Management of Lateral Calcaneus Conditions

Diagnosis and Treatment Approach

• The American Academy of Family Physicians recommends a stepwise treatment approach for lateral calcaneus conditions, starting with conservative measures before considering surgical intervention 1
• Delayed physical examination (4-5 days post-injury) optimizes sensitivity (84%) and specificity (96%) for ligament injuries, as recommended by the British Journal of Sports Medicine guidelines 2
• The Ottawa Ankle Rules can be applied to determine the need for imaging, which includes radiographs indicated if there is pain in the malleolar zone and bone tenderness at the posterior edge or tip of either malleolus, or inability to bear weight both immediately and in the emergency department, as recommended by the American College of Radiology 3

Imaging and Diagnostic Procedures

• First-line imaging for ankle fractures includes three-view ankle radiographs (anteroposterior, lateral, and mortise views), as recommended by the American College of Radiology 3
• CT scans are recommended for complex fracture patterns, posterior malleolar fractures, or when radiographs are inconclusive, according to the American College of Radiology 3
• MRI is recommended when osteochondral injury is suspected or for persistent pain with negative radiographs, as suggested by the American College of Radiology 4
• Stress views may be needed to assess syndesmotic injuries or instability, as recommended by the American College of Radiology 3
• Standing (weight-bearing) radiographs, including anteroposterior (AP), medial oblique, and lateral projections, are preferred to detect dynamic abnormalities, as recommended by the American Academy of Orthopaedic Surgeons 5

Treatment Options for Specific Conditions

• For Haglund's deformity and bursitis, the American Academy of Family Physicians recommends open-backed shoes, orthoses, and accommodative padding to reduce pressure on the area, as well as NSAIDs for pain and inflammation, and corticosteroid injections (avoiding the Achilles tendon) 1
• For insertional Achilles tendinitis, the American Academy of Family Physicians recommends open-backed shoes, heel lifts or orthoses, NSAIDs, decreased activity, stretching exercises, and weight loss if indicated, and notes that local injections of corticosteroids are not recommended 1
• Surgical management with resection of the prominent posterior superior aspect of the calcaneus and inflamed bursa is recommended for Haglund's deformity, and some patients may require calcaneal osteotomy to correct calcaneal alignment 1

Pain Management and Rehabilitation

• Multimodal analgesia, including NSAIDs as first-line treatment, acetaminophen, and consideration of peripheral nerve blocks for severe pain, is recommended for pain control, according to the World Journal of Emergency Surgery 6
• A multimodal pain control approach, including acetaminophen, NSAIDs, and opioids for breakthrough pain, is recommended for orthopedic procedures, according to the PROSPECT guidelines 7
• Early exercise therapy is preferred to recover joint functionality, as recommended by the British Journal of Sports Medicine 2
• Functional support (brace or tape) can be used based on patient preference, and allows for functional treatment approach recommended for ankle sprains, as suggested by the British Journal of Sports Medicine 2
• The following rehabilitation protocols are recommended:

Follow-up and Prevention

• Clinical and radiographic follow-up at 2 weeks and 4-6 weeks is necessary to ensure maintained alignment and assess healing, with monitoring for complications such as delayed union or non-union, post-traumatic arthritis, and persistent pain or instability 5
• No improvement after 6 weeks of conservative treatment, signs of delayed union or non-union, persistent pain despite appropriate treatment, and patients with complicating factors should be monitored closely, as recommended by the American Academy of Family Physicians 1
• Gradual increase in activity intensity and duration, appropriate footwear, cross-training to reduce repetitive stress, and addressing biomechanical abnormalities with orthoses can help prevent future stress fractures, as suggested by the American Academy of Family Physicians 1
• Regular muscle stretching and weight loss if indicated can also be beneficial, as suggested by the American Academy of Family Physicians 1