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Friday, November 11, 2022

Swollen Heel Bone: General Thoughts around a Calcaneal Stress Fracture

 Calcaneal (Heel Bone) Stress Fractures: A Cause of Significant Persistent        Heel Pain

                                    By Richard L Blake, DPM


   Heel stress fractures present the same way as plantar fascial tears. They present with swelling, typically an acute onset, and pain level in the 4-6 range or more. However, unlike plantar fascial tears, they may develop slowly probably progressing from a bone bruise, to stress reaction, and finally stress fracture. They do not show up on x ray normally, making an MRI or bone scan typically needed to confirm. Like plantar fascial tears, if this is suspected, and getting test confirmation is difficult to impossible, it is important to treat it as if it was a stress fracture. You do not want a calcaneal stress fracture to develop into a full fracture (typically needing surgery with some permanent disability possible). If you squeeze the heel from both sides, and you (the patient) is very sore compared to the other side, you may have a stress fracture. If you walk on your heels only for 3-4 steps, and you have excruciating pain, you either have a plantar heel bursitis or calcaneal stress fracture.

The top 10 treatments for calcaneal stress fractures:


1. 3 months removable boot and EvenUp on the other side (and many times the heel bone has to be floated for off weighting with 1/2 adhesive felt under the midfoot and forefoot only))

2. 1500 mg calcium and 1000 units Vit-D3 daily 

3. Bone density test if any question on why heel broke (did not make sense?)

4. Vit-D3 level if any question on why heel broke (or if your dietary intake is low, and you do not get much sun exposure without sunscreen). This is especially true when the stress fracture occurs in the winter months)

5. Custom or OTC orthotic device to produce the effect of a soft heel and weight transfer into arch

6. Ice pack 2x/day

7. Contrast bath each evening

8. Activity modification to maintain cardio

9. No NSAIDs like advil or aleve (slows bone healing)

10. Exogen bone stimulator for 9 months (if the diagnosis is confirmed by MRI as x-rays are not great for stress fractures)


    Patient presents with swelling under the heel bone. There is pain produced on side to side compression of the heel bone during physical examination. X-rays normally are inconclusive. The patient does not have to have a story of landing hard on the heel. Onset of pain normally occurs over a short time (acutely), whereas plantar fasciitis (more commonly a cause of heel pain) has a typically gradual onset of the pain, worsening slowly over a month or so. The typical differential diagnosis with significant heel pain with swelling is calcaneal stress fracture or plantar fascial tear, with some arthritic conditions much more rare.

    An MRI is the conclusive test. It is important to note how close the stress lines are to the subtalar joint. The closer to the subtalar joint, the more consideration of non weight bearing 8 weeks of permanent casting (yes, a real cast). This is totally devastating to a patient, so avoid when possible. The following are 4 MRI’s for patients with heel pain, each with different findings.

   This MRI showed the bone swelling above the bottom of the heel bone due to a tear in the plantar fascia. You can see the intense swelling above and below the plantar fascia. This is not the pattern of swelling of a calcaneal stress fracture. A small blood vessel is seen running through the heel bone which can look like a stress fracture. If it was there would have been reactive bone changes around it eliminating that nice tortuous pattern.


    This is a tremendous bone reaction from a calcaneal (heel bone) stress fracture that runs from the bottom to the top of the heel to the subtalar joint. A permanent non weight bearing cast for 4-8 weeks could be easily recommended to protect the joint. This particular patient would have mentally lost it, so I did treat this with a removable walking boot. She has done well, but did take longer than normal.


    Same patient from just above is 3 months into her treatment, still very sore, with still bone swelling within the heel bone. As long as there is bone swelling, there will be pain (like the pain you get from a sinus headache, although you never have to walk with full body weight on your sinuses). I never created a good pain free environment for multiple reasons, so the typical 3 months of immobilization actually lasted 6. She was however able to do intense spin classes and swim without problems during this time.  We consciously as a physician and patient team, traded early function for a potentially longer rehabilitation period.


Normal heel bone with organized blood vessels.


    Once the diagnosis is made, here is a checklist of events that should happen:

  1. Questions should be asked about bone density issues, dietary habits, activity levels leading to overuse, selection of shoe gear, and past history of fractures.

     2.The patient should be fitted for a removable walking boot, unless concern that the  fracture goes too close to the subtalar joint. If the fracture is deemed needing non-weight bearing, a permanent cast is normally used for 4 to 8 weeks. I use a 1/2 inch accommodative pad to float the heel of the walking boot, and tend to use a below the knee cast over a shorter one. An EvenUp is used on the other shoe.    

     3.Over the first 2 weeks post diagnosis, you strive to create a pain free environment. The ease or difficulty in creating this pain free environment is an important clue on how serious the problem is. The average patient needs to be in the removable cast for 3 or more months once the pain free status is attained.

     4. Activity modification is crucial at this time. Bike and swimming are commonly used to maintain cardio, especially if a removable boot is used. Floor exercises for strength and flexibility are recommended. Pilates is a great source of these exercises.

     5.Sole, PowerStep, or PureStride OTC orthotics are used within the cast (and later in the shoe gear) to produce heel padding and weight transfer into the arch.

     6.Contrast baths once or twice daily are vital at reducing heel bone edema (swelling). Swelling within the bone should be minimized since it actually can reduce the normal blood flow important for healing. This can slow healing.

     7. A Bone Stimulator for 6 to 9 months is used. I actually stop 2 months after full activity is resumed. I use Exogen ultrasound for this, but there are other good stimulators. For insurance, since there are no fracture gaps in a calcaneal stress fractures, many will not cover.

     8. The Primary Care Doc should discuss all the factors that affect bone healing including the right amounts of calcium, Vit D3, and other minerals. With bone injuries, I have the patients minimize their use of NSAIDs (like advil, etc).

     9. Monthly return visits can be scheduled for a while to monitor the progress and make changes.

Sole OTC inserts with extra cushion in heel and extra Hapad arch support to transfer weight into the heel.

     10. One month after the diagnosis, the patient is normally casted for custom fitting soft orthotics. I use the Hannaford technique, but most professional orthotic labs have their versions that can/are similar. These are dispensed in 1-4 weeks depending on the need to see that patient (if the pain free environment is established already, waiting 4 weeks to dispense the new orthotic devices is probably fine).

         This shows the memory foam of a Hannaford soft based custom orthotic device.

       11. One month later, normally now 2 months post diagnosis, physical therapy can be started to decrease inflammation and work on the damaging aspects of casting: stiffness, weakness, loss of proprioception (balance), and sometimes nerve hypersensitivity. Physical therapy can be helpful until you are back to full activity, probably 3-6 months. Most of the time physical therapy can be effective at 1-2 times per week.

Patient in physical therapy doing contrast bathing to reduce bone swelling and its resultant pain.

         12. Three months post diagnosis should mean that the patient has been pain-free for almost exactly 3 months with all of the above treatments. If it was tough to get the pain level under control, then this landmark may take much longer. It seems that the patient can successfully wean off the removable boot after being relatively pain free for 3 months, no matter how long that takes. To successfully wean off of the boot means that you can not have more pain out of the boot than in the boot. The removable boot or cast (I use those phrases to mean the same thing) is initially weaned off by keeping it on at work, and gradually adding more time out of the boot at home or doing errands. When you are completely weaned out of the boot for home, gradually spend less time at work. During this time there can be no increase in pain, you should ice 2 or 3 times a day extra (ice pack 15 minutes to the bottom of the heel), and the whole process can take 4 to 6 weeks. During this time always have the boot with you!! You never know when you will need it. Once you are out of the boot full time, you can gradually increase your activity.



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