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Clinical Image: Pain and swelling of the backfoot

Pain and swelling of the backfoot

[headline_subtitle subtitle=”Can you come up with the proper diagnosis?”]

A 42-year old female patient presented with chronic pain and swelling on the backfoot.


[WpProQuiz 29]

J. Opperman & M. Maas


S.A. Stufkens, orthopedic surgeon


A Haglund deformity (correct answer) is a bony prominence originating at the posterosuperior calcaneus and Achilles tendon insertion (blue arrow). 1 This condition, or ‘pump bump’, is most common in young women wearing badly fitting footwear. Repetitive pressure on the calcaneus and Achilles tendon causes irritation, which may result in retrocalcaneal bursitis.2 Treatment of this deformity and/or bursitis is aimed at decreasing pressure and inflammation, which can primarily be obtained by orthopedic inlays under the heel, supplemented by oral non-steroid anti-inflammatory drugs or local corticosteroid injections. Open or endoscopic surgical therapy with removal of the bony prominence and bursectomy may be required in resistant cases.3

Achilles tendinopathy is usually located around the middle section of the tendon with a sharp pain, exaggerated by physical activity with dorsiflexion of the foot. On X-ray, formation of enthesophytes may be present with thickening and calcification of the tendon at its insertion (red arrow).

Sever disease, only present in growing children, is caused by overuse of the heel whereby excessive traction of the Achilles tendon leads to calcaneal apophysitis. Both Achilles tendinopathy and Sever disease are treated with lowering pain-inducing activities, analgesic medication and stretching excercises.1

Heel spur, or fasciitis plantaris, is located at the plantar medial calcaneal tuberosity and fascia. Note that the underling process is noninflammatory or degenerative, unlike what the name implies.1 Findings of a plantar heel spur on X-ray (green arrow) are most often incidental and do not correspond well with the patient’s complaints.4

X-ray backfoot

  1. Tu P,Bytomski JR. Diagnosis of heel pain. American Family Physician Journal. 2011;84(8):909-916
  2. Stephens MM. Haglund’s deformity and retrocalcaneal bursitis. Orthopedic Clinics of North America. 1994;25(1):41-46
  3. Ortmann FW, McBryde AM. Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for treatment of Haglund deformity and retrocalcaneal bursitis. Foot and Ankle International. 2007;28(2):149-53
  4. Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-based review of diagnosis and therapy. American Family Physician Journal. 2005;72(11):2237-42

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