What is the recommended management for posterior short leg work?

Management of Posterior Short Leg Work

The recommended management for posterior short leg work includes open-backed shoes, heel lifts or orthoses, NSAIDs, decreased activity, and stretching exercises as first-line treatments, with more advanced interventions reserved for refractory cases. 1

Initial Assessment and Diagnosis

When evaluating posterior short leg pain, consider these common conditions:

• Insertional Achilles Tendonitis: Characterized by chronic posterior heel pain, swelling, and tenderness at the Achilles tendon insertion. Radiographs may show spurring or erosion at the insertion site. 1

• Bursitis Associated with Haglund's Deformity: Most common in women 20-30 years of age, with tenderness lateral to the Achilles tendon, often with a posterior lateral prominence visible on radiographs. 1

• Neurologic Heel Pain: Results from irritation or entrapment of nerves innervating the heel. 1

First-Line Treatment Approach

For most posterior short leg conditions, initial management includes:

1. Footwear Modification:

   • Open-backed shoes to reduce pressure on the affected area 1
   • Proper footwear with adequate shock absorption

2. Orthotic Interventions:

   • Heel lifts or orthoses to reduce tension on the Achilles tendon 1
   • Accommodative padding for bursitis cases 1

3. Activity Modification:

   • Decreased activity to reduce stress on the affected area 1
   • Gradual return to low-impact activities before progressing to higher-impact activities 2

4. Pain and Inflammation Control:

   • NSAIDs for pain relief and inflammation reduction 1, 2
   • Ice application for 20-30 minutes, 3-4 times daily 2

5. Rehabilitation Exercises:

   • Stretching exercises for the posterior leg muscles 1
   • Progressive strengthening focusing on controlled movements 2

Condition-Specific Management

For Insertional Achilles Tendonitis:

• Avoid corticosteroid injections near the Achilles tendon due to risk of tendon rupture 1
• Consider immobilization in particularly acute or refractory cases 1
• Continue initial treatments for 6-8 weeks if improvement occurs 1

For Bursitis with Haglund's Deformity:

• Consider corticosteroid injections into the bursa (avoiding the Achilles tendon) 1
• Physical therapy to improve biomechanics 1
• Weight loss if indicated 1

Management of Refractory Cases

If no improvement occurs after 6-8 weeks of conservative treatment:

1. Referral to a podiatric foot and ankle surgeon 1

2. Advanced Immobilization Options:

   • Immobilization cast or fixed-ankle walker-type device 1
   • Short leg casts (SLCs) have been shown to provide better ankle immobilization than low fracture boots during weightbearing 3

3. Surgical Interventions (for specific conditions):

   • For Haglund's deformity: Resection of the prominent posterior superior aspect of the calcaneus and inflamed bursa 1
   • Some patients may require calcaneal osteotomy to correct alignment 1

Red Flags Requiring Further Evaluation

• Persistent pain despite 2-3 weeks of conservative treatment
• Severe pain that doesn't improve with rest
• Night pain or pain at rest
• Symptoms suggesting compartment syndrome (such as in deep posterior compartment syndrome) 4

Follow-up and Monitoring

• Regular follow-up at 2-4 week intervals to assess progress
• If symptoms improve, continue initial treatments until resolution
• If no improvement after 6-8 weeks, consider advanced treatment options or referral

Common Pitfalls to Avoid

1. Misdiagnosis: Failing to differentiate between various causes of posterior leg pain can lead to inappropriate treatment.

2. Premature Return to Activity: Returning to high-impact activities before adequate healing can cause recurrence or worsening of symptoms.

3. Overuse of Corticosteroid Injections: Particularly near the Achilles tendon, which can increase risk of tendon rupture.

4. Neglecting Biomechanical Factors: Addressing only symptoms without correcting underlying biomechanical issues often leads to recurrence.