February 4, 2025 • 16 mins
Haglund's deformity and subcutaneous calcaneal bursitis are two prevalent yet distinct conditions that can cause heel pain. Understanding their anatomy, differences, and treatment strategies offers listeners a clear path to find relief and improve their quality of life.
• Overview of Haglund's deformity and subcutaneous calcaneal bursitis
• Anatomical structures involved in the posterior heel
• Symptoms distinguishing Haglund's deformity from bursitis
• Treatment strategies for both conditions
• Importance of footwear choice and techniques
• Managing pain and inflammation effectively
• Role of stretching and physical therapy in recovery
(Video) Heel Bursitis vs Achilles Tendinitis
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hello everyone and welcome to episode 368 of the
OrthoEvalPal podcast.
I'm your host, paul Marquis,and today we're going to be
talking about Haglund'sdeformity or subcutaneous
calcaneal bursitis.
We're going to be discussingthe anatomy surrounding the
posterior heel.
We're going to talk about howto differentiate between a
Haglund's deformity andsubcutaneous calcaneal bursitis.
(00:21):
We're going to be talking aboutsome of the contributing
factors.
We'll go over some tips fortreatment and so much more.
But before we get started, I'dlike to mention our sponsors.
We have Rangemaster.
Rangemaster is known for theirshoulder rehab equipment.
They offer products fromshoulder wands to finger ladders
, overhead pulleys to shoulderrehab kits.
Rangemaster is your one-stopshop to help with the treatment
(00:43):
of frozen shoulders, post-oprotator cuff repairs, total
shoulder and reverse totalshoulder replacements and so
much more.
If you'd like to get a freesample of Rangemaster's Blue
Ranger pulley system, just emailjim at myrangemastercom and add
OrthoEvalPal in the subjectline.
And we also have MedCorpProfessionals.
Now, I know the folks at MedcorProfessionals personally.
(01:04):
They're a locally owned andfamily operated medical supply
company.
They carry everything fromradial pressure wave units to
traction devices, resistancebands to compression garments.
Most impressively, though, isthe customer service.
It is second to none If you'relooking for medical products for
your clinic or products foryour patients?
Go to wwwmedcorprocom, that'sM-E-D-C-O-R-P-R-Ocom, and if you
(01:33):
use coupon code OEP10, you canget $10 off your next purchase.
Now on to today's show.
We are going to be talkingabout Hagelin's deformity and
subcutaneous calcaneal bursitis.
Now the first thing I want todo is talk about how similar
these are and how we do treatthem a little bit differently.
(01:54):
But some of the concepts thatwe use to treat these kind of
overlap, and that is perfectlyfine.
They're very closely associated.
One will respond a lot betterthan treating something caused
from the other, and I'll explainwhy that is in just a little
bit.
So the first thing I want to dois just go over some anatomy.
(02:15):
I want you to envision this weare looking at the back of the
heel and I want to work from theskin inward toward the
calcaneus.
So we're going to start at theskin.
Inside or beneath the skin is asubcutaneous calcaneal bursa.
That's like a smallfluid-filled sac.
(02:37):
Not everyone has this.
Some of us just develop theseover time as a mechanism to help
protect the back of the tendon,the back of the heel, from the
skin and the bursa.
You need to remember a bursaisn't like every picture you see
in a magazine, in a book, okay,like it looks like it's a big
(02:58):
ball of fluid that's sitting inthere.
It can become a big ball offluid if it becomes inflamed or
swollen, but it really imagineit as this, like a water balloon
that you've just taken all ofthe water out of, and it's
really skinny, it's really thin,um, wrinkly, a little bit, all
right.
So that's kind of more likewhat the bursa is like.
(03:22):
But when it does get irritatedit can start to swell, can
become inflamed and can causepain, all right.
So then, if we go in to thenext structure, then we have the
Achilles tendon, which insertsonto the posterior calcaneal
tubercle.
