award png

Musculoskeletal clinical topic of the month – Calcaneal stress injury

Traumatic calcaneal fractures are often associated with high-velocity impact injury to the heel, with mechanisms such as falling from a height or road traffic accidents. Stress fractures of the heel often present much more insidiously and are not always as clinically obvious.

Biomechanics and force transmission through the Calcaneum

The calcaneus is well designed to sustain high tensile, shearing, and compressive forces. It possesses a thin shell of cortical bone that encloses a highly organised array of trabecular bone. The relatively sparse cancellous bone within the calcaneus leaves space that is filled by blood. This high fluid content helps the calcaneus to function as a hydrodynamic shock absorber during impact.

The calcaneal bone itself is able to dissipate force travelling from the talus downwards, but also the ground contact upwards (see image below). This creates compression and tensile forces across the joint, akin to that of those in the in hip, which can further be split into primary and secondary forces. In addition, there is also a traction force coming from the achilles tendon to the posterior aspect of the heel. 

The complicated crossroad of force distribution makes the prediction and classification of calcaneal stress fractures difficult. 

Calcaneal Stress Fracture Musculoskeletal clinical topic of the month – Calcaneal stress injury
Left image. Load transfer pattern of calcaneus: Body weight (BW), primary compression lines (PC), secondary compression lines (SC), primary tensile lines (PT), secondary tensile lines (ST), Achilles tendon lines (AT) (Adapted from Elsevier, Drake et al., 2015).
Right image. Comparison load transfer pattern of proximal femur. 

Case Presentation

Clinical history;

  • 47 year old male ultrarunner
  • 7-8 month peroid away from running due to midportion right achilles tendinitis
  • Completed a tendon loading programme and resummed running over a peroid of 2 months with gradual increases of milage 
  • Worked from no running to 40-50 miles a week within 2 months of return
  • 10 miles into a run, felt “something go” in left ankle, however continued to run further 10 miles 
  • Unable to weight bear fully on left ankle thereafter with only mild ankle swelling
  • Went to A+E next day, where x-ray of ankle was reported normal (heel not imaged), diagnosed ankle sprain and sent home with RICE advice
  • Presented to LBSM clinic 1 week after injury still unable to fully weight bear due to pain 

Past Medical history;

  • BMI 28
  • Non-smoker
  • No history of previous stress injury
  • Previously good health apart from achilles tendinitis

Exercise history;

  • Ultrarunner
  • Running load in fitness usually 50-60km a week
  • Good variation of training, but more road running since lockdown
  • Good SnC routine

Social history;

  • Acturary 
  • Lives in Bermondsey and runs through central london

Clinical examination;

  • Good range of painfree movement in talo-crual joint and subtalar joints and midfoot
  • No swelling around ankle joint or lateral gutter
  • Tender around posterior talus with “puffiness” in posterior ankle and Kaegers fatpad
  • Traditional heel squeeze test did not reproduce symptoms
  • Posterior imingment signs negative

Point of Care Ultrasound – Left ankle

No effusion in the talo-crual joint. Normal lateral and medial ligaments. No tear in achilles tendon and no signs of retrocalcaneal bursitis. No obvious posterior ankle impingement on dynamic testing. 

Clincial suspicions, differentials and reasoning;

  1. Stress fracture in left talus or calcaneus. Most likely due to length peroid of deloading from the contralateral achilles tendinitis and the fast resumption in returning to high running volumes. All runs were steady state, on pavement and without much variation of training. Heel squeeze test at the posterior heel however was negative. 
  2. Insertional achilles tendinopathy/tear on left side. Possible, as had marked tendinopathic changes on the right side. Was doing all loading programmes bilaterally which should have mitigated this, but could have experienced an acute tear in distal achilles during the run. Was not visible on ultrasound so this differential diagnosis was excluded.
  3. Acute retrocalcaneal bursitis. This can present in runners with acute posterior ankle pain and be very painful. No other risk factors for retrocalcaneal bursitis e.g. obesity, metabolic disease. Was not visible on ultrasound so this differential diagnosis was excluded.
  4. Posterior impingement of the ankle. Unlikely, as patient not getting into extreme or forced plantar flexion positions (e.g dancers, gymanst). No obviously posterior impingement on Ultrasound but require MRI to fully visualise posterior talus and os trigone.

