What is the treatment for a stress fracture on the heel?

Treatment for Stress Fracture on the Heel

The primary treatment for a calcaneal (heel) stress fracture is activity modification with protected weight bearing, combined with topical NSAIDs and early mobilization as tolerated to prevent stiffness. 1

Diagnosis and Assessment

• Imaging: MRI is the gold standard for confirming stress fractures, though initial plain radiographs are recommended as the first imaging test 1, 2
• Clinical signs: Focal tenderness on compression of the calcaneus, pain that worsens with activity and improves with rest 1, 2
• Location assessment: Determine if the fracture is in a high-risk or low-risk zone
  • High-risk: Areas subject to tensile forces or with decreased vascularity 3
  • Low-risk: Areas subject to compressive forces 3

Treatment Protocol

Immediate Management (First 48-72 hours)

• PRICE protocol: Protection, Rest, Ice, Compression, Elevation 4
  • Apply ice for 20 minutes at a time with a thin barrier between ice and skin 4
  • After 48-72 hours, transition to heat therapy 4

Medication

• First-line: Topical NSAIDs with or without menthol gel applied 3-4 times daily directly to the painful area 4
• Second-line: Oral NSAIDs (ibuprofen, naproxen) or acetaminophen 4
• Avoid: Opioids, including tramadol, due to unfavorable risk-benefit ratio 4

Weight Bearing and Activity Modification

• Low-risk stress fractures:

  • Protected weight bearing with supportive footwear or walking boot
  • Activity modification to reduce loading on the injured bone 3
  • Early mobilization with gentle movement as tolerated 4

• High-risk stress fractures:

  • Restricted weight bearing (crutches or walker)
  • Referral to orthopedic specialist for consideration of surgical intervention 3, 5

Supportive Measures

• Specialized cushions or heel pads to reduce pressure on the affected area 4
• Footwear modifications with shock-absorbing insoles 2
• Calcium and vitamin D supplementation if deficient 2

Rehabilitation Protocol

Phase	Timeline	Activities
Early	0-4 weeks	Protected weight bearing, pain control, gentle range of motion
Middle	4-8 weeks	Progressive weight bearing, strengthening exercises
Late	8-14 weeks	Return to activity program, sport-specific training

Monitoring and Follow-up

• Monitor for pain during treatment progression - increased pain suggests overloading and requires temporary reduction in activity 4
• Follow-up imaging (MRI or plain radiographs) to confirm healing before full return to activities

Complications to Watch For

• Chronic pain (affects approximately 20% of patients) 4
• Delayed union or non-union, especially in high-risk fractures 5
• Post-traumatic arthritis 4

Return to Activity

• Gradual return to activities only when:
  • Patient is pain-free with normal daily activities
  • Imaging confirms adequate healing
  • Strength and flexibility have been restored
• Accelerated protocol: Return to activity possible in 13-14 weeks with early mobilization 4
• Traditional protocol: Return to activity in 18-19 weeks 4

Prevention of Recurrence

• Address modifiable risk factors: improve calcium/vitamin D intake, smoking cessation 2
• Gradual increase in activity intensity and duration
• Proper footwear with shock absorption
• Cross-training to reduce repetitive stress

Remember that early intervention is crucial for optimal healing and to prevent progression to a complete fracture or chronic problems.