Bumpy heel pain real

Conway McLean, DPM

Shoes are a big deal. Especially to some people, and I am not referring only to women. The shoe industry is a billion-dollar concern, and they are important to many different socio-economic groups. As evidence, you may recall the news stories about city kids getting murdered for their brand-name sneakers. I can say confidently shoes are quite important to some women. The “poster child” for a woman’s shoe obsession might be Imelda Marcos, the wife of the former president of the Philippines. Apparently, her country’s wealth was directed toward her expansive shoe collection, which numbered in the thousands.

Perhaps you can imagine how a fashion-conscious woman would feel if she could no longer comfortably wear any of her stylish shoes. If a woman has pain every time she wears her more fashionable shoe gear, she will likely want answers as to why. Obviously, there are many reasons stylish shoes may be uncomfortable, with one of them being that these shoes have no semblance to the shape of a woman’s foot (although this probably is not the explanation they want to hear).

It should not be a shocking statement to say that stylish woman’s shoes are not anatomically correct. Although there are a multitude of variations in contour and configuration, this type of foot gear tends to be excessively pointed and narrow, quite unlike that of most women. Humans vary tremendously in shape and size, so when you have a foot far outside the norm, a high heeled or more “stylish” shoe, will understandably tend to elicit pain. A hard, reddened bump at the base of the big toe (a bunion), will cause problems in this foot wear. Hammertoes, abnormally bent toes, will also be a source of discomfort.

Another variation on anatomy is an enlargement of bone at the back of the heel. When this is present, pain can develop there with the use of various types of shoes. The bony bump will put pressure on the soft tissue structures present between the bone and the shoe. Although there are no major nerve tracts, there are enough sensory nerves to produce pain. Nerves don’t like chronic and repeated physical stress.

The phrase often used to describe this condition, a bone prominence at the back of the heel, is a “pump bump” (although not a medical term) since, as the name suggests, the worst offenders is a woman’s pump. Technically-speaking, this pathologic variation is called a Haglund’s deformity. As is usually the case, a Dr. Haglund described it, then wrote about it, so naturally, he gets his name stamped on it.

Even those unfamiliar with the anatomy of the foot know about the Achilles tendon, which is the thick cord at the back of the ankle. This, the largest tendon in the body, attaches to the back of the heel bone and is frequently the cause of pain because of this prominence. When this extra bone moves against the tendon, it tends to become irritated, leading to chronic inflammation, and, you guessed it, pain. If this situation goes on long enough, and there is enough inflammation of the tendon, it’s also possible to develop calcifications within the tendon. Now the sufferer has developed a whole new set of problems.

What about the position of the heel? As one might guess, a heel bone which is more tilted upward will throw the bump back against the shoe even further. This is the case with a higher arched foot, also known as a cavus foot. Surprisingly, even the opposite type of foot, a flattened foot, can produce the same type of pain, but for different reasons. This kind of foot tends to be less stable, more mobile, and moves more when walking. This excessive motion of the foot, and consequently of the heel bone, will cause this prominent bump to move repeatedly against the soft tissue structures located in this area. Hence a greater likelihood of recurrent pain.

Also located at the back of the heel bone is a sack of fluid that protects the Achilles tendon. It resides between the tendon and the heel bone. This fluid-filled, soft tissue structure is termed a bursa, so, naturally, when it becomes inflamed, ‘-itis’ is added, and you have bursitis. Frequently, this develops along with other problems in this area, so it may occur in concert with other conditions.

Although the pain of a Haglund’s deformity sometimes comes and goes, after suffering for long enough, many will seek treatment, and many options exist. Like many problems, there is no one best treatment since the optimal course is determined by the cause. Altering your shoe gear is a good option, as should be obvious. Women who experience this problem will find themselves tending to favor those shoes that do not cause pain. Still, many will persist in the use of pain-causing shoe gear.

Various types of padding can be used, although their success is usually limited since one consequence is more material between the extra bone and the shoe. As should be obvious, this can increase the pressure to the symptomatic tissues. Prescription foot supports can be very effective at controlling heel motion, if that is part of the problem. Over-the-counter devices are generally not as good at achieving this. Because the chemical process of chronic inflammation is frequently what causes the pain, certain types of physical therapy, like ultrasound or electric stimulation, can be beneficial at reducing this process, and so, minimizing pain.

The same effect can be achieved via the injection of an anti-inflammatory medication. The most widely used is a corticosteroid (what most call cortisone). A concern with steroids is that they can weaken tendons, and the Achilles must be kept strong since it has tremendous forces running through it. This is much less likely with certain steroids.

Additionally, the medicine should be placed around the tendon and not into it, easily achieved with the use of diagnostic ultrasound. Overall, this is generally a very safe option with the use of the appropriate substance, administered into the right region.

You may be thinking at this juncture that this doesn’t change the anatomy, ie the presence of a bump of bone. And you would be correct. Only surgery can do that, although many different approaches and techniques have been used.

Making a long incision centered over the bump ensures complete removal but carries the disadvantages of a more difficult recovery, with prolonged swelling, as well as more trauma to the tendon. When performed through a tiny incision, while visualizing the excess bone with fluoroscopy (real time x-ray imaging), these undesirable consequences can be significantly reduced. This concept for surgical intervention is highly advantageous, especially when it comes to removing this bump.

For some, a Haglund’s deformity is more of an annoyance than a disabling condition. Humans come in all shapes and sizes, and so do ‘pump bumps’. If you have pain only when you wear your six- inch spiked high heels, I have a word of advice. But if pain occurs at the back of the heel with more sensible shoes, and you find it limiting your activity levels, it is time to take it seriously. As we all know, recurrent pain has many consequences, none of which are positive. It boils down to that all important question: is the problem reducing your quality of life?

Editor’s note: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.