pad Atrophy

Fat pad atrophy can occur at the front or back of the foot’s sole. It is diagnosed by the visible thinning (to less than three millimeters in thickness) on ultrasound of the fat pad and there tends to be pain at the heel center or margin, worsening pain when barefoot or after a long period of standing, and/or tenderness on the heel center. Fat pad atrophy is the second most common cause of heel pain on the sole of the foot and it tends to occur after the age of 40 due to age-related thinning of the fat pad. The fat pad loses water, collagen, and elastic tissue which together reduce its shock absorbency and protection (22). It may also occur due to a complication of a steroid injection in athletes at any age (18).

Haglund’s Deformity

Now, what is the ‘mysterious’ condition called Haglund’s deformity? Haglund’s deformity is a condition where a bony enlargement on the back of the calcaneus develops. Why this happens is poorly understood but potentially due to chronic Achilles tendonitis, wearing high-heeled shoes, and repeated rubbing/friction in the area. Tight Achilles tendons, high arches, ‘heredity,’ and rigid shoes have also been suggested as causes, but to my knowledge no high-quality study has yet been done to determine this condition’s cause (20).

The arrow in this image points to a Haglund’s deformity. Image: Tu, 2018 (19)

Haglund’s deformity often becomes Haglund’s syndrome, which involves the bony growth plus bursitis plus Achilles tendonitis. Friction on the bony growth causes the other two problems to occur and all of this together can be really painful.

Diagnosis can be made with history, physical examination, possibly x-ray, and ultrasound. High-quality ultrasound may be more useful than x-ray as it can find very small bony growths.

Haglund’s Deformity Deep Dive

We’ll spend the rest of this article deep diving into Haglund’s deformity. I have had a Haglund’s deformity for years, and both ultrasound and x-ray imaging from mine over this time can help us understand the injury a little better.

My ultrasound image shows classic Haglund’s syndrome. My swollen retrocalcaneal bursa is outlined in red, the bone spur is in blue, and the somewhat swollen Achilles tendon is in green. You can clearly see how the bone spur could rub the bursa, causing the bursa to leak into and push on the tendon. I was having pain at the time of this ultrasound. Image: Tracy Hoeg

X-ray images of my two heels while I had Haglund’s syndrome symptoms. The left image is my affected heel and the right my uninjured heel. As you can see, the Haglund’s deformity cannot be seen on x-ray, though it was clearly visible on ultrasound. Image: Tracy Høeg

The increased use of ultrasound and awareness of the condition may be two of the reasons more and more people seem to be diagnosed with Haglund’s deformity. As for me, my condition became a lot less painful once I received PRP in early 2019. (I wrote about this in our regenerative-medicine article.) This treated the tendonitis, but the irritation/mild pain and swelling from the bursa persisted… until quite recently.

Shoe Modification for Runners with Haglund’s Deformity

To be clear, the scientific literature does not yet describe if the bony protrusion/heel bump will resolve or regress if the irritating source (such as a hard-heeled shoe, high-heeled shoe, possibly longstanding insertional Achilles tendonitis, and more) is removed. However, it is anecdotally estimated that 50% of cases of Haglund’s deformity can be treated by removing the aspect of the shoe which is rubbing on the bony protrusion (4). Let’s look at three runners and one soccer player who altered their shoes for Haglund’s deformities (or suspected Haglund’s deformities).

Runner Søren Rasmussen’s shoe modification where he removed the hard, inner plastic of the shoe’s heel, but retained the shoe’s integrity. Image: Søren Rasmussen

Runner Chris Cochrane’s modified shoe. Image: Traileffect.com/2017/05/the-curse-of-pointy-heels-modifying.com

The modified shoe of professional soccer player Philippe Coutinho photographed in 2017. Though Coutinho has never confirmed this, this shoe modification could be to relieve Haglund’s deformity. The next year, in 2018, Coutinho had updated shoes, custom Nike Mercurial Vapor 11’s where the outer liner of the shoe appeared to cover a hole in the harder shoe lining. Image: Anfieldhq.com

My modified shoe. Image: Tracy Høeg

Haglund’s deformity and shoe altering for it was also recently discussed on the LetsRun forum. While I’m not sure where one of the commenters ‘Marketing guy’ got that 25% of the population has a Haglund’s deformity, it’s certainly a common problem in runners. I am also surprised there seems to be a total lack of shoes available to accommodate this.

