Haglund’ syndromes: diagnosis, treatments et algorithm for decision-making

First described in 1928 by Patrick Haglund, Haglund’s syndrome is a multifactorial entity comprising calcaneal anatomical factors (excess length, cavus foot, hypertrophy of the postero-superior aspect of the great tuberosity), Achilles insertional tendinopathy lesions by impingement and excess traction as well as reactive lesions of the surrounding soft tissues (retrocalcaneal bursitis). Retraction of gastrocnemius will be an aggravating factor.
The pre-therapeutic assessment will include WB x-rays on lateral view to determine the only 2 reproducible radiological measurements (Tourné X/Y ratio and Ruch pitch angle), investigate and quantify calcifications at the enthesis level and an MRI to assess the condition of the tendon at its calcaneal insertion.

The treatment is mainly surgical with the objectives of modifying the shape of the calcaneus, relaxing the gastrocnemius, resection of calcifications and improving the vascularization of the distal-end of the Achilles tendon.

Open techniques, more recently minimally invasive or endoscopic ones, will be used isolated or combined. They include postero-superior calcaneoplasty, Zadek osteotomy (calcaneus dorsal wedge osteotomy), detachement-reattatchement of the calcaneal tendon distal-end, and flexor hallucis longus transfer. These techniques will be described, their indications and results discussed.
A therapeutic algorithm is proposed to assist in surgical decision-making.