The Complicated Achilles Injury Sidelining Pros and Everyday Runners Alike—and How to Recover From It

Jump to:What are Haglund’s deformity and insertional Achilles tendinopathy?What causes Haglund’s syndrome in runners?What does it feel like?How is it diagnosed and treated?How do you know if you need surgery?Can you prevent Haglund’s syndrome and insertional Achilles tendinopathy?Are these conditions becoming more common?By all appearances, Vanessa Fraser’s pro running career was going well in 2020. That February, she ran her personal best of 14:48.51 in the 5,000 meters—at the time, the second-fastest U.S. indoor mark.But behind the scenes, nearly every step she took—on the track or off—brought excruciating pain in both heels.Each morning, Fraser would soak her feet in hot water for 10 minutes to loosen them up. At times, she dreaded getting up from the couch to get a glass of water. The pain was “a mental weight at all times,” she tells Runner’s World.Fraser, whose symptoms started in January 2017, was eventually diagnosed with insertional Achilles tendinopathy and bony growths called Haglund’s deformities. When the COVID-19 pandemic put racing on pause in spring 2020, she became one of many pro runners—including Olympians Galen Rupp, Donavan Brazier, and Karissa Schweizer—to undergo surgery to treat them.When Colorado-based physical therapist Ana Robinson, PT, DPT, learned about Haglund’s deformity in PT school, it was called “pump bump,” caused by rubbing from high heels or other tight footwear. But over her two decades of treating athletes, she’s seen many cases in athletes, including elite and recreational runners.Insertional Achilles tendinopathy, including cases linked to these bony growths, is less common than problems higher up along the tendon. It’s often more difficult to treat, requiring months of physical therapy and sometimes surgery. But in the long term, runners can usually get back to doing what they love, says Mark Dudek, PT, DPT, a physical therapist at Vail Health and Howard Head Sports.Don’t let an injury derail your training. Get back on your feet with the Runner’s World Guide to Common Injuries, packed with training tips, recovery guidelines, and injury knowledge from medical experts.What are Haglund’s deformity and insertional Achilles tendinopathy?The terminology can get confusing because there are many potential sources of heel pain and stiffness. Haglund’s deformity refers to a bony bump that forms on the back of the calcaneus, or heel bone, says Nick Strasser, MD, assistant professor of orthopedics in the division of foot and ankle surgery at Vanderbilt University. Often, the growth rubs on or compresses the tendon, causing degeneration or what Strasser calls “a fraying effect.”Because this occurs at or near the point where the tendon connects to the bone, it’s referred to as insertional Achilles tendinopathy. (Pain and stiffness higher up the tendon, meanwhile, is called midsubstance Achilles tendinopathy.) The bursa—a fluid-filled sac that provides cushioning between your heel bone and Achilles tendon—can also become red, swollen, and painful.These structures can get irritated on their own—for example, many people have insertional Achilles tendinopathy without a Haglund’s deformity. But collectively, this constellation of symptoms is known as Haglund’s syndrome. And as the swollen tissues expand, they can aggravate each other, says Dudek, who, with Robinson, published a recent paper on rehab protocols in the International Journal of Sports Physical Therapy.“Anytime a bone has stress through it, whether it be a pull or just rubbing, the bone grows,” Dudek says. That means friction from the damaged tendon can actually cause a Haglund’s deformity to form or worsen. What’s more, calcification or bone spurs can also form within the tendon itself. All this can further damage the Achilles—and in rare cases, even lead to rupture.What causes Haglund’s syndrome in runners?Haglund’s syndrome and insertional Achilles tendinopathy typically develop and worsen slowly. The causes aren’t completely clear. Genetics seem to play a role in the bony growth itself, says Amol Saxena, DPM, a surgeon in private practice in Palo Alto who’s operated on hundreds of Achilles tendons, including Rupp’s.Other factors may include adding load to the Achilles tendon—for example, by increasing mileage or running more hills—without allowing ample time for the tissue to repair and rebuild, says Robinson, who practices at GØAT Physical Therapy in Edwards, Colorado. Shoes with a stiff heel counter that rubs against the Achilles, or those with a lower drop—the difference in height between the heel and the forefoot—could also contribute.What does it feel like?You might notice tenderness, burning, redness, and swelling at the spot where the Achilles meets the heel. Symptoms typically worsen when you’re dorsiflexing, or moving the toes up closer to the shins, and improve when you’re barefoot, Dudek says.Fraser says her ankles felt stiff and “jammed all the time.” Her morning foot soaking routine helped her ankle pop, which slightly improved things. “You’ll do anything to try to get a little more space in that joint,” she says.Tina Muir—a former pro runner for Great Britain who now competes in ultra distances—describes a tender spot on the inside of her heel that at first hurt during runs and to the touch. Eventually, the pain crept into her everyday life. “Anytime it was bumped by anything, it made me jump to the ceiling,” says Muir, who’s also the host of the Running for Real podcast, for which she recorded an episode on this topic.If a Haglund’s deformity is involved, you’ll usually see it, Robinson says. But the size of the bump doesn’t always correspond to the severity of symptoms. Some people have large Haglund’s deformities and no issues, while others hurt too much to run despite smaller growths.How is it diagnosed and treated?If you have symptoms, seek out a physical therapist or sports medicine physician who specializes in treating the foot and ankle, Robinson recommends. A thorough evaluation of the heel—and sometimes, X-rays, or an MRI—can pinpoint which structures are involved and guide next steps.The first line of therapy often involves modifying training—for instance, backing off hills or speedwork. Adding a heel lift to your running shoes can reduce the strain on your Achilles, Dudek says. Some runners further modify