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CALCANEAL (HEEL BONE) STRESS FRACTURES
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What is it?

A calcaneal stress fracture is a small break in the heel bone, also known as the calcaneus, due to repetitive activity on the foot. That repetitive activity can cause small amounts of trauma to the bone, and without enough healing time between activities, it can results in microscopic damage that can progress to a stress fracture. This typically happens with overuse or a sudden increase in activity like running. The calcaneus is the second most common location for stress fractures in the foot.

 

Symptoms/Risks

The most common symptom is pain around the heel that becomes worse with activity and weight-bearing. Risk factors include tobacco or alcohol use, eating disorders and sudden increases in intensity or volume of training. Women, military recruits and long-distance runners are at higher risk for stress fractures.

 

Sports Medicine Evaluation & Treatment

A sports medicine physician will assess the patient’s symptoms, level of training and risk factors for this injury. The physician will perform a physical examination to determine the location of the pain. An x-ray is generally obtained, but stress fractures are often not seen until two to three weeks after the onset of pain.

If a stress fracture is not seen on initial x-ray, a repeat x-ray in two weeks or a bone scan or magnetic resonance imaging (MRI) scan may be ordered. If a calcaneal stress fracture is diagnosed, partial weight-bearing or non-weight-bearing with a boot for four to eight weeks is recommended. After that, a gradual return to activity can be guided by pain level. Most stress fractures will heal with conservative management, and surgery is rarely needed.

 

Injury Prevention

Calcaneal stress fractures can be prevented with risk factor reduction, including:

• Healthy diet with calcium and vitamin D,

• Avoidance of tobacco and alcohol use,

• Gradual progression of physical activity.

To prevent recurrence of injury, padded heel inserts and correction of biomechanical abnormalities may be beneficial.

 

Return to Play

Following an individualized plan for partial or non-weightbearing for four to eight weeks, activity can be gradually increased guided by pain level. Nearly all individuals with calcaneal stress fractures will return to normal activity without pain after 12 weeks.

AMSSM Member Authors
Shane Larson, MD and Adriel Dizon, MD

References
Kaeding CC, Yu JR, Wright R, Amendola A, Spindler KP. Management and return to play of stress fractures. Clin J Sport Med. 2005 Nov;15(6):442-7.
Lareau CR, Sawyer GA, Wang JH, DiGiovanni CW. Plantar and medial heel pain: diagnosis and management. J Am Acad Orthop Surg. 2014 Jun;22(6):372-80.
Mayer SW, Joyner PW, Almekinders LC, Parekh SG. Stress fractures of the foot and ankle in athletes. Sports Health. 2014 Nov;6(6):481-91.
Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Am Fam Physician. 2011 Jan 1;83(1):39-46.
Pegrum J, Dixit V, Padhiar N, Nugent I. The pathophysiology, diagnosis, and management of foot stress fractures. Phys Sportsmed. 2014 Nov;42(4):87-99
Robertson GA, Wood AM. Lower limb stress fractures in sport: Optimising their management and outcome. World J Orthop. 2017 Mar 18;8(3):242-255.
Welck MJ, Hayes T, Pastides P, Khan W, Rudge B. Stress fractures of the foot and ankle. Injury. 2017 Aug;48(8):1722-1726.

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