Heel pain is common in runners. While plantar fasciitis is the most frequent cause of heel pain in runners, a calcaneal stress fracture can also occur. How can we detect a calcaneus stress fracture, and how do we manage them?
What is the calcaneus?
The calcaneus is commonly known as the heel bone. The large Achilles tendon from the top and plantar fascia from the front are attached to the calcaneus. It provides stability, cushioning, and support for the foot. A stress fracture in the heel affects the calcaneus.
What causes a calcaneal stress fracture?
Usually, too much activity leads to tiny microtrauma in the calcaneal bone resulting in a break or fracture. This injury is different from a high-velocity fracture from a fall.
Generally, sportspeople or endurance runners are the most at risk of a stress fracture of the calcaneus. Some medical issues such as osteoporosis (weakening of bones) or vitamin D deficiency can increase the risk.
Heel stress fracture symptoms
First and foremost, a stress fracture in the calcaneus causes pain in the heel. Usually, the pain occurs with activities such as walking or running. In addition, people report swelling in the heel and limping or difficulty walking. Therefore, it is essential to differentiate a stress fracture of the heel from other causes of heel pain such as plantar fasciitis, Achilles tendonitis, or subtalar joint swelling.
Your doctor will examine you to confirm this diagnosis and rule out other causes. Often, squeezing the calcaneal bone with two fingers is tender – called the heel stress fracture test. Also, repeated hopping or jumping on one leg brings on the pain. In addition, examination of other structures such as Achilles or plantar fascia is often normal.
If the fracture is early, then an X-ray may be normal. Usually, we suggest an MRI scan showing swelling and a fracture of the calcaneus.
Heel stress fracture vs. plantar fasciitis
Overall, plantar fascia pain is different from calcaneal stress fracture pain.
Generally, plantar fascia pain is worse in the morning and warms up with activity. Tenderness is under the heel rather than the sides of the calcaneus.
However, it might be challenging to differentiate between these two conditions in the early stages.
Treatment
Generally, calcaneal stress fractures heal with rest from activity and sport. However, if the pain is severe, wearing a boot for six weeks will protect the heel until the calcaneus is strong enough. Crutches to reduce pressure on the bone in the first few weeks is also helpful. Once the acute pain has settled, wearing a good pair of cushioned, well-supported shoes to support walking is essential. Often cross-training such as swimming and cycling is allowed while the bone heals.
Return to running or sport after a stress fracture of the heel is very gradual. Initially, we recommend a walk/run program, making sure your activity does not reproduce pain. Physiotherapy is essential in recovery to build leg strength and robustness.
Finally, further investigations might be needed to rule out weak bones or vitamin deficiencies. Examples include blood tests to check your bone profile and vit D level and a DEXA scan for osteoporosis. Some people have osteoporosis, which increases the risk of further fractures and may slow healing time.
Calcaneal stress fracture recovery time
We underestimate the time needed for calcaneal stress to return to running. Generally, we suggest six weeks in a boot followed by six weeks of a slow and progressive return to walking and then running. However, returning to full fitness after a heel stress fracture may take six months.
Is shockwave a possible treatment for a calcaneal stress fracture?
Yes. Recent evidence suggests that a type of shockwave called focused shockwave may help with bony healing in stress fractures. Generally, we recommend 3-5 sessions of high-energy-focused shockwave therapy in addition to other treatments. Sometimes, additional shockwave therapy is performed when returning to running or sport.
Final word from Sportdoctorlondon about a calcaneal stress fracture
Often, calcaneal stress fractures can creep up on you as pain can be mistaken for plantar fasciitis. Generally, a normal ultrasound of the Achilles tendon and plantar fascia increases the suspicion of another cause, one of which is a calcaneal stress fracture. Most people must rest in a walking boot for at least six weeks.
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