Haglund's Deformity - What actually causes it and how you can run pain free again

​Haglund's deformity, or retrocalcaneal exostosis, is a bony enlargement of the back of the heel bone which was first described by Patrick Haglund in 1927. Haglund’s can be referred to as a “pump bump” because it’s been associated with people who wear rigid backed pump style shoes. It can become very painful and cause blisters and bursitis at the back of the heel from friction inside shoes. Haglund’s deformity may be accompanied by a calcaneal bone spur and/or intra-tendoneal calcification of the Achilles tendon.

​Traditional medicine and physical therapy often say Haglund’s is caused by hereditary factors such as high arches, tight Achilles tendons, and walking on the outside of their feet. In runners it is also said to be an overuse injury. First, it’s important to understand the body responds to stimulus and all those factors are a response to our environment rather than genetic.
 
Haglund’s always occurs on one heel and not both (at least at the same time and same intensity) just like all other injuries, which means that the injury is caused not by use or overuse but imbalances in the body left to right.

Below I will walk you through 3 simple tests to help you feel and understand what is causing your Haglund's deformity and pain. 

​If you experience heel pain and have a Haglund’s deformity on your right heel, that means your right foot, ankle, knee, hip, and shoulder are working and moving differently than your left. And yes, you heard me right, your shoulder has as much to do with the heel pain as your heel does. Why? Because the body is a unit (I’ll walk you through some experiments to feel this in a minute). Doing things including surgery, orthotics, physical therapy, and shoe changes, do nothing about the cause of the problem. This means the pain and Haglund’s can return. There are a number of famous ultra trail runners who have had multiple surgeries just to have Haglund’s return again and again. If you don’t eliminate the cause of the problem, the problem will keep reoccurring.

​Typical treatment plans include changing mileage and intensity, NSAIDS, icing, heel lifts and heel pads, casting, dry needling, shockwave therapy, ART (active release therapy), myofascial release, PRP (platelet rich plasma), stem cell injections, orthotics, exercises and stretches for the lower leg and foot, and surgery. These all are treatments for the symptom, but do not address the cause. They might offer temporary relief but won’t lead to long-term relief and ability to fully return to running pain free.
 
Only posture alignment therapy that corrects the imbalances in your foot, ankle, knee, hip, spine, and shoulder fix the cause of the problem.

​Different posture imbalances can cause Haglund’s deformity and pain including: thoracic flexion and rotation; lateral spinal flexion including scoliosis; pelvic rotation and elevation; femur internal or external rotation or valgus or varus stress; knee flexion or hyperextension; ankle/foot eversion, inversion, pronation, and supination.
 
Why and how do these posture imbalances lead to Achilles imbalance and eventually Haglund’s deformity and pain? All of the above posture imbalances will lead to a change in hip flexion and extension which the body will have to figure out how to move the body forward when running and those compensations the body must do to continue running can lead to changes in Achilles load and movement patterns. (These compensatory movement patterns can lead to Haglund's deformity, but also Achilles tendinopathy, heel bone spurs, plantar fasciitis (or plantar fascipothy), and other foot and ankle pain symptoms.)

Below are several tests and experiments you can do to see what posture imbalances might be causing your Haglund’s deformity:

1. Weight test: take off your shoes and socks and stand barefoot on a hard surface. Step up and down in place several times, and then stand relaxed with your eyes closed. Notice the weight distribution in your feet. Do you have more weight in one foot than the other? Is the weight more towards the front or back of one foot than the other? Is the weight more on the inside or outside of one foot? Many people with Haglund’s will notice that the weight is more towards the front and outside of the foot that has Haglund’s deformity. Why is that? When you excessively load the front and outside of your foot, you are putting an abnormal and excessive stress on your posterior leg muscles and Achilles tendon. This abnormal stress will slowly overload the Achilles attachment on the posterior heel and lead to a thickening of the bone, swelling, and pain. The only way to correct this and get back to running pain free is to correct your posture imbalances that are causing you to abnormally load your foot.
2. Balance test: Stand barefoot on a hard surface and look down at your feet and get them parallel and pointed straight ahead (this will often feel pigeon toed for many people). Lift one knee up to hip height so your knee is bent at 90 degrees and try to balance on your other leg for 10 seconds. Then align your feet again and switch sides. Which leg were you more stable on? Many people will notice they are less stable on the side with the Haglund’s deformity. The instability in your hip and leg are leading to a less stable foot/ankle complex as you walk and run and this is causing abnormal and excessive movement at the foot/ankle which is causing stress on your Achilles and leading to the Haglund’s deformity. The only way to eliminate this stress and get back to running pain free is by correcting your posture imbalances that are leading to the instability.
3. Gait test: while barefoot, walk across a hard floor several times at a normal pace and notice your foot strike. Basically, notice where you land on your heel, how the weight rolls through your foot, and where you push off from. Many people with Haglund’s will notice they land more towards the outside of the affected foot, roll through the outside of the affected foot, and push off more towards the outside of the foot. This is because their femur is often externally rotated and lacks proper internal rotation, foot pronation, and dorsiflexion. This faulty movement pattern leads to an overloading of the Achilles because of a lack of internal rotation of the femur and tibia and dorsiflexion of the ankle.

Earlier I talked about how your shoulder is as much a cause of the problem as your foot is. Now is the time to test that. After performing the above tests, write down what you felt – your findings. Now repeat all three tests, but this time with a small but powerful change. Interlace your fingers together, put your hands behind your head, and pull your elbows back hard. Hold this position as you repeat all three tests. What was different in each of these tests with your hands behind your head? Almost everyone will feel their weight distribution is more balanced and even in the first test. Most people will notice their balance is improved in the second test, especially on the unstable side. And most people will notice their gait is much more symmetrical and even – meaning they land more in the center of the heel, roll through the center of the foot, and push off all five toes more evenly. You might also notice you have less pain and discomfort walking with your hands behind your head. Why is this? The improvements happen because putting your hands behind your head helps to improve your shoulder imbalances, which in turn improve your spinal alignment, which balances your pelvis and hips, and allows your legs and feet to work more closely to how they are designed.

​We all know it’d be pretty awkward to run ultras with your hands behind your head, so I’m not going to advice that, but what I do advise is getting a free 30-minute video posture evaluation online by me to help you understand what posture imbalances throughout your body are causing your uneven loading of your foot so we can correct them and fix the underlying cause of your Haglund’s deformity and get you back running pain free.

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Do you suffer from Haglund's deformity? Comment below about what you learned from these 3 simple tests.