Edited by Kenneth Hunt, MD
Pump bumps are prominent bony lumps on the outside back part of the heel. They may be asymptomatic or they may be associated with discomfort, due to irritation from shoe wear. The pump bump itself is a prominent bone on the outer aspect of the heel bone (calcaneus), near where the Achilles tendon inserts. It is sometimes called a Haglund’s deformity. Pump bumps can usually be treated with appropriate shoe wear, so as to minimize irritation to the prominent bump. Occasionally surgery to remove the bony bump and the overlying fluid filled sac (bursa) is necessary.
Patients with a symptomatic “pump bump” will complain of a painful lump on the back and outside part of one or both heels. Symptoms are usually exacerbated by rubbing on the heel counter of a shoe or sneaker, and can also be aggravated by an increase in activity. Patients will often try to pad or protect the area in order to improve their symptoms, and frequently note that open backed shoewear or going barefoot lessens the mechanical irritation (but does not decrease the prominence). They will usually report that the size of the bump can vary. However, most patients feel that the pump bump does tend to gradually increase in size over time. A history of trauma can sometimes be elicited, but this is not common. The prominence is often found by patients to be present on both feet, even though those who present with pump bumps often complain of symptoms only on one side.
On physical exam, a prominent bump is both visible and palpable just to the outside upper aspect of the heel (posterolateral heel). This is adjacent to where the Achilles tendon inserts into the heel bone itself. While this bump typically involves an oversized area of bone that exists in front of and even also occasionally within the Achilles itself, it may appear on exam to involve both bone and soft tissue. The area of irritation frequently involves a slightly swollen bursa around it. There is also usually some thickening of the skin (callusing), which the body has created over time as a means of trying to protect this spot against shoe rubbing. Patients with pump bumps usually have full mobility and strength of their foot, ankle, and lower extremity, and typically exhibit an otherwise normal foot structure and function to any further examination.
Pump bumps are best seen on plain x-rays taken of the ankle, heel, or foot. Imaging studies that are most often performed in patients with pump bumps include plain x-rays of the hindfoot. Aside from noting this bony prominence posteriorly (i.e., an area of bone that is normal in shape, location, and alignment, excepting its enlarged size), these are otherwise usually unremarkable. A special axillary heel view (Harris heel view) may show an increased prominence of bone on the outside (lateral) of the foot. In more unusual cases, the area of prominence can involve a portion of the Achilles tendon itself as an arguably separate but symptomatically contributory phenomenon (i.e., Achilles calcification).
CT or MRI assessment is usually not indicated to make this diagnosis. If it is performed, it will typically demonstrate some increase prominence of bone, and also often an associated fluid-filled bursal sac with some swollen soft tissue noted along the back and outside part of the heel bone (the posterolateral aspect of the calcaneus, or “heel” bone).
Most pump bumps can be successfully managed non-surgically. The best treatment involves avoiding shoes that will irritate the inflamed and enlarged area behind the heel itself. A softly cushioned, more forgiving, and less frictional heel counter associated with any shoe or sneaker will usually be quite helpful in alleviating the associated pain, swelling, and bursal inflammation that results from this chronic mechanical rubbing. Open back shoes are also helpful if the patient can tolerate them. Alternatively, patients can choose to insert a donut or other accommodative heel insert that is made of felt, moleskin, or other soft material, and can be placed and centered around the prominence to avoid friction directly on the site.
Occasionally, non-operative treatment will not sufficiently alleviate the discomfort associated with a pump bump because it becomes too large an area to offload. When that is the case, these prominences begin to become noticeably prominent and painful, to the point that they interfere with even routine daily activity and begin to severely restrict otherwise reasonable shoe wear choices. In these instances, surgical resection may be a viable solution.
Surgery involves making an incision adjacent to the bump, while taking care to avoid nearby sensory nerves and the Achilles tendon, and then exposing and excising the overlying fluid-filled bursal sac along with the bony prominence itself. The underlying bone is rasped down to a more normal level so that it no longer has a size which will serve to irritate the surrounding skin and everything else with which it comes into contact. Occasionally, bone wax is applied to minimize the risk of new bone formation after the resection, and sometimes a small portion of the Achilles must be opened to remove areas of calcification next to this, which may be contributing to its perceived size. Once these issues have been resolved and confirmed by direct external palpation from the surgeon, the incision is then carefully closed.
It is very important that the patient be relatively immobilized, restricted in weight-bearing, and relatively inactive for the few weeks following surgery, until the incision has healed. Complete healing often takes four to six weeks until patients become satisfactorily comfortable, and this can often take even longer. Once patients are comfortable enough to freely weight bear in regular shoes without issue, they can gradually transition to their prior level of activity.
The most common complications specific to surgical removal (resection) of a pump bump include:
- Wound healing problems
- Trouble healing the skin edges: this is the most common problem and is often associated with non-compliance or excessive activity in the early post-operative setting
Edited on September 29, 2017
(Previously edited by Christopher DiGiovanni MD and Justin Greisberg, MD)