There's two calcaneal tubercles.
One, the most common one, isthe one underneath your foot.
So people come in and say Ihave plantar fasciitis and I've
got a heel spur.
Okay, that is the oneunderneath the heel.
(03:43):
This one, though, where theAchilles attaches, is that
posterior calcaneal tubercle.
Now there is the retrocalcaneal bursa, which we all
have at birth, all right, andthis one sits between the
Achilles tendon and theposterior calcaneus.
It's just a little bit superiorto the subcutaneous calcaneal
(04:04):
bursa, all right.
So that's what we have.
And then we have our calcaneus.
All right, so what is theHaglund's deformity?
Well, it's an overgrowth ofthat posterior calcaneal
tubercle, kind of like anOsgood's slaughters.
You take your thumb and indexfinger, grab a little skin on
(04:24):
your forearm and pull it awayfrom you, and if you continue to
pull that and imagine itbecoming bony and hard, it will
develop a spur.
And so this is what happens atthe backside of the calcane it
will develop a spur.
Okay, and so this is whathappens at the backside of the
calcaneus.
Is we develop this spur?
Some people develop, maybebecause they're super active as
kids, and they develop a largerspur.
(04:46):
Maybe we have a lot oftightness in the calves.
Our foot posture can make a bigdifference here.
An excessive amount ofcompression to the back of the
heel can cause this spur to kindof build up and it becomes this
large outgrowth.
Okay, that sits on the back ofthe heel.
Many people have them andthey're not all painful, okay.
(05:08):
A lot of people come into theclinic and it's interesting
because I'll say, oh, you've gotyourself, you know, quite a
spur on the back of your heelthere, and most of them will say
they were quite active.
As younger individuals.
They played sports or maybethey did a lot of hard,
aggressive labor where they hadto push up off their toes a lot
and that could cause a spur, butnot everybody has pain with it.
(05:30):
So, like the calcaneal tubercleand the plantar surface of the
foot, they generally disperseItself, doesn't generate pain,
okay, but I think it's somethingto be aware of that.
Somebody has it.
So what happens if there'soveruse and or overpressure over
the deformity?
Well, that will cause someinflammation to the Achilles
(05:52):
tendon and the surroundingbursae in that region.
Okay, so you know, imagine youhave this nice round posterior
heel and you take a couplenickels, you glue them together
and you stick them on the bone.
Now we have this excessivetissue that is now sticking out
the back even more.
Okay, and so we see this withthe use of new footwear.
(06:16):
Or if people have thisincreased calf tightness, which,
when you have a tight calf, theheel is more likely to pull up
out of the shoe a micro amount,okay, millimeters and piston up
and down in the shoe, well, ifit continues to do that, the
back of the heel will rub on theinside part of the shoe or the
(06:37):
boot usually a new leather bootthat hasn't been broken in yet.
It will cause these, and sothat will cause some irritation
to the surrounding structures,because there's just more stuff
in there, okay, which is thespur.
Now, how does this differ from asubcutaneous calcaneal bursitis
?
Now, we've probably heard moreof a retrocalcaneal bursitis and
(06:59):
that's probably what you'rethinking here.
But the most outer bursitis,closest to the skin, is the
subcutaneous calcaneal bursitis.
The retrocalcaneal bursitissits behind the calcaneus but
just anterior to the Achillestendon, a little bit smaller,
but can become quite inflamedand irritated.
So we talked about theHaglund's deformity as not being
(07:22):
a big pain generator, but thebursitis okay, the bursa can be
a very big pain generator.
It can be very easy to inflame.
People who have this bursitiswill generally be tender to
touch.
It can be a little bit warm.
What I find is that the way todifferentiate between one and
the other is that the bursitiswill be very puffy, fluid filled
(07:45):
, kind of like a sack, and it'skind of squishy a little bit,
and so that would be more of aninflamed bursa rather than a
bone spur back there, where thebone spur is going to be really
hard and it's not going to beforgiving at all and, like I
said, if it's a bursitis itcould be a little red, could be
(08:05):
a little swollen.
