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.

 

 

Resolved Calcaneal Stress Fracture: Email Advice

Hi Dr. Blake,

Good news - my foot is back in action!  I’ve put it to the test over the summer and all systems are a go.  I’ve been running 100%, gone backpacking, and hiked dozens of miles (including a 17 mile day) without pain!  Thanks for all of your help getting me back in action!

I don’t see a need to meet up again, but am curious about how I should proceed over the long term.  My recovery program was focused on 1) protecting my damaged heel (now recovered), and 2) supporting my high (collapsing?) arches - presumably until they can hold their own.  I’ve got orthotics in all of my athletic shoes, am using cushy HOKA’s or Oofos 90% of the time (in everyday life), and am doing 15 minutes of stretches after all of my runs.  Since I’ve been babying my heel and arches for 2+ years, I’m wondering if I should be conditioning them over time to "toughen them up" and/or get them more used to “unassisted”  or “less-assisted” walking/running.  Questions:

• At what point (if any) should I stop wearing orthotics?  I’ve been rotating shoes and orthotics, sometimes going without (eg. Just walking around) with the thinking that they shouldn’t get too comfortable with one set system.  My hope is that at some point my high arches will be able to “hold their own” without the aid of my heavily-built up supports, but I don’t want to rush it.  Just wondering if I should be taking some sort of gradual approach to ween them off of the super-duper high arch supports that I’m currently using.  

• Are HOKA’s a good choice from here on out?  I have several pairs of different levels of cushiness that I use for all athletic activities.  Is there value in moving back to (or rotating in) non-rocker footwear or shoes that aren’t so cushy?  

Many thanks!

Dr Blake’s Response: Thanks for your feedback and great questions. I reviewed your chart today before answering so everything was clear. You developed a heel stress fracture from pounding at heel strike while running. The goal of each of your mechanical treatments are: cushy shoes for impact shock attenuation, arch supports for weight transfer into the arch and off the heel, and rocker bottom to decrease the pull of plantar fascia that push off on the heel bone. 

     So, theoretically you could now just go “cold turkey” back into traditional shoes with no rocker and no orthotic devices. I love to gradually change stresses since you are doing so well. You may find that you love either the orthotic devices or rocker bottom cushy shoes so running forever, or the orthotic devices while you have the added weight in backpacking. So, as you gradually change the mechanics, each level should be evaluated for any symptoms. 

     If would emphasize, especially for the reader, that orthotic wearers should do single leg balancing for 2 minutes each evening and metatarsal doming once a day (10 repetitions). You can use the search box on this blog to find these videos. This keeps the feet very strong if any weakness is occurring with the orthoses. 

     So, for now I would start and do half of your runs in Hokas and half in traditional shoes. Listen for any symptoms. You could very easily keep this pattern for years to expertly vary stresses. Initially, start with longer runs with Hokas and shorter runs with traditional shoes, but over the next month you will not have to be particular about the distance any more. 

If there are no increase in symptoms, in 2 months start not wearing your orthotic devices on short runs only, and short walks. I would stay this way until 4 months from now (therefore all the highest stress activities have the extra protection of the orthotic devices). If all is going well, the next 2 month interval you could either go without Hokas completely, or without orthotics in all activities but running. In two more months, you could then go with no orthotic devices at all. 

     So, this outlines a gradual 8 month progression into both traditional shoes and away from orthotic devices if that is your goal. If you have some symptoms as you change, we would have to address that if it comes up. Right now you are doing so well with all this protection, but like a cast, we eventually have to cut it off! 

I sure hope this makes sense. Rich 

Calcaneal Stress Fracture: A Cause of Acute Heel Pain

https://youtu.be/8xxbQwogdb8

I love Dr. Nabil Eberheim. He runs a simple straight forward You Tube channel with great medical education. Please review some of my other posts on calcaneal stress fractures, a common cause of acute heel pain. 

https://www.drblakeshealingsole.com/2012/11/calcaneal-heel-bone-stress-fractures.html

https://www.drblakeshealingsole.com/2020/07/how-i-approach-problems-plantar.html

https://www.drblakeshealingsole.com/2020/07/how-i-approach-problems-heel-pain.html

https://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guidelines-11.html

Heel Stress Fracture: But Is It Due To Weight Bearing?