Now, let’s examine before-and-after pictures of the heels of two runners prior to and after removing the hard, plastic heel of their running shoes.

Søren Rasmussen’s heels before (left) and after (right) removing the hard plastic from the back of his right shoe. Following a period of shoe modifications and identification of shoes which did not rub on his bony heel growth, Søren has a less swollen and less painful heel. While his heels don’t appear completely symmetric, he can now run and walk mostly without pain. Søren seems overall happy he did not have surgery done, but denies that his heel feels ‘perfect.’ He is currently able to race at a highly competitive level, but does intermittently get heel pain. Images: Søren Rasmussen

My heel before (left) and then two weeks after (right) modifying my left shoe. I also had a noticeable decrease in the size of my heel and the discomfort I felt in it. Once again, there still appears to be some swelling, but the pain is gone. I ran more than 100 miles the week before I took the ‘after’ image, and I am hopeful that the remaining bursitis/swelling will disappear over time. Certainly my tiny bone spur itself is not the cause of the remaining bump, but the residual thick fluid in the bursa is. Images: Tracy Høeg

Yes, you saw it here first, before in the scientific literature! Shoe alteration helps some runners.

Surgery for Runners with Haglund’s Deformity

Though surgical excision of the bony growth of the calcaneus is only required in resistant cases (20), it seems many athletes are being convinced that surgery is the only valid option. And perhaps it is for some people.

Case Studies of Haglund’s Deformity in Runners

Here are four case studies of runners with Haglund’s deformity and the methods they used to treat it.

Case #1: Gwen Jorgensen

Gwen Jorgensen is a professional distance runner and former triathlete who won the gold medal in triathlon at the 2016 Olympics. Gwen developed heel pain in 2017 that was eventually found to be due to a Haglund’s deformity causing retrocalcaneal bursitis and Achilles tendonitis–also known as Haglund’s syndrome. She was treated successfully for Achilles tendonitis with PRP but as soon as she started training and racing again, the pain came back, this time mostly due to the Haglund’s and bursitis.

In an interview with Rich Roll, she described how Nike made a custom shoe for her with spikes and a larger heel drop. She also stated on her YouTube channel that she liked the shoe because “it doesn’t put as much pressure on my heel.” Unfortunately, the injury didn’t improve and she had surgery–once she found a surgeon who would not cut into her Achilles tendon, but operated on the calcaneus and bursae only (16). This is the Achilles-sparing type of surgery for Haglund’s deformity. To be clear, the previous standard procedure usually involved lifting up part of the Achilles tendon from the bone, debriding (cleaning up) the tendon, and then reattaching it (21). In another YouTube video on her channel, Gwen describes her decision to pursue surgery.

Gwen Jorgensen’s modified Nike Vaporfly 4%. Image: Youtube.com/watch?v=F6cFK2szjdg

At the time of this article’s writing, Gwen is about five months post-surgery. I reached out to her and she was kind enough to respond in a written message that she was happy she had the surgery, had failed with trying shoe modifications, and was running again.

Case #2: Jenny Hitchings

Jenny Hitchings is a 56-year-old runner on the Sacramento Running Association Elite Team in California. In an interview, she described her experience, “I battled Haglund’s and sore Achilles tendons for a few years. My left was worse in the beginning but I ended up having surgery on my right! I tried everything before resorting to surgery, including physical therapy, massage, bone stimulators, extracorporeal shockwave therapy, electronic muscle stimulation, ultrasound, cutting holes in my shoes, and time off. Nothing gave me relief. The surgery included taking one inch off the heel bone, cleaning up the Achilles and bursae, and PRP. I did no running for 12 weeks. But I may have started too soon and ran an easy 10-mile race and that set me back three more months! I was really out for six months or so. But when I started racing again, I have never had heel or Achilles issues again.”