their footwear by cutting out stiff heel counters and replacing them with softer foam. Wearing clogs or other backless shoes when you’re not running can further ease the pressure.Strength training is critical, especially heavy, slow calf raises to gradually load the tendon, Dudek says. But it’s important to do them on a flat surface, not off a step. That way, you avoid unnecessary dorsiflexion, which puts extra strain on the injured part of the tendon. A physical therapist can further guide you on form and weight progression. Research also suggests that extracorporeal shockwave therapy (ESWT) can provide relief, although it isn’t always covered by insurance, Saxena says.About 85 to 95 percent of patients with insertional Achilles tendinopathy and Haglund’s syndrome successfully improve without surgery, but it can take a while for tendons to heal. “The literature shows 6 to 18 months,” Dudek says. “I usually tell people it could take about 12 months—a whole year—until you’re pain-free.”Because many insurance plans also don’t cover extended physical therapy, Robinson recommends an honest conversation with your healthcare team about your benefits and resources. With the right therapist, “a plan can be made for the long game,” she says—for example, appointments at less frequent intervals, with phone or email check-ins in between.How do you know if you need surgery?If you’ve done PT but can’t get back to running as much as you want without pain, it’s worth considering surgery, Dudek says. Many recreational runners Saxena operates on have tried conservative therapies for a year, while pro runners might make the choice sooner, after about six months.Muir, for instance, tried about a year of strength training, shoe changes, shockwave, and periods of time off running. “It would calm down, and as soon as I started running again, it would come roaring back,” she says. “I had to make the choice: Do I want to stop and deal with this now and get back to running and feeling good, or do I want to keep suffering every day?”The typical surgery involves detaching at least a portion of the Achilles from the heel bone and shaving down the Haglund’s deformity, along with removing calcifications, inflamed bursae, and damaged tendon tissue. Then, the surgeon reattaches the tendon with sutures.Because the Achilles has to stand up to significant stress and the area gets little blood flow, the recovery time is lengthy. Sticking to the postoperative rehab plan laid out by your surgeon and physical therapist—one that involves strength training and a gradual return to activity—is critical to a successful comeback, Robinson says. While you might start running again within four to six months, it can take a year or longer to get back to your previous mileage.In some cases, arthroscopic or similar techniques are an option, Strasser says. Fraser, for example, had both feet operated on at once using a minimally invasive tool. She was back to her previous levels of training in six months, and competing at the U.S. Olympic Trials 13 months post-op.But these approaches aren’t an option for everyone, and some runners who try them wind up needing additional surgery later, Saxena says. If possible, getting an opinion from more than one surgeon can help you make the best choice for your situation.Can you prevent Haglund’s syndrome and insertional Achilles tendinopathy?Because the causes are complex, there’s no surefire prevention strategy. Being cautious with training changes—for example, adding mileage and hills gradually—may help, Dudek says. So can taking action when you first notice symptoms.“If you start to feel some twinges and pulls in the area of the Achilles, if you can see somebody who’s familiar with working with runners and has dealt with Achilles pathology, getting in sooner rather than later is going to be beneficial,” Strasser says. “Sometimes a little tweak here and there, and they can stop that process from happening.”Are these conditions becoming more common?There’s evidence that Achilles tendon injuries overall are on the rise; they already affect about one in five recreational runners and as many as half of elites. Experts estimate that about one-fourth of all Achilles tendinopathies are insertional, and about one-fourth of those cases are related to Haglund’s syndrome.While it isn’t clear if cases of Haglund’s or insertional Achilles tendinopathy specifically are increasing overall, Saxena says athletes like Rupp have increased awareness. Rupp went on to run 2:06:35, less than 30 seconds off his personal best, at the Chicago Marathon three years after his surgery, and he’s still at it—last weekend, the 40-year-old broke the masters record by running 2:06:54 at the same race. He’s one of many runners who have successfully returned to the sport after similar procedures, according to a paper Saxena published in The Journal of Foot & Ankle Surgery documenting his results.Six years after her procedure, Fraser says she has no lingering symptoms as she continues to compete, most recently at the USATF Outdoor National Championships. Muir, too, has returned to mostly pain-free running. Last November, a year and a half after her surgery, she ran her first 100K, the Ultra-Trail 100 in Cape Town, South Africa, placing eighth in 16 hours, 11 minutes, and 11 seconds.“It’s hard to imagine, when you’re in it, how it could possibly be better to willingly take one to two years of your running life and sacrifice it. But for me, it was worth it in every way,” she says. “Now I feel excited about my next career step as a runner, versus wondering how many more miles I have left.”Even more importantly, she no longer flinches or hides one foot behind the other when her kids run toward her. “What I got back in terms of my life was actually more of the win than the running,” she says.Cindy is a freelance health and fitness writer, author, and podcaster who’s contributed regularly to Runner’s World since 2013. She’s the coauthor of both Breakthrough Women’s Running: Dream Big and Train Smart and Rebound: Train Your Mind to Bounce Back Stronger from Sports Injuries, a book about the psychology of sports injury from Bloomsbury Sport. Cindy specializes in covering injury prevention and recovery, everyday athletes accomplishing extraordinary things, and the active community in her beloved Chicago, where winter forges deep bonds between those brave enough to train through it.