Exostosis (Osteochondrosis, Apophysites, and Haglund’s Deformity)



Osteochondroses are characterized by disorderliness of endochondral ossification in the growing skeleton affecting various joint developments throughout the body. This process, which starts in adolescence, can cause permanent bony and/or articular alterations that require management in the adult phase of life. Examples in the foot and ankle include Freiberg’s infraction, Köhler disease, sesamoid osteochondrosis, Sever’s disease and Iselin’s disease. Etiology, symptoms, diagnostics, non-operative management and surgical options are discussed. Haglund’s deformity of the posterior calcaneus is a predisposing factor for painful retrocalcaneal bursitis. Diagnosis relies on weight-bearing lateral radiographs of the foot; numerous radiological parameters have been developed. Operative options include calcaneoplasty (open or arthroscopic) and calcaneal osteotomy. Most of these conditions can be treated non-operatively. Symptom control, immobilization, activity modification and appropriate rehabilitation can all play a role in a safe and timely return to sport.


Osteochondrosis Freiberg’s Köhler Sesamoid Sever’s Iselin’s Hugland 


  1. 1.
    Siffert RS. Classification of the osteochondroses. Clin Orthop Relat Res. 1981;158:10–8.Google Scholar
  2. 2.
    Gillespie H. Osteochondroses and apophyseal injuries of the foot in the young athlete. Curr Sports Med Rep. 2010;9(5):265–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Douglas G, Rang M. The role of trauma in the pathogenesis of the osteochondroses. Clin Orthop Relat Res. 1981;158:28–32.Google Scholar
  4. 4.
    Duthie RB, Houghton GR. Constitutional aspects of the osteochondroses. Clin Orthop Relat Res. 1981;158:19–27.Google Scholar
  5. 5.
    Binek R, Levinsohn EM, Bersani F, Rubenstein H. Freiberg disease complicating unrelated trauma. Orthopedics. 1988;11(5):753–7.PubMedGoogle Scholar
  6. 6.
    Talusan PG, Diaz-Collado PJ, Reach Jr JS. Freiberg’s infraction: diagnosis and treatment. Foot Ankle Spec. 2014;7(1):52–6.CrossRefPubMedGoogle Scholar
  7. 7.
    Helal B, Gibb P. Freiberg’s disease: a suggested pattern of management. Foot Ankle. 1987;8(2):94–102.CrossRefPubMedGoogle Scholar
  8. 8.
    Katcherian DA. Treatment of Freiberg’s disease. Orthop Clin North Am. 1994;25(1):69–81.PubMedGoogle Scholar
  9. 9.
    Smillie IS. Treatment of Freiberg’s infraction. Proc R Soc Med. 1967;60(1):29–31.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Lee HJ, Kim JW, Min WK. Operative treatment of Freiberg disease using extra-articular dorsal closing-wedge osteotomy: technical tip and clinical outcomes in 13 patients. Foot Ankle Int. 2013;34(1):111–6.CrossRefPubMedGoogle Scholar
  11. 11.
    Kim J, Choi WJ, Park YJ, Lee JW. Modified Weil osteotomy for the treatment of Freiberg’s disease. Clin Orthop Surg. 2012;4(4):300–6.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Kilic A, Cepni KS, Aybar A, Polat H, May C, Parmaksizoglu AS. A comperative study between two different surgical techniques in the treatment of late-stage Freiberg’s disease. Foot Ankle Surg. 2013;19(4):234–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Waugh W. The ossification and vascularisation of the tarsal navicular and their relation to Kohler’s disease. J Bone Joint Surg Br. 1958;40–B(4):765–77.PubMedGoogle Scholar
  14. 14.
    Richardson EG. Hallucal sesamoid pain: causes and surgical treatment. J Am Acad Orthop Surg. 1999;7(4):270–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Jahss MH. Spontaneous hallux varus: relation to poliomyelitis and congenital absence of the fibular sesamoid. Foot Ankle. 1983;3(4):224–6.CrossRefPubMedGoogle Scholar
  16. 16.
    Leventen EO. Sesamoid disorders and treatment. An update. Clin Orthop Relat Res. 1991;269:236–40.Google Scholar
  17. 17.
