What is the treatment for stress fractures in the heel?

Treatment for Stress Fractures in the Heel

The primary treatment for stress fractures in the heel consists of protected weight-bearing with a removable walking boot or cast for 4-6 weeks, followed by gradual return to activity as pain allows. 1

Diagnosis and Assessment

• Initial evaluation:

  • Suspect stress fracture with focal tenderness on compression of the calcaneus, particularly at the lateral wall slightly posterior to the facet 1
  • Pain may be present before radiographic evidence appears
  • Swelling and warmth may be present in the affected area

• Imaging:

  • Plain radiographs should be obtained first, though they may initially be negative 1, 2
  • If negative but clinical suspicion is high, repeat radiographs after 2-3 weeks 2
  • For urgent diagnosis, MRI or bone scintigraphy is recommended 2
    • Both have similar sensitivity, but MRI offers greater specificity 2

Treatment Protocol

Conservative Management (First-Line)

1. Activity Modification:

   • Protected weight-bearing with CAM boot or removable walking boot 1, 3
   • Use of non-weight-bearing crutches if needed for pain relief 2
   • Avoid barefoot walking and flat shoes 1

2. Immobilization:

   • 4-6 weeks in a removable walking boot or cast 3
   • Diabetic patients may require non-removable knee-high devices 3

3. Pain Management:

   • NSAIDs for pain control 1, 3
   • Topical NSAIDs with or without menthol gel as first-line treatment 3
   • Acetaminophen as an alternative 3
   • Avoid opioids due to potential risks 3

4. Supportive Measures:

   • Heel cushions and arch supports 1
   • Regular calf-muscle stretching 1
   • Weight loss if indicated 1
   • Pneumatic bracing to facilitate healing 2

Rehabilitation Phase

• Begin early gentle movement as tolerated to prevent stiffness 3
• Gradually increase activity level once pain resolves and examination shows improvement 2
• Follow-up at 2 weeks and 4-6 weeks to ensure proper alignment and healing 3

Special Considerations

• High-risk vs. Low-risk:

  • Calcaneal stress fractures are generally considered low-risk 4
  • Monitor for signs of delayed union or non-union 3

• Return to Activity Timeline:

  • Traditional protocol: Full return to activity in 18-19 weeks 3
  • Accelerated protocol: Full return to activity in 13-14 weeks with early mobilization 3

When to Refer to a Specialist

• No improvement after 6 weeks of conservative treatment 1
• Signs of delayed union or non-union 3
• Persistent pain despite appropriate treatment 3
• Patients with complicating factors (diabetes, osteoporosis) 1, 3

Complications to Monitor

• Approximately 20% of patients may experience chronic pain 3
• Other potential complications include:
  • Delayed union or non-union
  • Post-traumatic arthritis
  • Persistent pain or instability 3

Prevention Strategies

• Gradual increase in activity intensity and duration
• Appropriate footwear
• Cross-training to reduce repetitive stress
• Addressing biomechanical abnormalities with orthoses 1

While most calcaneal stress fractures respond well to conservative treatment, it's crucial to monitor healing progress and adjust the treatment plan if symptoms persist beyond the expected timeframe.