What is the appropriate workup and management for an 18-year-old male with bilateral heel pain, tenderness, and a positive squeeze test, exacerbated by marching and physical training in basic training?

Management of Bilateral Heel Pain in a Military Recruit

The appropriate management for this 18-year-old male in basic training with bilateral heel pain is to obtain x-rays and remove him from marching and physical training until re-evaluation (option A). 1, 2

Clinical Assessment and Diagnosis

This patient presents with classic signs of a stress-related heel injury:

• 18-year-old male in basic military training
• 6 weeks of intensive marching and physical training
• Bilateral heel pain during activity, pain-free at rest
• Tenderness on heels with positive squeeze test

The positive squeeze test is highly specific (100%) for calcaneal apophysitis or stress injury 3. The bilateral nature and timing of symptoms (6 weeks into basic training) strongly suggest an overuse injury, which is extremely common in military recruits. Military studies indicate that 60-80% of basic training injuries are overuse injuries, with 80-90% occurring in the lower extremities 1.

Recommended Workup

1. Obtain plain radiographs of both heels to:

   • Rule out stress fractures of the calcaneus
   • Assess for other bony abnormalities
   • Establish a baseline for follow-up

2. Remove from marching and physical training until re-evaluation to:

   • Allow for adequate healing
   • Prevent progression to a more severe injury
   • Reduce risk of chronic injury

Rationale for Management Choice

The American College of Foot and Ankle Surgeons guidelines specifically recommend:

• Radiographic studies to confirm diagnosis in traumatic heel pain 1
• Rest and activity modification as first-line treatment for overuse injuries 1, 2

Military studies show that progressive loading and adapted physical training significantly reduce injury incidence (by up to 33%) and attrition rates (by up to 53%) 4. Continuing to march with symptoms risks progression to a more severe injury that could lead to prolonged recovery or medical discharge.

Treatment Plan Following Initial Workup

If radiographs are negative for stress fracture:

• Rest from impact activities for 2-4 weeks
• Ice application to reduce inflammation
• Non-steroidal anti-inflammatory drugs (NSAIDs) for pain control
• Heel cushions or arch supports
• Gradual return to activity with modified training program

If radiographs show stress fracture:

• Immobilization may be necessary
• Longer period of activity restriction
• More gradual return to training

Follow-up Recommendations

• Re-evaluate in 2-4 weeks 2
• If no improvement after 6-8 weeks of treatment, consider:
  • Referral to podiatric foot and ankle surgeon
  • Additional imaging (MRI or bone scan) to detect early stress fractures not visible on initial x-rays
  • More aggressive immobilization with cast or walker boot

Why Other Options Are Not Appropriate

• Option B (MRI): While MRI is more sensitive for early stress injuries, it is not necessary as first-line imaging. X-rays are appropriate initial studies, with MRI reserved for cases that don't respond to initial management 2.

• Option C (Continue marching with analgesics): This approach risks progression to more severe injury. Military studies show that continued activity without adequate rest leads to higher injury rates and attrition 1, 4.

• Option D (Medical discharge): This is premature without attempting conservative management first. Most overuse injuries respond well to appropriate rest and rehabilitation, with approximately 90% of cases resolving with non-surgical management 5.