Foot and Ankle International - 2026-04-21 - Journal Article
Sports-Related Posterior Ankle Pain: Diagnosis and Management of Lateral Calcaneal Branch Neuropathy of the Sural Nerve (A Case Series).
Chun DI, Cho J, Won SH, Lee SH, Baek SL, Yi Y
Topics
Key Takeaway
In 23 patients with lateral calcaneal branch sural nerve neuropathy, targeted local anesthetic injection confirmed diagnosis and conservative management achieved significant AOFAS-hindfoot score improvement at 1 year, with 6 of 23 (26%) requiring surgical neurolysis.
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Summary
This retrospective case series characterized the clinical presentation and treatment outcomes of lateral calcaneal branch sural nerve (LCBSN) neuropathy in 23 patients with posterolateral ankle pain exacerbated by dorsiflexion or shoe contact. Diagnosis was confirmed by immediate pain relief with targeted local anesthetic block; symptom severity (0–4 scale) and AOFAS-hindfoot scores improved significantly (P<.05) at both 1-month and 1-year follow-up. Six patients (26%) failed conservative management and underwent surgery, with pathology revealing perineural adhesions with arterial wall thickening (n=3), neuroma (n=2), and isolated nerve entrapment (n=1).
Key Limitation
The absence of a control group or blinded outcome assessment introduces significant ascertainment bias, and it is unclear whether AOFAS-hindfoot score improvements exceed the minimal clinically important difference for this patient population.
Original Abstract
BACKGROUND
Posterior ankle pain has varied etiologies, with sural nerve (SN) entrapment contributing to posterolateral ankle discomfort. The SN is a pure sensory nerve that innervates the lateral ankle and foot up to the fifth metatarsal. Although SN pathologies are known, specific clinical features and management of neuropathy affecting the lateral calcaneal branch of the sural nerve (LCBSN), which supplies the lateral heel, are less defined. This condition is often exacerbated by repetitive ankle dorsiflexion in sports or external compression from tight footwear. We hypothesized that LCBSN lesions cause a distinct pattern of heel pain that is uniquely aggravated by ankle dorsiflexion or shoe contact, thereby distinguishing this entity from other causes of posterior ankle pain.
METHODS
This retrospective case series included 23 patients. We reviewed records of 23 patients presenting with posterolateral ankle pain and localized LCBSN tenderness. Key diagnostic features included pain aggravation with ankle dorsiflexion or shoe contact, lacking motor deficits. Diagnosis was primarily confirmed by immediate, significant pain relief after local anesthetic injection around the LCBSN. Symptom severity (0-4 scale) and American Orthopaedic Foot & Ankle Society (AOFAS)-hindfoot scores were assessed at 1 month and 1 year post-treatment. Surgical intervention was performed for recurrent pain after 6 months of conservative management.
RESULTS
Improvement ( P < .05) in both symptoms and AOFAS-hindfoot scores was observed at 1-month and 1-year follow-ups. Six patients required surgical treatment for recurrent symptoms. Pathologic findings included arterial wall thickening with dense perineural adhesions and scarring (3 cases), neuroma formation (2 cases), and nerve entrapment due to adhesions (1 case). Conservative treatment was effective for the remaining patients.
CONCLUSION
Accurate and timely diagnosis of LCBSN lesions is crucial for effective treatment and enabling prompt return to sports activities. A diagnostic, small volume local anesthetic injection may serve as a practical diagnostic adjunct and an initial therapeutic measure for this clinically significant condition.