    Wiegerinck JI, Yntema C, Brouwer HJ, Struijs PA. Incidence of calcaneal apophysitis in the general population. Eur J Pediatr. 2014;173(5):677–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Suzue N, Matsuura T, Iwame T, Hamada D, Goto T, Takata Y, Iwase T, Sairyo K. Prevalence of childhood and adolescent soccer-related overuse injuries. J Med Investig JMI. 2014;61(3–4):369–73.CrossRefGoogle Scholar
  19. 19.
    James AM, Williams CM, Haines TP. Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever’s disease): a systematic review. J Foot Ankle Res. 2013;6(1):16.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Kose O, Celiktas M, Yigit S, Kisin B. Can we make a diagnosis with radiographic examination alone in calcaneal apophysitis (Sever’s disease)? J Pediatr Orthop B. 2010;19(5):396–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Elengard T, Karlsson J, Silbernagel KG. Aspects of treatment for posterior heel pain in young athletes. Open access J Sports Med. 2010;1:223–32.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Deniz G, Kose O, Guneri B, Duygun F. Traction apophysitis of the fifth metatarsal base in a child: Iselin’s disease. BMJ Case Rep. 2014;2014.Google Scholar
  23. 23.
    Lehman RC, Gregg JR, Torg E. Iselin’s disease. Am J Sports Med. 1986;14(6):494–6.CrossRefPubMedGoogle Scholar
  24. 24.
    van Dijk CN, van Sterkenburg MN, Wiegerinck JI, Karlsson J, Maffulli N. Terminology for Achilles tendon related disorders. Knee Surg Sports Traumatol Arthrosc. 2011;19(5):835–41.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Lu CC, Cheng YM, Fu YC, Tien YC, Chen SK, Huang PJ. Angle analysis of Haglund syndrome and its relationship with osseous variations and Achilles tendon calcification. Foot Ankle Int. 2007;28(2):181–5.CrossRefPubMedGoogle Scholar
  26. 26.
    Sammarco GJ, Taylor AL. Operative management of Haglund’s deformity in the nonathlete: a retrospective study. Foot Ankle Int. 1998;19(11):724–9.CrossRefPubMedGoogle Scholar
  27. 27.
    Singh R, Rohilla R, Siwach RC, Magu NK, Sangwan SS, Sharma A. Diagnostic significance of radiologic measurements in posterior heel pain. Foot (Edinb). 2008;18(2):91–8.CrossRefGoogle Scholar
  28. 28.
    McCabe LR. Understanding the pathology and mechanisms of type I diabetic bone loss. J Cell Biochem. 2007;102(6):1343–57.CrossRefPubMedGoogle Scholar
  29. 29.
    Sundararajan PP, Wilde TS. Radiographic, clinical, and magnetic resonance imaging analysis of insertional Achilles tendinopathy. J Foot Ankle Surg. 2014;53(2):147–51.CrossRefPubMedGoogle Scholar
  30. 30.
    Kang S, Thordarson DB, Charlton TP. Insertional Achilles tendinitis and Haglund’s deformity. Foot Ankle Int. 2012;33(6):487–91.CrossRefPubMedGoogle Scholar
  31. 31.
    van Sterkenburg MN, Muller B, Maas M, Sierevelt IN, van Dijk CN. Appearance of the weight-bearing lateral radiograph in retrocalcaneal bursitis. Acta Orthop. 2010;81(3):387–90.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Lienau J, Schell H, Duda GN, Seebeck P, Muchow S, Bail HJ. Initial vascularization and tissue differentiation are influenced by fixation stability. J Orthop Res. 2005;23(3):639–45.CrossRefPubMedGoogle Scholar
  33. 33.
    Haims AH, Schweitzer ME, Patel RS, Hecht P, Wapner KL. MR imaging of the Achilles tendon: overlap of findings in symptomatic and asymptomatic individuals. Skeletal Radiol. 2000;29(11):640–5.CrossRefPubMedGoogle Scholar
  34. 34.
    Irwin TA. Current concepts review: insertional achilles tendinopathy. Foot Ankle Int. 2010;31(10):933–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Ortmann FW, McBryde AM. Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis. Foot Ankle Int. 2007;28(2):149–53.CrossRefPubMedGoogle Scholar
  36. 36.
    Giannoudis PV, Einhorn TA, Marsh D. Fracture healing: a harmony of optimal biology and optimal fixation? Injury. 2007;38 Suppl 4:S1–2.Google Scholar
  37. 37.