Now we see this a lot in peoplewho don't unlace their shoes to
take them off or to put them on.
They just kind of slide in theshoe and they take maybe the
ball of the foot on the oppositefoot and they slide the shoe
off and they're just reallycompressing that bursa on the
back of the heel.
So it just causes thisrepetitive, cumulative trauma to
(08:27):
the back of the heel.
Now think about this If you'rewearing a tall boot and you're
sliding your foot into that boot, you're just grinding that
bursa on the way in and thenwhen you pull it out, same thing
, you're grinding it on the wayout.
So just that alone can causesome of this, okay, so what do
we do with these?
Well, for both of them and I'mgoing to talk about how you
(08:49):
would treat them a little bitdifferently, but really a
majority of the treatment ispretty much the same.
Number one you want to removethe trauma to the direct contact
to the back of the heel.
Okay, so maybe a larger shoe,or what I like to do is, if
somebody is wearing a leatherboot or a shoe that has material
that can be kind of tight, butnot just like a soft material,
(09:12):
but something that's a littlebit harder.
You can go to a cobbler.
They have this nice littledevice that has a ring and a
ball and what you do is you putthe ring on the outside of the
back of the um of the heel ofthe shoe and then you put the
ball on the inside and yousqueeze them together.
You might wet that down, use aleather softener, and basically
it just does a little punch outthe back of the shoe.
(09:34):
It doesn't open it upcompletely, but it just makes an
out dent, not an indent, but anout dent on the back of the
heel.
And people love this.
Ok, they get into their bootsor their shoes and there's this
immediate relief.
You can use this for both ofthose diagnoses.
Ok, and it's hard to find acobbler these days, but if you
can, this is a great way to dothat.
(09:56):
Some people will get shoestretchers where you can stretch
the front to the back a littlebit, so to give yourself a
little bit more room or just goup in size.
Look at the materials backthere.
Make sure those materials arenot driving into the heel and
that they're kind of flaredoutward away from the heel.
Some shoes have a very slipperysurface back there and that can
(10:17):
be helpful.
Sliding the foot in and outcause less trauma.
You need to unlace the boot orthe shoe to prevent the rubbing
on the way into and out of thefootwear.
Okay, I just say it blows meaway at how many people just
jump into their shoes.
They're all tied up and theyjust jam their feet in there.
Number one it just wrecks theretrocalcaneal bursa, that
(10:37):
subcutaneous calcaneal bursa.
It irritates all the structuresover the Hagelin's deformity
and it ruins your shoes Like inno time the back of the shoe is
gone.
So I really instill in peoplethat they need to unlace their
shoes when they put their shoeson and take their shoes off, all
right.
Next, I like to gaindorsiflexion range of motion.
(10:58):
I like to stretch that calf alittle bit.
I only do this on a slant boardand I'm very cautious with
these.
Usually I'm a pretty aggressivestretcher, um, depending on
what the issue is.
But if we have a retrocalcanealbursitis, a distal Achilles
insertional tendonitis, too muchstretch into dorsiflexion can
cause a little impingement downthere.
So if you're getting a nicecomfortable stretch in the calf
(11:23):
muscle, the musculotendinousjunction maybe behind the knee a
little bit bonus, okay.
But you don't want it to behurting in that retrocalcaneal
region.
So just kind of find that happymedium.
A light stretch for a long timeis way better than aggressive
short stretch.
Okay, remember, the Haglund'sdeformity will not change, okay,
(11:44):
the only thing that can changethat is surgery.
So manage the inflammation inthe surrounding tissues around
it, okay.
So prevent the irritation tothat spur around that spur and
decrease that inflammationaround that area.
Now I really like it I know ifyou've been listening to me for
a while to that spur around thatspur and decrease that
inflammation around that area.
Now I really like it.