Jenny Hitchings running after recovering from Haglund’s surgery. Image: Molly Hitchings

Case #3: Rob Krar

Ultrarunner Rob Krar was also diagnosed with Haglund’s deformity on both heels after an intense period of training and racing in 2009. He underwent the recommended surgery on both heels in April of 2010 and took about two years away from running before he fully recovered. He went on to win the Western States 100 twice in 2014 and 2015 and much more. I was thrilled to speak with Rob for this article.

Rob Krar on his way to winning the 2015 Western States 100 after recovering from surgery for Haglund’s deformity on both of his heels. Photo: iRunFar/Meghan Hicks

iRunFar: How long did you have Haglund’s symptoms before your diagnosis?

Rob Krar: It’s hard to remember exactly when the symptoms began. My feet in general had been troublesome since 2007, and working 10-hour graveyard shifts while standing on my feet [in my previous career] didn’t help. My symptoms were quite severe from January to August of 2009 when I was training for the TransRockies Run (TRR). I trained and raced TRR with a compensated stride and pinched my sciatic nerve just a half mile from the finish after six days and 120 miles of running. I couldn’t run again until January of 2010, and even after four months away from running, the pain was worse. The bumps on my heels were just as big, if not bigger, and it hurt to even walk or hike. Ultimately both my heels were just as bad and I had surgery on both at the same time.

iRunFar: Did you find out what caused your Haglund’s?

Krar: No. The Haglund’s seems to remain a bit of a mystery, at least in my experience.

iRunFar: Did you try modifying your shoes to accommodate the deformities before surgery?

Krar: Not to try and resolve the issue. Once they were there, they weren’t going away. I tried cutting holes in the back of a few shoes to relieve the pressure with mixed results.

iRunFar: Do you know what type of surgery you had? Was it Achilles-sparing?

Krar: My surgery was Achilles-sparing, although my surgeon had my permission to detach my Achilles if he felt it was the best option once he was in there and had a better look. Interestingly, I’d never heard of Haglund’s until I had it, but since then it seems to be more and more common. I’ve had countless inquiries from others asking for my thoughts.

iRunFar: What happened after the surgery, in your recovery?

Krar: My surgeon told me to expect a year of recovery before running comfortably again. Like many impatient runners, I rushed that timeline and tried running about three months after surgery. It was a terrible idea. I set my recovery back and ultimately gave up the idea of ever running, let alone racing, again. I was not a model of perseverance and determination at the time and at times the frustration was overwhelming.

It wasn’t until May of 2011 (13 months post-surgery) that I started running some short and slow runs with my wife and that I realized the pain had subsided and I could get back out on the trails. It was a balancing act though, too much speed or distance and I’d be out a couple days letting my heels settle down. The rest of 2011 was more of the same and I’d still not entertained any idea of returning to training and racing.

The winter of 2011/2012 was the turnaround for me. I didn’t run a step, but logged huge vertical while ski mountaineering, unknowingly getting myself into ridiculously good shape. I jumped into the Moab Red Hot 33k in February (22 months post-surgery) with no running under my legs. I won the race and felt great. From that point on, my heels were mostly good to go and I dove head first back into significant training and racing with only a few mild and short flare-ups.

I think the point is that although each individual is different, from the Haglund’s surgery folks I’ve spoken to, nearly everyone has the same story, including myself: have surgery, come back too soon, and set yourself back. The difference is those who completely walk away for some time seem to succeed the most in returning to full competitiveness and those who continue to play the cat-and-mouse game end up walking away for good.

