Review Question - QID 4625

Based on the clinical findings and imaging shown, one should be suspicious for a calcaneal stress fracture. This can be confirmed by obtaining an MRI.

Calcaneal stress fractures are often associated with increases in training intensity. They may be seen in patients with the female athletic triad. An MRI is used to help delineate the diagnosis when it is not clear from the history and physical exam.

Neufeld et al. review the diagnosis and management of plantar fasciitis. They note that there are many causes of inferior heel pain, including nerve compression, FHL tendinitis and calcaneal stress fractures. The latter commonly presents with diffuse swelling and pain with medial to lateral compression of the heel.

Figure A shows a lateral radiograph of the foot with no obvious osseous abnormality of the calcaneus.

Illustration A shows a T1 weighted sagittal reconstruction of an MRI that is demonstrative of a dark line; this is consistent with a stress fracture.

Incorrect Answers
Answer 1: EMG would be indicated in evaluation for tarsal tunnel syndrome
Answer 2: Heel pad injections are not indicated in the treatment of calcaneal stress fractures
Answer 3: Observation alone is not indicated
Answer 5: A cast can be used for immobilization initially based on history and exam and discussion with patient or after the diagnosis is confirmed with a MRI. However, in this scenario 4-6 months of nonweightbearing is likely excessive.