(12:06):
I know if you've been listeningto me for a while, you know
that I like iontophoresis withdexamethasone, sodium phosphate
over that area.
That bursa sits right below theskin, okay, so that medication
can get in there a lot easier.
It's not like doing a deepperiformis muscle.
You can't iontophoresis that.
Don't try an upper trap, don'tdo anything that isn't close to
the surface, okay, you'll havevery low success with that and I
(12:28):
know there's a lot of you outthere saying, well, insurance
doesn't really pay for this verywell and my employer tells me I
really shouldn't use it becausewe're not getting well
reimbursed for it.
Well, you know, it's one ofthose things where I've had
great success using it.
So we might take a littlefinancial hit on it.
But when your patient getsbetter, you explain to them how
it works and why it works andwhy it's more successful in that
(12:48):
area.
Then they're more likely tocome back to you for more
treatment to manage theirsituations in the future.
All right, now here's the otherthing and I really like to use
to use compression.
Now, I know what you'rethinking.
I just said don't compress it,don't irritate it, don't do
anything like that.
But what I like to do is I liketo co-flex the foot and ankle
(13:08):
and when I come around the backof that heel, I pull the co-flex
nice and tight so that there'sa compression that goes in
toward the heel.
What it does is it pulls thebursa away from the back of the
shoe and it brings the frictionto the shoe and coflex rather
than the shoe and skin, allright.
(13:30):
So there's just a little bitless friction and shearing that
happens at the bursa and at theretrocalcaneal region where that
hygolens deformity is.
So I really like to use coflex.
If you don't have coflex, thenutilize something like you know,
like kinesio tape or somethinglike that.
I'm not a big kinesio taper,but it's very smooth, it slides,
(13:55):
slides nicely.
So you should get into and outof the shoe better and it's
comfortable, you can leave it onfor several days and just you
know, take a piece, pull somepretty good tension on it, hit
the center of thatretrocalcaneal bursa region and
then come around toward themedial and lateral side of the
foot and anchor it there.
And people usually like that.
If they like that, it'sobviously tough for them to wrap
themselves, so they can getinto like a pull on silicone
(14:18):
heel protector.
That can help in that area.
Now, if you don't have access tothese things, you know, like
iontophoresis or something likethat, maybe you want to try
something like Voltaren.
It's got a littleanti-inflammatory.
Again, I'm not big on creams,but because it's close to the
skin you might have someanti-inflammatory effect that
could be helpful there, allright.
So once that inflammationstarts to settle down, gait is
(14:42):
improving.
We've got good shoes, maybeorthotics to prevent lateral
rocking of the heel, you know,and they're doing better.
Then we want to start loadingthat calf a little bit.
We want to start with some youknow isometric loading and a
little bit of plantar flexion,kind of in a neutral position,
maybe on a slant board, andyou're holding that for 20-30
seconds and you build that upultimately to doing, you know,
(15:05):
double legged 45 seconds andthen single legged 45 seconds,
then increase a load and hold onto 10 to 20 pounds while doing
that for 45 seconds and start toincrease tension, because
sometimes you're going to havethis inflammation at the
insertion of the Achilles.
That also contributes to a lotof this.
So you want to manage thatbetter, get that tissue, you
(15:25):
know, put a little tension on itso it heals itself up some.
Now, if conservative measuresdon't work, then you might want
to refer to orthopedics.
Sometimes an injection can behelpful in that region.
I know we get all panicky aboutinjecting around the Achilles
tendon, but I think getting itmore near the bursa is helpful
and sometimes these folks justneed surgery.
(15:45):
Sometimes the spur is juststicking out so much you can't
get around it and then that justbecomes so inflamed and
irritated it just chronicallycauses all kinds of problems
with gait and how you function.
So there you have it, folksHagelin's deformity and
subcutaneous calcaneal bursitisall in one show.
All in a nutshell.
(16:07):
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(16:27):
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So thank you all.
