Pain Generators in Calcaneal Malunion: Evaluation of a Case Series With Mixed Treatment

Introduction Chronic heel pain secondary to malunited fractures of the calcaneus can be quite disabling in nature. The etiology of pain depends upon the modality of primary treatment (i.e., operative or nonoperative), as well as the quality of articular reduction. While a number of probable causes have been identified, none of these pain generators have been adequately researched. Methods A total of 32 patients were prospectively evaluated. All had residual heel pain following calcaneal fracture and were divided into two groups (operated and non-operated) based on their primary treatment. The cause of heel pain was identified based on clinical examination findings as well as radiological results. Functional parameters used to objectify pain and disability were the Visual Analogue Scale and the American Orthopaedic Foot & Ankle Society hindfoot scores. Results There were 10 feet in the operated group and 22 in the non-operated group. The most common cause of residual heel pain in the operated group was pain due to prominent hardware. In sharp contrast, subtalar arthritis and peroneal tendon impingement secondary to calcaneal malunion were primarily seen in patients managed conservatively. Calcaneal fractures managed with anatomical reduction and fixation had better functional scores than those treated conservatively. Of the radiological parameters, Böhler angle and talocalcaneal height were significantly associated with the patients' disability scores. Conclusions The traditional view among orthopedic surgeons that chronic pain in the sequelae of old intra-articular calcaneal fractures is secondary to subtalar arthritis only is incorrect. Patients undergoing fixation may have pain due to prominent hardware. All causes must be thoroughly assessed, as more than one may coexist.