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Friday, December 21, 2012

Calcaneal Stress Fracture: Email Advice

     Hi. I developed bad heel pain on one of my runs 9 weeks ago. I pulled up sore and limping from that run. I had severe difficulty just walking around. I stopped running and managed to see a sports doctor 2 weeks after the onset of pain and had an ultrasound scan - it was diagnosed as retro calcaneal bursitis and I got a cortisone shot under ultrasound guidance into the bursa. 

The pain decreased significantly after about 2.5 weeks so I tried a little 5 minute pitter-patter but I still felt something was not right in the heel. I went to see the doctor again 2 weeks after the injection for a follow-up and he said to get an MRI done to rule out a calcaneal stress fracture just in case. Unfortunately, the MRI showed that I had a significant high grade calcaneal fracture. The MRI was done 6 weeks after I first developed the pain and I had done absolutely no running during this time (except for 5 minutes to test out the foot after I got the cortisone injection). By the time of the stress-fracture diagnosis (3 weeks ago), I was already walking pain-free, yet the MRI showed that there was a huge crack in my calcaneus!

 I just have a few questions:

1. Is it possible that the cortisone shot is masking the pain from the stress fracture? I am getting rather worried because the break in the bone looks very big on the MRI and yet I'm not feeling any significant pain, and I'm afraid that I am unknowingly putting more stress on the bone with my daily activities.

2. Will the cortisone shot significantly delay the healing of the bone? I did receive the injection directly into the bursa under ultrasound guidance but will the cortisone "leak" out of the bursa and affect recovery of the stress fracture?

Thank you :)
Dr Blake's Response: 

Hey Sarah, thank you for the email.Here are some general guidelines I can give you now based on the information you have given me. First of all, the cortisone shot could only affect the fracture by small amounts getting into the blood stream and giving you some anti-inflammatory effect. It will have no negative impact on the healing of the stress fracture. You probably felt better since you were good to it and the irritation across the fracture line calmed down. 
Calcaneal fractures are delicate beings, and it the risk of breaking into the joint above, I overprotect my patients. I place all my patients in removable boots for 3 months with some off weight bearing padding. We probably reduce the pressure on the heel by 50%. Then 1 month or so is used to wean off of the boot and into a supportive shoe and an orthotic device that can protect the heel and place the pressure at impact on the arch area. I counsel the patient about VitD3 and Calcium, any issues with bone density/diet, get them riding a stationary or road bike as much as possible for conditioning, and have them ice twice daily and contrast bath once daily. A Walk/Run Program can be started around 4 to 6 months based on the extent of the injury. When you walk your body has to absorb 1 to 1.25 times body weight. When you run, your body has to absorb 2-5 times body weight. Sure hope this helps. See my blog post on calcaneal fractures. Rich

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.