So much for listening.
Be kind to each other and takecare.
Hello everyone and welcome to episode 368 of the
OrthoEvalPal podcast.
I'm your host, paul Marquis,and today we're going to be
talking about Haglund'sdeformity or subcutaneous
calcaneal bursitis.
We're going to be discussingthe anatomy surrounding the
posterior heel.
We're going to talk about howto differentiate between a
Haglund's deformity andsubcutaneous calcaneal bursitis.
(00:21):
We're going to be talking aboutsome of the contributing
factors.
We'll go over some tips fortreatment and so much more.
But before we get started, I'dlike to mention our sponsors.
We have Rangemaster.
Rangemaster is known for theirshoulder rehab equipment.
They offer products fromshoulder wands to finger ladders
, overhead pulleys to shoulderrehab kits.
Rangemaster is your one-stopshop to help with the treatment
(00:43):
of frozen shoulders, post-oprotator cuff repairs, total
shoulder and reverse totalshoulder replacements and so
much more.
If you'd like to get a freesample of Rangemaster's Blue
Ranger pulley system, just emailjim at myrangemastercom and add
OrthoEvalPal in the subjectline.
And we also have MedCorpProfessionals.
Now, I know the folks at MedcorProfessionals personally.
(01:04):
They're a locally owned andfamily operated medical supply
company.
They carry everything fromradial pressure wave units to
traction devices, resistancebands to compression garments.
Most impressively, though, isthe customer service.
It is second to none If you'relooking for medical products for
your clinic or products foryour patients?
Go to wwwmedcorprocom, that'sM-E-D-C-O-R-P-R-Ocom, and if you
(01:33):
use coupon code OEP10, you canget $10 off your next purchase.
Now on to today's show.
We are going to be talkingabout Hagelin's deformity and
subcutaneous calcaneal bursitis.
Now the first thing I want todo is talk about how similar
these are and how we do treatthem a little bit differently.
(01:54):
But some of the concepts thatwe use to treat these kind of
overlap, and that is perfectlyfine.
They're very closely associated.
One will respond a lot betterthan treating something caused
from the other, and I'll explainwhy that is in just a little
bit.
So the first thing I want to dois just go over some anatomy.
(02:15):
I want you to envision this weare looking at the back of the
heel and I want to work from theskin inward toward the
calcaneus.
So we're going to start at theskin.
Inside or beneath the skin is asubcutaneous calcaneal bursa.
That's like a smallfluid-filled sac.
(02:37):
Not everyone has this.
Some of us just develop theseover time as a mechanism to help
protect the back of the tendon,the back of the heel, from the
skin and the bursa.
You need to remember a bursaisn't like every picture you see
in a magazine, in a book, okay,like it looks like it's a big
(02:58):
ball of fluid that's sitting inthere.
It can become a big ball offluid if it becomes inflamed or
swollen, but it really imagineit as this, like a water balloon
that you've just taken all ofthe water out of, and it's
really skinny, it's really thin,um, wrinkly, a little bit, all
right.
So that's kind of more likewhat the bursa is like.
(03:22):
But when it does get irritatedit can start to swell, can
become inflamed and can causepain, all right.
So then, if we go in to thenext structure, then we have the
Achilles tendon, which insertsonto the posterior calcaneal
tubercle.
There's two calcaneal tubercles.
One, the most common one, isthe one underneath your foot.
So people come in and say Ihave plantar fasciitis and I've
got a heel spur.
Okay, that is the oneunderneath the heel.
(03:43):
This one, though, where theAchilles attaches, is that
posterior calcaneal tubercle.
Now there is the retrocalcaneal bursa, which we all
have at birth, all right, andthis one sits between the
Achilles tendon and theposterior calcaneus.
It's just a little bit superiorto the subcutaneous calcaneal
(04:04):
bursa, all right.
So that's what we have.
And then we have our calcaneus.
All right, so what is theHaglund's deformity?
