A stress fracture of the calcaneus are a common overuse injury in military recruits and is the second most common stress fracture in the foot. Considered a low risk stress fracture as it typically responds to conservative care and very unlikely to have any long term complications. The stress fracture could be in any part of the calcaneus, but most common posteriorly.
Risk Factors:
Military; runner; relative energy deficiency; nutritional issues; sudden changes in activity levels and type; steroid use; heel fat pad atrophy; overweight
Has been reported in older people following joint replacements. The risk here is possibly related to osteoporosis; a change in gait from the arthroplasty and increased activity levels after the surgery.
Mechanism:
Not clear if its the tension from pull of Achilles tendon on the bone (increased shear stress) and/or the repetitive stress from ground reaction forces when heel striking.
There were numerous anecdotal reports during the barefoot running fad of 2009-2013 of barefoot runners who did not heel strike getting calcaneal stress fractures, perhaps suggesting that it might not be impact related.
Clinical Features:
Usually start to appear 1-3 weeks after changes in activity levels or type. The pain is worse with activity
Moist common site is posterior calcaneal pain, near the Achilles insertion and sometimes more plantarly near the insertion of the plantar fascia – pain is usually worse laterally; but can affect the middle of the calcaneus body and the anterior part of the calcaneus.
Typically there is exquisite point tenderness on palpation.
Positive calcaneal squeeze test
Some are painful on calf stretching, but this may depend on the location of the stress fracture in the calcaneus.
Imaging:
Plain radiograph: changes may lag behind symptoms by up to 2-4 weeks; seen as a subtle sclerotic line perpendicular to trabecular stress lines.
MRI: good sensitivity and specificity
CT:
Sonography: may see thickening of the periosteum and subcutaneous edema
Bone scintigraphy: positive within 72 hours
Based on MRI, Labronici et al (2021) classified calcaneus stress fractures as:
Low-grade:
– Grade I: when associated with periosteal edema
– Grade II: endosteal edema
– Grade III: muscle edema
High-grade:
– Grade IV: visible fracture line on MRI
Of their 9 cases, 6 were in the posterior calcaneus; 2 in the middle and 1 in the anterior calcaneus.
Two were low grade and 7 high grade.
Differential diagnosis: plantar fasciitis (will have post static dyskinesia); insertional Achilles tendonopathy (will have morning stiffness); retrocalcaneal bursitis (Haglund’s deformity, Bauer Bump); Baxter’s neuritis; calcaneal apophysitis (Sever’s disease, in younger population); rheumatological conditions.
Management:
Activity modification and restricted activity to tolerance with a gradual resumption.
Short period of no weightbearing or boot immobilization if pain level high initially.
Physical therapy and muscle rehabilitation if had a longer period of immobilization.
Probably will need up to 2-3 months following resolution of symptoms to reintroduce previous activity levels or there may be a high risk for recurrence.
Deep water running or other non-weighting aerobic activities may be used when weightbearing still needs to be limited.
Anti-gravity treadmill in early stages of return to sport may be useful.
Cushioned heel pad
May need vitamin d and calcium supplements.
Commentary:
- Many of the standard sports medicine text books state that stress fractures of the calcaneus are due to the ground reaction forces from heel striking, which is clearly not definitively the case.
External Link:
Calcaneal stress fractures in minimalist/barefoot runners (Podiatry Arena)
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