This is the side view of the heel bone on an MRI.

The view is a T2 image highlighting swelling.

The heel bone (calcaneus) should be very dark if normal.

The fracture line with surrounding inflammation is seen at the top of the heel bone.

Here is the same image but T1 which highlights the bone.

The fracture line in the heel bone is very clearly seen.

Again, this fracture did not originate from the impact of the heel on the ground.

Perhaps harder to understand, but this is a cross section through the back of the heel bone.

It is T2 so highlights fluid or inflammation

Again, the inflammation is in the upper half of the heel bone. 

This fracture was not caused by striking the heel to the ground, but perhaps a weak spot in a bone that is weak with osteoporosis.

"How I Approach Problems": Heel Pain, Sudden Onset, Swelling

    This is a new series of blog posts on various injuries entitled "How I Approach Problems". I will be going through common injuries to start and then the areas that prove more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.

With the description of heel pain, sudden onset (you can remember the day), and swelling, you are not dealing with plantar fasciitis, but either a heel bone stress fracture or plantar fascial tear. The post today will look at the calcaneal (heel) stress fracture and the thought process in treatment. 

In the 2 MRIs above, the patient's sudden heel pain with swelling was diagnosed as a calcaneal (heel bone) stress fracture. The xrays taken the week before were completely negative. This case completely resolved with the repeat MRI 6 months later.
     When you talk about any stress fracture, or gross fracture for that matter, you have to ask yourself if the patient deserved the fracture by how they treated their foot. By this I mean, did they seem to overdo or over stress the foot, and seemed to get what they deserved. If your answer is no, then you have to look for other reasons a bone would break like low Vitamin D, low bone density, eating disorders, celiac's disease, history of osteoporosis, etc. Even if they seem to deserve it, over 50 years old, I get a bone density, and ask about family history of osteoporosis, and a personal history of low Vitamin D or funny diets.
     I am going to attach the original video I did on heel pain so you can see the examination of someone pointing to a heel stress fracture. Heel stress fractures are treated very differently than plantar fasciitis as the patient was initially diagnosed due to heel pain. Heel stress fractures need soft cushions, perhaps custom Hannaford orthotic devices, bone density and Vitamin D blood levels, possible bone stimulator, and occasionally they break all the way through and need some surgical pinning. Making the correct diagnosis at the beginning of the process saves alot of time.

https://youtu.be/plbBvPASXwM

Calcaneal Stress Fracture: Last Patient of 2019

     My last official patient of 2019 was the 95 year old mother of a wonderful patient of mine. He brought her into the treatment room in a wheelchair with acute one day pain in her right heel. There was no incident of trauma. She has been struggling with pain in her left knee for a long time and perhaps is favoring her right foot. I went right to an MRI which they were able to get within the hour at our hospital fearing broken bone with this age and history until proven otherwise. Xrays can take weeks show subtle signs of a stress fracture, but the MRI images below (both T1 and T2) dramatically show the stress fracture non-displaced. I will keep her off her foot for the next month and start an Exogen bone stimulator if I can get approval for. Interestingly, her son fractured his heel bone doing ball room dancing 10 years ago in the same place. Genetic do give us weak spots. You can tell by the MRIs that the stress fracture was not due to weight bearing compression forces, but to the pull of the achilles tendon similar to many cases of Severs. Look how strong the achilles looks and the overall bone density seen on T2 throughout the area looks fine and not demineralized like in disuse atrophy. 

On a side note: This is my 2000th Blog Post since my start of blogging in March 2010! No one cares but me, but that will not stop me from raising a glass of champagne or bubbly tonight! Happy New Years. 

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

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

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, 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. 

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. This is totally desvastating to a patient, so avoided when possible. The following are 4 MRIs for the 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.

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 cast. She has done well, but did take longer than normal. 

Same patient above, 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). 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 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 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 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 OTC orthotics are used within the cast 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.
8. The Primary Care Doc should discuss all the factors that effect 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. 

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

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 are similiar.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. 

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. 

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 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. This is definitely for another post.