Well, it's an overgrowth ofthat posterior calcaneal
tubercle, kind of like anOsgood's slaughters.
You take your thumb and indexfinger, grab a little skin on
(04:24):
your forearm and pull it awayfrom you, and if you continue to
pull that and imagine itbecoming bony and hard, it will
develop a spur.
And so this is what happens atthe backside of the calcane it
will develop a spur.
Okay, and so this is whathappens at the backside of the
calcaneus.
Is we develop this spur?
Some people develop, maybebecause they're super active as
kids, and they develop a largerspur.
(04:46):
Maybe we have a lot oftightness in the calves.
Our foot posture can make a bigdifference here.
An excessive amount ofcompression to the back of the
heel can cause this spur to kindof build up and it becomes this
large outgrowth.
Okay, that sits on the back ofthe heel.
Many people have them andthey're not all painful, okay.
(05:08):
A lot of people come into theclinic and it's interesting
because I'll say, oh, you've gotyourself, you know, quite a
spur on the back of your heelthere, and most of them will say
they were quite active.
As younger individuals.
They played sports or maybethey did a lot of hard,
aggressive labor where they hadto push up off their toes a lot
and that could cause a spur, butnot everybody has pain with it.
(05:30):
So, like the calcaneal tubercleand the plantar surface of the
foot, they generally disperseItself, doesn't generate pain,
okay, but I think it's somethingto be aware of that.
Somebody has it.
So what happens if there'soveruse and or overpressure over
the deformity?
Well, that will cause someinflammation to the Achilles
(05:52):
tendon and the surroundingbursae in that region.
Okay, so you know, imagine youhave this nice round posterior
heel and you take a couplenickels, you glue them together
and you stick them on the bone.
Now we have this excessivetissue that is now sticking out
the back even more.
Okay, and so we see this withthe use of new footwear.
(06:16):
Or if people have thisincreased calf tightness, which,
when you have a tight calf, theheel is more likely to pull up
out of the shoe a micro amount,okay, millimeters and piston up
and down in the shoe, well, ifit continues to do that, the
back of the heel will rub on theinside part of the shoe or the
(06:37):
boot usually a new leather bootthat hasn't been broken in yet.
It will cause these, and sothat will cause some irritation
to the surrounding structures,because there's just more stuff
in there, okay, which is thespur.
Now, how does this differ from asubcutaneous calcaneal bursitis
?
Now, we've probably heard moreof a retrocalcaneal bursitis and
(06:59):
that's probably what you'rethinking here.
But the most outer bursitis,closest to the skin, is the
subcutaneous calcaneal bursitis.
The retrocalcaneal bursitissits behind the calcaneus but
just anterior to the Achillestendon, a little bit smaller,
but can become quite inflamedand irritated.
So we talked about theHaglund's deformity as not being
(07:22):
a big pain generator, but thebursitis okay, the bursa can be
a very big pain generator.
It can be very easy to inflame.
People who have this bursitiswill generally be tender to
touch.
It can be a little bit warm.
What I find is that the way todifferentiate between one and
the other is that the bursitiswill be very puffy, fluid filled
(07:45):
, kind of like a sack, and it'skind of squishy a little bit,
and so that would be more of aninflamed bursa rather than a
bone spur back there, where thebone spur is going to be really
hard and it's not going to beforgiving at all and, like I
said, if it's a bursitis itcould be a little red, could be
(08:05):
a little swollen.
Now we see this a lot in peoplewho don't unlace their shoes to
take them off or to put them on.
They just kind of slide in theshoe and they take maybe the
ball of the foot on the oppositefoot and they slide the shoe
off and they're just reallycompressing that bursa on the
back of the heel.
So it just causes thisrepetitive, cumulative trauma to
(08:27):
the back of the heel.
Now think about this If you'rewearing a tall boot and you're
sliding your foot into that boot, you're just grinding that
bursa on the way in and thenwhen you pull it out, same thing
, you're grinding it on the wayout.
