When should a repeat X-ray be done for right heel pain after a fall 1 week ago with a negative initial X-ray?

Repeat X-ray Timing for Heel Pain After Fall

For heel pain persisting 1 week after a fall with negative initial radiographs, repeat X-rays should be obtained at 10-14 days post-injury if symptoms persist, or proceed directly to MRI without IV contrast for definitive diagnosis of occult fracture. 1

Clinical Context and Imaging Strategy

The heel (calcaneus) is a common site for occult fractures that may not be visible on initial radiographs, particularly stress fractures and nondisplaced fractures. 1 At 1 week post-injury with persistent pain, you are at a critical decision point where the sensitivity of repeat radiographs increases compared to initial imaging. 1

Recommended Approach

If symptoms are persistent or worsening:

• Repeat radiographs at 10-14 days post-injury show increased sensitivity compared to initial films due to bone resorption at fracture margins and early callus formation making fractures more visible. 1
• However, MRI without IV contrast is superior and should be considered as the next imaging study after initial negative radiographs to prevent delayed diagnosis, as it has excellent sensitivity for occult fractures and allows definitive diagnosis. 1

Key decision factors:

• Severity of pain and functional limitation: If the patient cannot bear weight or has severe pain limiting activities, proceed directly to MRI rather than waiting for repeat radiographs. 1
• Clinical suspicion for fracture: High clinical suspicion (point tenderness over calcaneus, inability to bear weight, significant mechanism) warrants more aggressive imaging. 2
• Risk factors: Obesity, osteoporosis, or bisphosphonate therapy increase risk of fracture and may warrant earlier advanced imaging. 1

Alternative Imaging Modalities

MRI without IV contrast is the preferred advanced imaging modality because:

• It is beneficial after initial negative radiographs to prevent delayed diagnosis. 1
• It has excellent sensitivity for stress fractures, bone contusions, and soft tissue injuries. 1
• It can identify associated complications such as osteonecrosis or delayed healing. 1

CT without IV contrast may be considered if:

• MRI is contraindicated or unavailable. 1
• There is concern for articular surface involvement or need for surgical planning. 1

Ultrasound has limited utility for calcaneal fractures as it does not adequately evaluate subchondral bone, though it can detect cortical irregularities in some cases. 1

Common Pitfalls to Avoid

• Delaying diagnosis of occult fractures: Subchondral insufficiency fractures are typically radiographically occult until collapse or flattening occurs, at which point morbidity is significantly increased. 1 Waiting too long for repeat radiographs may delay appropriate treatment.

• Missing alternative diagnoses: Persistent heel pain may be due to plantar fasciitis, Achilles tendinopathy, calcaneal stress fracture, or Baxter's neuropathy rather than acute fracture. 1, 3 MRI can evaluate all these conditions simultaneously.

• Inadequate clinical reassessment: If initial evaluation is negative and symptoms persist or worsen, follow-up clinical reassessment is necessary before deciding on imaging strategy. 1

• Ignoring red flags: Severe pain out of proportion to examination, inability to bear weight, or systemic symptoms may indicate more serious pathology requiring urgent advanced imaging. 4

Practical Algorithm

1. At 1 week post-injury with persistent pain: Perform thorough clinical reassessment including point tenderness, weight-bearing ability, and mechanism of injury. 2

2. If high clinical suspicion or severe symptoms: Proceed directly to MRI without IV contrast for definitive diagnosis. 1

3. If moderate suspicion with improving symptoms: Consider repeat radiographs at 10-14 days post-injury. 1

4. If repeat radiographs remain negative but pain persists: Obtain MRI without IV contrast to exclude occult fracture and evaluate alternative diagnoses. 1