    Laporte S, Mismetti P. Epidemiology of thrombotic risk factors: the difficulty in using clinical trials to develop a risk assessment model. Crit Care Med. 2010;38(2 Suppl):S10–7.CrossRefPubMedGoogle Scholar
  38. 38.
    Calori GM, Phillips M, Jeetle S, Tagliabue L, Giannoudis PV. Classification of non-union: need for a new scoring system? Injury. 2008;39 Suppl 2:S59–63.CrossRefPubMedGoogle Scholar
  39. 39.
    Caprini JA, Arcelus JI, Reyna JJ. Effective risk stratification of surgical and nonsurgical patients for venous thromboembolic disease. Semin Hematol. 2001;38(2 Suppl 5):12–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Anderson JA, Suero E, O’Loughlin PF, Kennedy JG. Surgery for retrocalcaneal bursitis: a tendon-splitting versus a lateral approach. Clin Orthop Relat Res. 2008;466(7):1678–82.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Leitze Z, Sella EJ, Aversa JM. Endoscopic decompression of the retrocalcaneal space. J Bone Joint Surg Am. 2003;85–A(8):1488–96.CrossRefPubMedGoogle Scholar
  42. 42.
    Huber HM. Prominence of the calcaneus: late results of bone resection. J Bone Joint Surg Br. 1992;74(2):315–6.PubMedGoogle Scholar
  43. 43.
    Fridrich F. Tendon-splitting approach for the surgical treatment of Haglund’s deformity and associated condition. Evaluation and results. Acta Chir Orthop Traumatol Cech. 2009;76(3):212–7.PubMedGoogle Scholar
  44. 44.
    Johnson KW, Zalavras C, Thordarson DB. Surgical management of insertional calcific achilles tendinosis with a central tendon splitting approach. Foot Ankle Int. 2006;27(4):245–50.CrossRefPubMedGoogle Scholar
  45. 45.
    Lohrer H, Nauck T, Dorn NV, Konerding MA. Comparison of endoscopic and open resection for Haglund tuberosity in a cadaver study. Foot Ankle Int. 2006;27(6):445–50.PubMedGoogle Scholar
  46. 46.
    van Dijk CN, van Dyk GE, Scholten PE, Kort NP. Endoscopic calcaneoplasty. Am J Sports Med. 2001;29(2):185–9.PubMedGoogle Scholar
  47. 47.
    Russell MW, Taylor DC, Cummins G, Huse DM. Use of managed care claims data in the risk assessment of venous thromboembolism in outpatients. Am J Manag Care. 2002;8(1 Suppl):S3–9.PubMedGoogle Scholar
  48. 48.
    Boffeli TJ, Peterson MC. The Keck and Kelly wedge calcaneal osteotomy for Haglund’s deformity: a technique for reproducible results. J Foot Ankle Surg. 2012;51(3):398–401.CrossRefPubMedGoogle Scholar
  49. 49.
    Keck SW, Kelly PJ. Bursitis of the posterior part of the heel; evaluation of surgical treatment of eighteen patients. J Bone Joint Surg Am. 1965;47:267–73.CrossRefPubMedGoogle Scholar
  50. 50.
    Miller AE, Vogel TA. Haglund’s deformity and the Keck and Kelly osteotomy: a retrospective analysis. J Foot Surg. 1989;28(1):23–9.PubMedGoogle Scholar
  51. 51.
    Kelsall KN, Chapman WA, Sangar A, Farrar MJ, Taylor HP. Zadek’s calcaneal osteotomy for insertional achilles pathology. Bone Joint J Orthop Proc Suppl. 2014;296-B(Supp 2):19.Google Scholar
  52. 52.
    Taylor GJ. Prominence of the calcaneus: is operation justified? J Bone Joint Surg Br. 1986;68(3):467–70.CrossRefPubMedGoogle Scholar
  53. 53.
    Maynou C, Mestdagh H, Dubois HH, Petroff E, Elise S. Is calcaneal osteotomy justified in Haglund’s disease? Rev Chir Orthop Reparatrice Appar Mot. 1998;84(8):734–8.PubMedGoogle Scholar
  54. 54.
    Brunner J, Anderson J, O’Malley M, Bohne W, Deland J, Kennedy J. Physician and patient based outcomes following surgical resection of Haglund's deformity. Acta Orthop Belg. 2005;71(6):718–23.PubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.St. Michael’s HospitalTorontoCanada
  2. 2.Adam Gruca Autonomous Public Clinical HospitalOtwockPoland

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