So just that alone can causesome of this, okay, so what do
we do with these?
Well, for both of them and I'mgoing to talk about how you
(08:49):
would treat them a little bitdifferently, but really a
majority of the treatment ispretty much the same.
Number one you want to removethe trauma to the direct contact
to the back of the heel.
Okay, so maybe a larger shoe,or what I like to do is, if
somebody is wearing a leatherboot or a shoe that has material
that can be kind of tight, butnot just like a soft material,
(09:12):
but something that's a littlebit harder.
You can go to a cobbler.
They have this nice littledevice that has a ring and a
ball and what you do is you putthe ring on the outside of the
back of the um of the heel ofthe shoe and then you put the
ball on the inside and yousqueeze them together.
You might wet that down, use aleather softener, and basically
it just does a little punch outthe back of the shoe.
(09:34):
It doesn't open it upcompletely, but it just makes an
out dent, not an indent, but anout dent on the back of the
heel.
And people love this.
Ok, they get into their bootsor their shoes and there's this
immediate relief.
You can use this for both ofthose diagnoses.
Ok, and it's hard to find acobbler these days, but if you
can, this is a great way to dothat.
(09:56):
Some people will get shoestretchers where you can stretch
the front to the back a littlebit, so to give yourself a
little bit more room or just goup in size.
Look at the materials backthere.
Make sure those materials arenot driving into the heel and
that they're kind of flaredoutward away from the heel.
Some shoes have a very slipperysurface back there and that can
(10:17):
be helpful.
Sliding the foot in and outcause less trauma.
You need to unlace the boot orthe shoe to prevent the rubbing
on the way into and out of thefootwear.
Okay, I just say it blows meaway at how many people just
jump into their shoes.
They're all tied up and theyjust jam their feet in there.
Number one it just wrecks theretrocalcaneal bursa, that
(10:37):
subcutaneous calcaneal bursa.
It irritates all the structuresover the Hagelin's deformity
and it ruins your shoes Like inno time the back of the shoe is
gone.
So I really instill in peoplethat they need to unlace their
shoes when they put their shoeson and take their shoes off, all
right.
Next, I like to gaindorsiflexion range of motion.
(10:58):
I like to stretch that calf alittle bit.
I only do this on a slant boardand I'm very cautious with
these.
Usually I'm a pretty aggressivestretcher, um, depending on
what the issue is.
But if we have a retrocalcanealbursitis, a distal Achilles
insertional tendonitis, too muchstretch into dorsiflexion can
cause a little impingement downthere.
So if you're getting a nicecomfortable stretch in the calf
(11:23):
muscle, the musculotendinousjunction maybe behind the knee a
little bit bonus, okay.
But you don't want it to behurting in that retrocalcaneal
region.
So just kind of find that happymedium.
A light stretch for a long timeis way better than aggressive
short stretch.
Okay, remember, the Haglund'sdeformity will not change, okay,
(11:44):
the only thing that can changethat is surgery.
So manage the inflammation inthe surrounding tissues around
it, okay.
So prevent the irritation tothat spur around that spur and
decrease that inflammationaround that area.
Now I really like it I know ifyou've been listening to me for
a while to that spur around thatspur and decrease that
inflammation around that area.
Now I really like it.
(12:06):
I know if you've been listeningto me for a while, you know
that I like iontophoresis withdexamethasone, sodium phosphate
over that area.
That bursa sits right below theskin, okay, so that medication
can get in there a lot easier.
It's not like doing a deepperiformis muscle.
You can't iontophoresis that.
Don't try an upper trap, don'tdo anything that isn't close to
the surface, okay, you'll havevery low success with that and I
(12:28):
know there's a lot of you outthere saying, well, insurance
doesn't really pay for this verywell and my employer tells me I
really shouldn't use it becausewe're not getting well
reimbursed for it.