These days when I’m in my heaviest training phases, my heels still ache and I have to nurse them along, but they don’t get in the way of racing to my potential. I have little doubt now, nine years post-surgery, that it was the best decision for me at that time.

Case #4: Tracy Høeg (the Author)

Wrapping up with my own experience, I have had a very similar course to Gwen Jorgensen, prior to her surgery. I’ve had swelling and pain in my posterior heel since 2013, which would initially come and go and then just would not go away starting a little over a year ago. It seemed to only partially respond to eccentric calf loading (heel lowerings).

After the New Year’s Resolution Race in Auburn in January of 2019, I had a worsening of my heel pain and did a high-resolution ultrasound on my Achilles tendon. I could clearly see a bone spur, diffuse Achilles tendonitis around a tear, and increased fluid volume in my retrocalcaneal bursa. I had the previously mentioned PRP treatment to my Achilles. Three months later, the pain was better, but the swelling was still there, albeit less, and my tendon mechanics were still off. I rescanned my tendon and indeed saw resolution of the tendonitis and tear, but the bone spur and retrocalcaneal bursitis remained.

My coworker attempted to aspirate the fluid out of my bursa, but it was actually a gel-like substance which was too thick to suck out even with a large-bore needle. Ouch! My interpretation of this is that it was previously very swollen and filled with fluid. As the fluid leaked out and the inflammation resolved, inflammatory cells remained in the bursa and created this gel. This is likely why people retain a sizable bump on their heel long after the active inflammation is gone. Whether this bump affects Achilles function, I do not know.

Then something really lucky happened: I got a blister on my heel from new running shoes. This led me to cut a hole in the heel of my normal running shoes which allowed me to run without heel pain. After now seeming to be able to run endless miles, I find myself wondering how many other runners with Haglund’s deformity/a calcaneal bone spur could also benefit from a running-shoe plastitectomy rather than an invasive surgery. I also find myself wondering where I can buy a pair or two of heel-less running shoes. I suspect that whether or not shoe modifications will be successful depends on the location and size of the heel deformity, the shoe type, and the type of modification done to the shoe.

Final Thoughts on Haglund’s Deformity

When is surgery indicated for Haglund’s? When can a much simpler shoe modification be done instead? How can this condition be prevented? I am ending with perhaps more questions than answers, but I hope this article will bring attention to and conversation about a common, often devastating, and poorly understood condition.

Call for Comments

Have you suffered from or do you suffer from Haglund’s deformity or syndrome? Have you had success with any treatment? We would love to hear your story.

References

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Tracy Beth Høeg MD, PhD

is currently a Sports and Spine Medicine physician at Mountain View Rehabilitation in Grass Valley, California, and an assistant professor at UC Davis. She completed residency in Physical Medicine and Rehabilitation at UC Davis and a PhD in Ophthalmology at The University of Copenhagen. She is a Danish-American double citizen who ran for the United States at the 2013 IAU Trail World Championships and for Denmark at the 2018 WMRA Long Distance Mountain Running Championships. She is married to Dr. Rasmus Høeg and they have two sons.

There are 24 comments

  1. Wendy L. Wheeler-jacobs

    Thank you for covering Haglund’s. I have been cutting holes in my heels for years after noticing I was wearing the holes in the back of the shoe anyhow. I was finally able to settle it down and find the right shoe/orthotic combination to alleviate the pressure, but it took several months before I could run without the pain. I recently won a different pair of shoes, and unfortunately irritated the heel again after wearing them out for only 2 runs/25 miles. So you need to be constantly aware of it.

  2. Nick

    I was recently diagnosed with Haglund’s after it was misdiagnosed as insertional Achilles tendinosis for almost five years by several different physical therapists. I should have been referred to an orthopedist long ago, because they seemed to know it was Haglund’s the instant they examined me, but I kept on doing the eccentric heel drop/stabilizing exercise game thinking it would eventually stick.

