How to order an X-ray for the heel

How to Order an X-ray for the Heel

Order a standard three-view foot radiograph series consisting of anteroposterior (AP), medial oblique, and lateral projections, with weight-bearing films if the patient can tolerate standing, and add an axial Harris-Beath view specifically for calcaneal evaluation. 1, 2, 3

Standard Ordering Protocol

Essential Views for Heel Imaging

• Request three standard views: anteroposterior (AP), medial oblique, and lateral projections as your baseline imaging series 1, 3
• Add the axial Harris-Beath view specifically when evaluating the calcaneus (heel bone), as this view optimally assesses the posterior foot and subtalar joint anatomy that standard views may miss 1, 2
• Specify weight-bearing films on your requisition if the patient can stand, as these detect dynamic abnormalities like structural changes and alignment issues not visible on non-weight-bearing images 1, 2, 3

Key Ordering Details

• Write "Foot X-ray, three views plus axial Harris-Beath" on your requisition to ensure adequate coverage of the heel and adjacent structures 3
• Specify "weight-bearing" or "standing" unless contraindicated by patient mobility, severe pain, or risk of fracture displacement 2, 3
• Include your clinical indication (e.g., "heel pain," "rule out calcaneal fracture," "plantar fasciitis") to guide the radiologist's interpretation 3

Clinical Context and Rationale

Why Weight-Bearing Matters

• Weight-bearing radiographs provide functional information about how the heel performs under physiologic load, revealing hardware loosening, joint malalignment, or structural abnormalities that disappear when unloaded 2
• Non-weight-bearing films are acceptable alternatives only when patients cannot bear weight due to pain or limited mobility, though they provide less clinically useful information 2
• The combination of thickened plantar fascia and fat pad abnormalities on weight-bearing radiographs has 85% sensitivity and 95% specificity for plantar fasciitis 1

Why the Axial Harris-Beath View Is Critical

• The axial Harris-Beath view is specifically designed for suspected calcaneal fractures and determines intra-articular extent that standard views cannot adequately visualize 1
• This view should be added to the standard three views for optimal evaluation of hardware in the calcaneus and assessment of posterior foot anatomy 2

Common Pitfalls to Avoid

• Don't order only "heel films" or "calcaneus films"—the standard three-view foot series provides better anatomic coverage and context for interpreting heel pathology 3
• Don't skip weight-bearing views unless absolutely necessary, as relying solely on non-weight-bearing films can miss clinically significant displacement, loosening, or alignment issues 2, 3
• Don't forget the axial Harris-Beath view when specifically evaluating the calcaneus, as standard views alone may miss important calcaneal fractures or subtalar joint pathology 1, 2
• Don't rely solely on radiographs if clinical suspicion remains high despite normal films—heel pain conditions like early stress fractures or plantar fasciitis may not show radiographic changes for 10-14 days after symptom onset 3, 4

When Initial Radiographs Are Insufficient

• Consider bilateral comparison films when evaluating subtle alignment or structural changes, particularly helpful in complex midfoot-hindfoot relationships 2, 3
• If radiographs are normal but clinical suspicion remains high, MRI should be ordered next for soft tissue evaluation (plantar fascia, Achilles tendon pathology) 1, 3
• CT should be considered for complex fracture patterns, assessing bone quality, or when plain radiographs are equivocal regarding fracture extent 2