Well, you know, it's one ofthose things where I've had
great success using it.
So we might take a littlefinancial hit on it.
But when your patient getsbetter, you explain to them how
it works and why it works andwhy it's more successful in that
(12:48):
area.
Then they're more likely tocome back to you for more
treatment to manage theirsituations in the future.
All right, now here's the otherthing and I really like to use
to use compression.
Now, I know what you'rethinking.
I just said don't compress it,don't irritate it, don't do
anything like that.
But what I like to do is I liketo co-flex the foot and ankle
(13:08):
and when I come around the backof that heel, I pull the co-flex
nice and tight so that there'sa compression that goes in
toward the heel.
What it does is it pulls thebursa away from the back of the
shoe and it brings the frictionto the shoe and coflex rather
than the shoe and skin, allright.
(13:30):
So there's just a little bitless friction and shearing that
happens at the bursa and at theretrocalcaneal region where that
hygolens deformity is.
So I really like to use coflex.
If you don't have coflex, thenutilize something like you know,
like kinesio tape or somethinglike that.
I'm not a big kinesio taper,but it's very smooth, it slides,
(13:55):
slides nicely.
So you should get into and outof the shoe better and it's
comfortable, you can leave it onfor several days and just you
know, take a piece, pull somepretty good tension on it, hit
the center of thatretrocalcaneal bursa region and
then come around toward themedial and lateral side of the
foot and anchor it there.
And people usually like that.
If they like that, it'sobviously tough for them to wrap
themselves, so they can getinto like a pull on silicone
(14:18):
heel protector.
That can help in that area.
Now, if you don't have access tothese things, you know, like
iontophoresis or something likethat, maybe you want to try
something like Voltaren.
It's got a littleanti-inflammatory.
Again, I'm not big on creams,but because it's close to the
skin you might have someanti-inflammatory effect that
could be helpful there, allright.
So once that inflammationstarts to settle down, gait is
(14:42):
improving.
We've got good shoes, maybeorthotics to prevent lateral
rocking of the heel, you know,and they're doing better.
Then we want to start loadingthat calf a little bit.
We want to start with some youknow isometric loading and a
little bit of plantar flexion,kind of in a neutral position,
maybe on a slant board, andyou're holding that for 20-30
seconds and you build that upultimately to doing, you know,
(15:05):
double legged 45 seconds andthen single legged 45 seconds,
then increase a load and hold onto 10 to 20 pounds while doing
that for 45 seconds and start toincrease tension, because
sometimes you're going to havethis inflammation at the
insertion of the Achilles.
That also contributes to a lotof this.
So you want to manage thatbetter, get that tissue, you
(15:25):
know, put a little tension on itso it heals itself up some.
Now, if conservative measuresdon't work, then you might want
to refer to orthopedics.
Sometimes an injection can behelpful in that region.
I know we get all panicky aboutinjecting around the Achilles
tendon, but I think getting itmore near the bursa is helpful
and sometimes these folks justneed surgery.
(15:45):
Sometimes the spur is juststicking out so much you can't
get around it and then that justbecomes so inflamed and
irritated it just chronicallycauses all kinds of problems
with gait and how you function.
So there you have it, folksHagelin's deformity and
subcutaneous calcaneal bursitisall in one show.
All in a nutshell.
(16:07):
I hope you enjoyed the show.
If you're not on our email list, be sure to get on, because
we're going to be sending outsome updates pretty soon for our
upcoming podcast.
We're also going to do a newrelease to our website in the
next week to two weeks and wealso have some dates coming up
for some live courses.
We've got a shoulder coursecoming up in May and we're going
to be giving some specificsreal soon about that.
(16:27):
So if you're interested in anyof that stuff, or you know
you're ready you want to checkout the new website, just be
sure to click on the link in theshow notes, go to the current
website, sign up for our emaillist and we'll get you on it.
So thank you all.
So much for listening.
Be kind to each other and takecare.
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