Review Question - QID 4443

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Calcaneus Fractures Imaging MRI QID: 4443 (OBQ12.83)

QID 4443 (Type "4443" in App Search)

A 19-year-old military recruit complains of 7 weeks of right heel pain. He notes the pain is worse with jumping and long distance running. He has completed a course of plantar fascia and Achilles tendon stretching with no significant improvement in his symptoms. He denies constitutional symptoms. On examination, his body mass index is 22, he has a normal foot posture and can perform a single leg heel rise without difficulty. There is no pain with palpation of the lateral border of the foot or with external rotation stress to the midfoot. There is tenderness with medial and lateral compression of the hindfoot and there is a negative syndesmosis squeeze test. There is a negative Tinel's sign at the tibial nerve. Axial and lateral radiographs are shown in Figures A and B. What is the most appropriate next step in management?

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Heel pad cortisone injection

173/5707

Platelet rich plasma injection and 6 weeks of physical therapy

83/5707

Restricted weight bearing and magnetic resonance imaging of the foot

84%

4790/5707

Release of the first branch of the lateral plantar nerve

115/5707

ASTYM or Graston physical therapy techniques to the achilles and plantar fascia

505/5707

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Restricted weight bearing and magnetic resonance imaging of the foot is indicated in this military recruit with a positive heel compression test and suspicion for calcaneal stress fracture.

Calcaneal stress fractures occur as a result of repetitive loading and are more common in females with the female athlete triad (anorexia athletica) of disordered eating, amenorrhea, and osteoporosis. On exam tenderness is obtained with medial and lateral compression of the calcaneus.

Sormaala et al. performed a Level 4 review over 8 years of the Finnish military. They found 34 calcaneal stress fractures with 19 occurring in the posterior part of the calcaneus. Only 15% of the patients had the stress fracture visualized on plain radiography. They conclude that MRI is warranted if plain radiography does not show abnormalities in a physically active patient with exercise-induced pain in the ankle or heel. A nuclear medicine bone scan is also appropriate for diagnosis but MRI may give greater detail.

Gehrmann et al. present a Level 5 review of foot stress fractures. They report that with calcaneal stress fractures the fracture lines are oriented vertically or obliquely in the tuberosity of the calcaneus.

Figures A and B show some sclerosis in the central calcaneus with no evidence of overt fracture and an enthesophyte at the Achilles tendon insertion. Illustration A and B are T2 sagittal and coronal images demonstrating a stress fracture in the superior calcaneal tuberosity with surrounding edema.

Incorrect Answers:
Answer 1: Heel pad cortisone injections are typically avoided due to risk of fat pad atrophy and are not indicated in calcaneal stress fractures.
Answer 2: Platelet rich plasma is not indicated in calcaneal stress fractures.
Answer 4: The patient presents with a negative Tinel's at the tibial nerve and presentation is not consistent with first branch of the lateral plantar nerve entrapment.
Answer 5: ASTYM and Graston physical therapies are not indicated for calcaneal stress fractures.

ILLUSTRATIONS: