We now know the heel has a protrusion, but let’s keep it simple. ‘Posterosuperior‘ is an anatomical position. The back of the heel! What about the tendon? Most people only have a minor form of the bump. However, in a few people, the bump becomes larger. If the extent of the bone extends across the heel, where the big tendon of the calf is anchored, then part of the tendon can also be involved. The tendon can be damaged, or the skin can form a spongy fluid-filled sac called a bursa. Where the deep tendon sac becomes inflamed, the condition can deteriorate. The skin surface can form a blister.

Altered Biomechanics

The skin rubs against the shoe, but deeper pressure changes the thickness of the bone lining (periosteum). The periosteum adapts by laying down more bone. This arises where pressure and stress are most significant. This video makes for a good education for those with a fascination for biology. The process of adapting bone is well-known and is called Wolff’s law. But what starts it off? Back to that word BIO-mechanics. 

Mechanics implies the way things work or function according to physical principles. The foot is a wonder of mechanics. As it is living and biological, we call the movement and function ‘biomechanics’. As the heel contacts the ground, it rotates sideways, making contact with the inside lining of the shoe. This movement is called eversion and inversion, so in reality, tipping motions. This movement happens at one key joint. This is the subtalar joint. The forty-eight-second video will be helpful in understanding ankle movements. You can tell if this is a long-standing problem because the bone wears a small hole in the lining of the shoe. 

If there is too much movement between the foot and the shoe, then the skin builds up friction (Fig.1). The foot moves in other directions, such as up and down at the true ankle joint (Fig. 2). Compression of the skin and deeper parts distort and set up shearing. Shearing forces are made from both friction (C) and compression (D) and create deep damage.

What is the Solution?

The first consideration is managing any broken skin (acute injury). Prevention is better, so awareness of the shoe, your foot deformity, and the surrounding terrain becomes a helpful formula. Haglund’s ‘syndrome’ suggests (1) the skin might be irritated or that (2) a deep bursa has become inflamed. This might have developed with some (3) tendon involvement. All three components might be present, but often, only the bump causes soreness. If it is simply the communal garden swelling, conservative management can be achieved by altering the heel height in shoe wear or using local protection.

Any self-help management aims to prevent blistering from arising or the skin from breaking and forming a ‘wound’. For anyone with neuropathy, DO NOTE that damage can occur without immediate knowledge. Naturally, this is a more significant concern for patients with diabetes who suffer from numbness or neuropathy.

Gel sleeve is made from a thin elastic stocking with a thin spongy pad formed into the sock, as shown.

Acute Problems

A blister patch can alleviate direct skin pressure, but it should be used only when acutely inflamed or where the skin has broken. Blister patches are sold in local pharmacies and chemist outlets.

A wound dressing will help absorb any leaking fluid to prevent infection. Change this regularly until any fluid leakage has stopped. Leave open to air at night so the foot does not stick to the sheets. Place a soft pillow or reposition yourself at night at the back of the leg (above the heel) to take pressure away from the raw skin.

Use a fresh, dry dressing during the day.  Avoid any further pressure and reduce the use of dressings unless necessary. Footwear such as flip flops, sandals or Crocs will help limit skin pressure while the skin mends. Pain medication is not required unless the level of pain is high, in which case if this is sustained for more than 2 days, seek help from a professional—regular pain medicines for headaches work. Try not to burst the roof of any blister unless it has become so large it will burst with footwear pressure. To burst a blister, you must use a clean technique.  Using a standard antiseptic dressing is better than the recommendation to use Vaseline, and it is certainly preferred over antibiotic creams. As a rule, ointments should not be used on open wounds. There are always exceptions.

Prevention

The use of a siliconised gel sleeve, as shown in the picture above, is highly effective, and I have used this for walks when shoes that I know cause me problems despite fitting well enough. A felt pad cut out stuck to the inside of the shoe is helpful. This is often called a doughnut pad and is similar to the bunion pad I have demonstrated as part of my self-help videos.

Surgery

Most of the formal professional sites I have recommended all say something about surgery. This is not always a successful operation for large bumps. More minor bumps, like mine, would work well enough if operated on. Recovery time is longer than you may realise; no less than 6 weeks and sometimes longer. Surgery is not for the faint-hearted, and the inconvenience has more to do with inconvenience than any lack of success. The usual risks exist, but this is where most sites do offer detailed information. As Vaishya suggests, ‘surgical excision of the bony exostoses of the calcaneum is only required in resistant cases.’ His further advice is also valid. ‘Inflammation of the different parts of soft tissue in the area can lead to an isolated condition; however, the treatment options are different in these conditions, so they should be differentiated.’  This condition can affect one or both heels. A history of arthritic conditions such as gout, rheumatoid arthritis, or seronegative spondyloarthropathies should be considered (Vaishya).