A 57-year-old woman presented with an insidious onset of heel pain. She has recently taken up walking football. She is also a keen walker (averaging about 60 km per week). She had no significant medical history of note. On examination she was found to have an antalgic gait, was unable to hop and had localised tenderness over the calcaneus. She also had pain with squeezing the calcaneus between the examiners hands.
A lateral x-ray image showed a sagittally orientated sclerotic line running through the posterior calcaneus. A subsequent MRI scanshowed an incomplete band of low signal (on T1 images) disrupting the dorsal cortex of the posterior calcaneus. This fracture line ran from medial to lateral, involving 50% of the width consistent with a bone stress injury.
This woman was successfully treated with a three-month period of rest. She wore a walking boot for the first two weeks (for comfort only). After this she wore a supportive sports shoe and avoided pain-provoking activity. She was able to start a walking programme at three months and was able to return to normal activities 4-5 months after her diagnosis.
Calcaneal stress fractures are the second most common tarsal stress injury (after the navicular). Historically they were associated with marching but they also occur in sport. As with other stress injuries they typically present with an insidious onset of pain aggravated by weight bearing. Examination findings include tenderness over the medial or lateral aspects of the posterior calcaneus and pain with squeezing the heel. X-ray images can often define the injury with the x-ray images in this case being very characteristic of this problem – showing sclerotic changes on a lateral view parallel to the posterior aspect of the calcaneus. MRI is generally used to confirm the diagnosis (or to exclude other causes of heel pain.
In almost all cases this injury resolves with a period of rest. In some situations a short period of non-weight bearing rest may be needed to manage the patient’s pain. Calf and plantar fascia stretching may have a role, as does strengthening of the muscles about the ankle. Foot orthosis may also have a role.
Calcaneal stress fractures are often associated with low bone mineral density. As a result consideration should also be given to obtaining a DEXA scan.
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