A calcaneal stress fracture is one of those injuries that appears out of nowhere- no sexy downward fall, no dramatic event, simply heel pain that refuses to go away. As the weight bearing bone in the body, the calcaneus is subjected to tremendous loading during gait, yet it remains paradoxically at risk for a repetitive stress injury. Those who have increased their activity suddenly or escalate their activity levels with abrupt and excessive training are at risk for a stress fracture of the heel.
Recognizing this injury, establishing an accurate diagnosis, and instituting a proper recovery plan are critical to determining how quickly you make take to the field again. The following will walk you through all you need to know about calcaneal stress fracture management and recovery.
How Calcaneal Stress Fractures Occur
Under normal physiologic conditions, bone is not a static tissue- it is constantly in a state of flux as old tissue is replaced by new tissue. When repetitive loads-induced forces become greater than the body’s ultimate capacity to repair this tissue, a meandering healing process ensues where tiny cracks (micro-fractures) in the calcaneus occur which may or may not progress if the bone is not given a chance to rest.
Why Overuse Leads to Calcaneal Stress Fracture Development
Disrupting the balance of new bone formation and bone resorption (whether through overtraining or learning to run on a hard surface) is the foundation for the development of a stress fracture.
Since the hallmark of remodeling is the process of anterior and posterior displacement of cells, disrupting this delicate balance can simply render a bone more prone to injury. Overtraining in athletes is perhaps the best known example of the phenomenon. Studies analyzing the incidence of stress fractures in military recruits during basic training show rates as high as 5% in men, and even higher in females with longer training periods.
Equally distressing findings exist for the distance runner-athlete who ignores the early warning signs (a young fracture) of this injury by pushing through initial pain and presenting with a fully displaced healed stress fracture.
Other factors contributing to fracture development in those who are otherwise healthy include: low bone mineral density from osteoporosis, women triad syndrome, nutritional deficiencies, or low intakes of vitamin D or calcium, and biomechanical abnormalities, inadequate biomechanical control secondary to worn out footwear, hard terrain, and excessive or abrupt changes in training surfaces.
Recognizing Calcaneal Stress Fracture Symptoms and Diagnosis
Heel pain is common and common in the general population. The time is long gone were the days when a stress fracture was assumed for any case of heel pain. Several other causes (plantar fasciitis, Achilles tendinopathy, retro-calcaneal bursitis) mimic the diffuse aching pain associated with a stress fracture of the calcaneus, which should preclude self-diagnosis.
How the Pain Manifests
Pain from a calcaneal stress fracture over time is usually more insidious than sudden.
Generally complains of dull ache to deep soreness in the heel which intensifies with weight bearing activity and subsides with rest, at least initially, and evolves into persistent pain during walking and morning pain. Examination may reveal localized swelling and tenderness along the lateral tubero-heelesic process; isolated tenderness to palpation along the superior surface of the heel callus should be considered negative. The classic “squeeze” test, in which a clinician compresses the calcaneus on either side of the heel in the transverse plane, is often positive among those individuals with a fracture.
Imaging studies are notoriously prone to underestimation -X-rays frequently do not reveal trabecular or cortico-trabecular fractures during the early recognizable phases of injury, bone scans reveal only increases in uptake, and magnetic resonance imaging provides the earliest visualization of fracture line and peri-micro-fracture edematous changes. Diagnosis matters -failure to institute relative rest in the face of an identified injury, and to pursue different treatment strategies for an identified stress fracture versus heel pain can result in a displaced complete fracture, nonunion or misunion requiring surgery.
Treatment, Recovery, and Getting Back on Your Feet
The vast majority of calcaneal stress fractures resolve with conservative management, but don’t kid yourself: patients who are motivated to ramp up activity too soon will derail an otherwise achievable outcome.
Conservative Management… Exercise Modification
The mainstay of treatment of a calcaneal stress fracture is alteration of activity to eliminate weight bearing on the affected side. Physicians utilize crutches, walking boots or complete non-weightbearing 4-8 weeks. as needed; ice and aspirin- placebo or not- has been used to reduce swelling, but some practitioners advocate limiting use of non-steroidal anti-inflammatories due to the effects on bone strength in the injured location.
Maintaining cardiovascular fitness without subjecting the heel to stress “cross training” in the pool or on a stationary cycle has proven invaluable in this regard. Factors contributing to the issue other than activity level must be addressed, particularly adequacy of vitamin D and calcium supplements in the face of lowered bone density (and should be administered accordingly) and the condition of the footwear (I.e. Too old, or the use of pronation correction orthotics).
Returning to Play… Patient Patience
There is substantial literature on the frequency and severity of complications resulting from athletes who rush through a stress fracture too quickly.
Structured return to activity protocols are thus instituted to prevent the development of a displaced fracture requiring operative stabilization. Cross-training by way of embrocation, still water running, and cycling may be suggested; pains should be reinforced -any signs of return with pain must be dealt with accordingly. Reassessing footwear, using orthotics, or appointing instructions for subsequent training advancements reduce the ongoing risk of recurrence.
Full return to normal activity levels takes on average 3-6 months.