    I even invented new exercises with kettle bells that seemed to help. I’ve done shoe modification, removing the heel cup but maintaining the soft heel material, and it does help alleviate symptoms. I carried a heel lift during races for when things got bad. I also used a graston tool to calm the area, which works for about half an hour.

    But I got to the point recently where I decided surgery was the only option – I enjoy long races, and it has started to get exceptionally painful at 50 miles, to the point that by 100 miles I’m hobbling and can no longer flex my ankle. And I also looked at all the ridiculous modalities I was applying and I realized this was something I could not fix.

    It seems like there are two recovery stories for Haglund’s surgery – folks running within a few months and doing fine, and other folks like Rob needing to take at least a year to get back to normal. There doesn’t seem to be a rhyme or reason to who gets which experience. But at this point, even though I’ve been racing/running for four years with Hadlund’s…I haven’t really been racing or running like I used to. So I suppose my perspective is that I shouldn’t be hurried to get back to running – because I haven’t been doing it for “real” for a while, anyway!

    If I could give folks some advice – if you get an Achilles injury that seems to be right on the bone and is accompanied by even minor swelling, and it doesn’t respond to treatment and relative rest after 6 months or so, or it flares up during runs and goes away within a day – go see an orthopedist and get some imaging. At worst, you will be out an office visit and copay, and at best, you will save yourself time, which is something you can never get back. I will never get five years of poor running and racing back. But I’m hopeful that with surgery, I will get back the future running I would otherwise never have.

  3. Jim Skaggs

    Very interesting article. I had surgery for Haglund’s in Oct. 2017. The doc did detach my achilles. He did tell me to expect a year long recovery, three months no weight bearing, a boot for 8 weeks, and no running for five months. Although I was a bit impatient at times, I did listen to my doc and didn’t even try running until about 4.5 months, and then for only very short stretches. I also found a very good PT post surgery. I mentioned that my goal was to run Wasatch 100 in 2018. He thought I was crazy, but to his credit said let’s do it. I did run and complete Wasatch 11 months after surgery. It wasn’t fast (but neither am I), but I got it done. Two years post surgery and that achilles is doing just fine. The key for me was being patient and listening to my doc and PT. I had no setbacks at all, it was just a long grind to get back in shape. I don’t quite have the flexibility in that leg that I used to, but it doesn’t stop or slow me down (age is doing a very adequate job of that). BTW, I have pics from my surgery if anyone wants to see them :-)

  4. Jessi G

    I had surgery for Haglund’s in Aug 2017 (I had also initially been diagnosed with insertional Achilles tendinosis two years prior). I went to the Alfredson Tendon clinic in Sweden as I knew he would not detach the tendon (and even out of pocket with travel costs was cheaper than getting it done in the US!). I had my achilles bursa and the bone spur removed – I was running again in about 10 weeks. It took a little while before I could ramp up the mileage but I’m back to running ultras now with no issues – at least not related to the Haglunds. :-) For me having the surgery was completely worth it!

    1. Nick

      Jessi (and Jim),

      Any advice on what to watch for when returning from surgery?

      In the article Rob mentions needing to let his heels settle down…have you experienced inflammation, deep achy bone pains, tendon issues, etc., that guided you on when you could return to running and increase mileage? Did it take longer to feel comfortable running hills/technical trails?

      1. Jessi

        Hi Nick – I was given a conservative plan to ease back into running very slowly around 8-10 weeks after my surgery (I think my first run was less than mile with walk breaks) and not more than 3 days a week initially and only flat/on track. Since that went well, being a typical runner I of course then jumped right into a 10k trail race before I should have and set myself back a little. I was back on trails before the end of 2017 but was just really cautious and backed off on mileage if I felt any soreness that lasted more for than a day. (Interestingly it was typically speedwork and not technical trails that would cause me discomfort the next day.) The area where I had the bone spur and bursa removed filled in with soft tissue that would get really tight after a run – I found that if I just stretched it and did the PT exercises I was given I was fine within a day. I did try to reduce inflammation overall (supplements, topicals, diet, etc) and I was also working with a PT that was helping to guide me after I had overdone it initially. I did a 100k the following May (9 months post-surgery) with no issues during my training or during the race and a 100 miler later that year. I have zero regrets with my decision to have the surgery – I should have just been a little more cautious initially about not pushing too soon to get back to it. But everything ended up all good in the end. :-) I hope this helps!

