What is the management approach for a condition affecting the lateral calcaneus?

Management of Lateral Calcaneus Conditions

The management of lateral calcaneus conditions should focus on identifying the specific diagnosis and implementing a stepwise treatment approach, starting with conservative measures before considering surgical intervention. 1

Diagnosis and Assessment

• Key conditions affecting the lateral calcaneus:

  • Bursitis associated with Haglund's deformity
  • Insertional Achilles tendinitis
  • Calcaneal fractures (traumatic or avulsion)
  • Neurologic heel pain

• Physical examination findings:

  • For Haglund's deformity: Tenderness lateral to Achilles tendon with posterior lateral prominence 1
  • For insertional Achilles tendinitis: Prominence medially and laterally to Achilles insertion with central tenderness 1
  • For fractures: Focal pain on palpation in the anatomic area of the fracture 1

• Imaging considerations:

  • Three-view ankle radiographs (anteroposterior, lateral, and mortise views) as first-line imaging 2
  • Standing (weight-bearing) radiographs to detect dynamic abnormalities 2
  • CT scans for complex fracture patterns 2
  • MRI when osteochondral injury is suspected or for persistent pain with negative radiographs 2

Treatment Algorithm

1. Conservative Management (First 6-8 weeks)

For Haglund's Deformity and Bursitis:

• Open-backed shoes to reduce pressure on the area
• Orthoses and accommodative padding
• NSAIDs for pain and inflammation
• Corticosteroid injections (avoiding the Achilles tendon)
• Weight loss if indicated
• Physical therapy 1

For Insertional Achilles Tendinitis:

• Open-backed shoes
• Heel lifts or orthoses
• NSAIDs
• Decreased activity
• Stretching exercises
• Weight loss if indicated
• Note: Local injections of corticosteroids are NOT recommended for insertional Achilles tendinitis 1

For Calcaneal Fractures:

• Non-displaced fractures: Immobilization with removable splint
• Orthopedic referral within 1 week 2
• Displaced fractures: Immediate orthopedic referral for potential surgical management 2

2. Secondary Management (If no improvement after 6-8 weeks)

• Referral to a podiatric foot and ankle surgeon
• Continue initial treatments
• Consider immobilization cast or fixed-ankle walker-type device
• Bursa injection may be considered for Haglund's deformity 1

3. Advanced Management (If no improvement after 2-3 months)

• Surgical options:
  • For Haglund's deformity: Resection of the prominent posterior superior aspect of the calcaneus and inflamed bursa
  • Some patients may require calcaneal osteotomy to correct calcaneal alignment 1
  • For calcaneal fractures: Internal fixation with locking plates may be considered 3

Special Considerations

• Early weight-bearing: Recent evidence suggests that early weight-bearing (starting at 6 weeks) after surgical fixation of calcaneal fractures with locking plates does not have unfavorable effects on outcomes 3, 4

• Associated injuries: Be vigilant for concomitant injuries, especially with traumatic calcaneal fractures:

  • Vertebral fractures (particularly lumbar spine) occur in approximately 7% of calcaneal fractures 5
  • Other potential associated injuries include ankle fractures (22.5%), metatarsal fractures (25.8%), and midfoot fractures (17.7%) 6

• Avulsion fractures: These occur in reproducible locations due to the specific attachment points of stabilizing ligaments and the Achilles tendon 7

Follow-up Recommendations

• Clinical and radiographic follow-up at 2 weeks and 4-6 weeks to ensure maintained alignment and assess healing 2

• Red flags warranting closer monitoring:

  • No improvement after 6 weeks of conservative treatment
  • Signs of delayed union or non-union
  • Persistent pain despite appropriate treatment 2

• Prevention strategies:

  • Appropriate footwear
  • Address biomechanical abnormalities with orthoses
  • Regular muscle stretching
  • Weight loss if indicated 2

Common Pitfalls to Avoid

1. Misdiagnosis: Lateral calcaneal pain can have multiple etiologies; ensure proper diagnosis before treatment

2. Corticosteroid injections: Avoid in insertional Achilles tendinitis as they may weaken the tendon and increase rupture risk 1

3. Overlooking associated injuries: Particularly spinal fractures in traumatic calcaneal fractures 5

4. Prolonged immobilization: Can lead to deconditioning and delayed recovery; consider early mobilization when appropriate 2