      2. Jim Skaggs

        Nick,
        I had a bunch of takeaways. First, I found an ortho that specializes in ankle/achilles and sports injuries. It did help that his wife is a fellow ultrarunner that I occasionally run with. Second, I knew of a couple of people that had the surgery and tried to get back running too soon. Set them back a couple of years, so like Jessi said, be conservative and listen to your doc. Third, like I mentioned in my comment above, find a good PT that understands runners. Mine was pure gold. When I finished Wasatch, I stopped by his office to show him the plaque and buckle. He was so excited to see it.
        Understand that total recovery will take about a year. Once I was back running I found that my gait was off, my leg had atrophied big time, I was scared to fall, scared to jump off anything higher than a few inches. I had some residual nerve pain that made me think that I was undoing the surgery. I had times during recovery when I wondered if it was worth it, if I would ever get back to running “normally”. It took awhile to get back to running hills and technical stuff. I really listened to what my body was telling me as I got back running. I did push my training because of a short training window, but backed off when I thought I needed to. Cross train. My doc let me get into a pool and swim laps while I was still in the boot. The day I was out of the boot, he gave me permission to get back into the gym, so I did.
        Hope that helps a bit.

      3. Andrew

        Hi Nick,
        I also had surgery for Haglund’s (remove Achilles, shave down bone spur, debride Achilles, reattach Achilles), in 2013. My experience was a bit different from Jessi and Jim. It took me about 2 years to return to regular running, and I didn’t run an ultra until 2016. During that time I had intermittent pain and swelling that guided how much I could run. I was a bit conservative and stopped running when there was any noticeable pain after the first few minutes running. I found that road running hurt more than trail running, and I didn’t regularly run on roads until 2018. The same goes for running uphill, which I didn’t do on grades more than about 8% until 2018. Technical trails didn’t pose that much of an issue as I greatly increased my ankle mobility during the recovery process.
        During the 2 years where I was running minimally, I really thought I would never be able to return to the sport. It took longer than I anticipated, but I eventually did return to ultrarunning.

  5. Oscar

    Great article! Galen Rupp recently just came back to racing after being away for a year from surgery for his Haglund deformity. I believe he did have his achilles detached. There are some videos out there showing what his recovery process entailed.

      1. Oscar

        Yes Tracy, he ended up dropping out towards the end of the race, had a calf issue. Hopefully not related to the surgery, but I haven’t found any other updates yet.

  6. Mike Jones

    I am going to have the surgery performed on my foot this upcoming winter. After a number of years dealing with the inflammation on my own I finally went to an orthopedic specialist. I went through a few months of PT and while that did get rid of the inflammation, the problem persisted after returning to running. The inflammation seemed to get worse and worse over time and for the last races I did I was limping in the last few weeks before the race. I’ve tried shoe modifications and while they do allow me to run with much less pain, any running done over an hour or with more intensity will cause irritation and inflammation on the insertional part of my Achilles. I know a good number of runners who have gotten the surgery done within the last year and they all are glad to have had it done. My surgery will just remove the bone spur portion and not detach the Achilles as I have no signs of fraying or damage to the Achilles at this point. It looks like the key to a good recovery is being patient and easing the return back to running.

    P.S. Another person who had the surgery is the top american at the Chicago Marathon this last weekend Jacob Riley.
    He had an article on podium runner about his recovery and return to racing

  7. GMack

    Thank you for a wonderful article.

    My Haglund’s was caused by running inclines. I’m also a forefoot runner which doesn’t seem to help.

    About 8 years ago when the condition flared up, I’d do a shoe modification which helped tremendously.

    I’d use a heat gun to soften up the plastic heal cup, alternating outside to inside and being careful not to melt the shoe’s inner liner. Then use the back end of a screwdriver which is the same size as my heel bump and push out a divot from the inside of the shoe creating heel space.

    It’s reliable and doesn’t drastically alter the back of the shoe.

    I’ve talked to a doctor and decided against surgery. I’m in my 50’s and the time on my butt recovering and future ultrarunning years didn’t seem to warrant it.

  8. George Ruiz

    I had battled Achilles’ tendon pain for about 10 years before it really started to be so painful I started to get physical therapy that included everything from PRP, dry needling and tooling to break up scar tissue. Basically it was all miss diagnosed as simple Achilles tendinitis. After 20-100 milers and countless other ultra distance races I could hardly walk or hike with out extreme pain.

    I was finally referred to a foot and ankle specialist. He too one look at my heal and wrote on his card, Haglund’s Deformity. WTF is this? After the MRI he told me it was in really bad shape and a complete tear from the insertion was imminent. There was no possibility to have a non invasive surgery with the Achilles.

    Once the surgeon was in there, there was evidence of many years of tearing and calcination. After taking down the calcaneal spur and another heal spur, the debriding of the tendon fiber as extensive, so much so he needed to harvest FHL tendon from my big toe. It was harvested through my heal and used to reattach Achilles’ tendon with bio-ten odes is screws.

    It was a really major repair and rebuild of my Achilles. I’m happy to say after 35 weeks I’m done with PT and hiking walking without pain and have recently introduced running a couple of miles a few days a week. I still have a long ways to go and reach the “one year” bench mark to be fully recovered. It scares to read Rod Karr was out for two years before running. I’m trying to keep the rains pulled back and not over do it.

    I’m I glad I had the surgery, yes but I didn’t really have a choice, I could do much of anything any way. Will I be an ultra runner again, I don’t know and it doesn’t really matter, I can walk and hike and run a few miles with out pain.

    As Ultra Runner’s, that is all we do is run though pain. I can say from experience, if your reading this have acute Achilles’ tendon pain, get it handled now and don’t run through it. It will only progress into something like Haglund’s, it’s not a fun fix. I never heard of this before that office visit, but now I’m hearing more ultra runners that I thought have had this so listen to your body, or better your heal pain!

    1. Jim Skaggs

      George,
      That’s exactly what the surgeon did to mine. Grabbed a chunk of tendon from teh bottom of my big toe (I can’t bend it very well now). I think you’re around the same age as I am (61). I’m back doing ultras pretty much whenever I want, so there is hope if that’s what you want to do. Good luck with your continued recovery.

      1. George Ruiz

        Thanks Jim. Good to know a few that have been through it! I read your comments about nerve and bone pain that scares you that everything is being undone. I get that And it scares me, but that’s a good thing to keep a healthy respect!

        I’ll be 63 in a few months so I’m not sure how many ultras I have left in me or want to train for. Getting ready for ski season is my main focus now!

  9. Joe Uhan

    First off: another outstanding article by Dr. Høeg! So thorough and information-rich! And the runner case studies are also insightful.

    I’d like to add some clinical perspective as well:

    * Haglund’s Deformity is a bony hypertrophy in response to [over-]stress. This is a pervaisive physiological adaptation of bone to any over-stress. In kids, we see these syndromes as “Severe’s Disease” (heel) and “Osgood-Schaltter” (knee). And while some pediatricians/orthopedics simply write these off to “growing pains”, these are indeed issues of bony over-stress due to **inefficient overloading** at the heel and knee, respective

    Haglund’s has the same origins: over-loading of the heel. The question is why:

    * Haglund’s is driven by **footstrike landing inefficiency**. Over-striding — the most common running gait inefficiency — and “over-pronation” are the top two stressors that add chronic overload to the heel, via the gastroc-soleus-Achilles mechanism. This chronic overload pulls-pulls-pulls on this complex, causing bony hypertrophy.

    The tipping point for Haglund’s is when that bony over-growth gets so big that it begins to interfere with normal tissue function (bursa, tendon, etc).

    * Haglund’s Deformity is very similar to other bony over-growth issues: calcaneal bone spurs (often found in folks with plantar foot pain) and subacromial (shoulder) bone spurs. And here’s what we know about them:

    1. They are hypertrophic responses to [excess/inefficient] load
    2. They **do not necessarily CREATE pain**!

    This is an improtant distinction. Many studies, for example, have found no association between heel spurs and pain (in other words: some folks have them, with zero heel pain; some people have nasty heel pain with no bone spurs).

    Can the same thing be true with Haglund’s? Can you have a sizeable deformity with no pain? / No deformity and tons of pain?

    My thought is Yes.

    This brings up function: if a runner continues to over-stride or (possibly worse) narrow stride^, the pain will not go away, whether you have the surgery or not.

    (^ https://www.irunfar.com/2013/03/going-wide-the-role-of-stride-width-in-running-injury-and-economy.html)

    A landing inefficiency will continue to produce excessive ankle/heel stress.

    As such, a couple final points:

    * First, it seems that if cutting the back of your heel off the shoe alleivates/abolishes the pain, that’s a strong indication you have the retrocalcaneal bursa pain associated with Haglund’s — thus, that deformity IS relevant

    * Second, fixing stride efficiency is a must-do: whether you have surgery or not. And if faced with a year+ rehab (and/or you cannot afford that time/$$$), investing in stride optimization is an absolute must.

    – It starts with posture: https://www.irunfar.com/2018/11/posture-first-how-alignment-affects-our-running.html
    – which leads to sufficient hip hinge: https://www.irunfar.com/2014/08/the-best-running-exercise-that-no-one-is-doing.html
    – being mindful of landing underneath your center of mass: https://www.irunfar.com/2014/07/the-pawback-drill-for-trail-runners.html
    – and landing whole-foot: https://www.irunfar.com/2015/05/elite-feet-strong-strides-start-at-the-foot.html
    – and underneath (but not too narrow): https://www.irunfar.com/2013/03/going-wide-the-role-of-stride-width-in-running-injury-and-economy.html

    (Of note, both Rob Krar and Gwen Jorgenson (especially!) have had (or still have) postural deficits of excessive lumbar extension and deficient hip hinge that results in over-stride landing stress)

    1. GMack

      I hadn’t seen the post on “going wide” but had figured on my own this was the was the way to alleviate Haglund’s and occasional Achilles pain.

      Watching my footstrike pattern in a mirror while on a treadmill, I could tell I was running heal-to-toe. This was a running habit I apparently picked up running on narrow trails.

      This didn’t seem natural so I tried widening my stride (when not on narrow trails). The problem wasn’t completely solved but it did help.

      I’m naturally a forefoot runner and supinator, so I also tried moving my footstrike back to midfoot and keeping my foot level on impact. This greatly helped and was only possible by running wide.

      I don’t think my Haglund’s is as bad as some of the other commenters and won’t go under the knife. The key is awareness and prompt running form corrections if you get symptoms.

      1. Mike Jones

        Yea,

        My haglunds was caused by limited ROM on my affected foot dorsiflexion, effectively tightening up my calf on that side. While I’ve known about my condition for a few years, it was only in the last year that it has gotten to the point that I would need surgery to run without inflaming my Achilles again. Had I made changes earlier a few years ago I might not have needed surgery.

  10. Chris

    I know this article is concentrating on Haglund’s, which I know will be helpful to those dealing with that, but what about help for those suffering the indignity of fat pad atrophy? Treatments? Injections from another area? Super cushioned shoes?

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