Imaging

MRI T2 weighted showed a superior border calcaneal stress fracture with surrounding bone oedema. 

stress fracture Musculoskeletal clinical topic of the month – Calcaneal stress injury

Diagnosis

Calcaneal stress fracture due to repetitive overloading from rapid return to running post achilles tendinitis on contralateral side.

Management

Rehabilitation

  • First 8 weeks  
    • Aircast boot for immobilisation
    • Limited steps to 2000 day outdoors (with boot)
    • Asked to wear soft slippers or padded trainers indoors
    • Gentle prioceptive exercises and banded exercise for muscle activation
  • 8-12 weeks
    • CT scan to confirm full bony union of fracture and stability across fracture site
    • Reintroduction of strength and condition, weight lifting and calf raises
  • 12 weeks+
    • Gradual return to impact training and pylometric exercises 
    • Walk to run programme
    • Strict running periodised programme to ensure patient is protected from repeat stress injury (e.g. non-consectutive day running)  
    • Biomechanical analysis reveals patient is a “heavy heel striker”
    • Foot wear, orthotics and running style adapted to move ground reaction force away from heel

Medical

  • Calorie and nutritional intake optimised to help fracture healing
  • Interval CT scan at 8 weeks to ensure full union of fracture

Patient Self-monitoring tools

  • LBSM pain and symptom diary
  • LBSM load monitoring diary

Alternative patterns of calneal stress fractures

There are several orthopaedic classifications for traumatic stress fractures including the Sander Classifiction and Essex-Lopresti. There is currently no classification system or studies looking specifically at calcaneum stress fracture patterns.

Most calcaneal fractures will occur due to excessive axial compressive loading and therefore fall along the primary compression lines (red lines in diagram above). However, excessive traction from the achilles tendon injury can also produce stress on the calcaneal (yellow lines in diagram above). This may also lead to potential fracture, particularly in more pylometric based sports. The MRI images below show an achilles based stress fracture in a young jumper. 

Calcaneal Stress Fracture Imaging Musculoskeletal clinical topic of the month – Calcaneal stress injury

Key Summary and learning points – Calcaneal Stress Fractures

  • Calcaneal Stress Fractures should be considered in patients with heel pain participating in lower body impact sports such as running
  • They can be vague in their presentation and may be confused with ankle sprains, achilles tendinitis and plantar fascitis
  • There may be an associated history of low energy availbility or poor bone health
  • There is a varying distribution of calcaneal stress fractures, but they are more common along the primary compression force lines and around the achilles anchor
  • Superior border calcaneal stress fractures may not be positive on squeeze testing
  • No current classification system for calcaneal stress fractures
  • Intra-articular calcaneal fractures are common in traumatic fractures but not for stress fractures
  • If there is an intra-aricular compenent, surgical opinion should be sought for fixation
  • Biomechanical and Medical causes must be investigated to uncover all possible aetiological factors
  • When rehabilitating patients after a peroid of absence from training, remember that bone will have been deloaded and may have lost some density. Be sure to progressively increase and monitor load and volume to avoid stress injury
Recent posts
Subscribe to the free sports medicine newsletter

The medical world can sometimes be daunting. Our experts discuss the latest medical updates in the sport, health and fitness world, and break it down for you into and an easy to understand, digestible summary. And of course, it’s free.

If you have a particular health care question in mind, please get in touch to let us know and we will do our best to guide you.

The LBSM newsletter, written by our doctors, for our patients.

ISOBAR Referral

ISOBAR Referral Form
  • Patient Details
  • Clinician Details
  • Garments
    • Payment
    Patient Address
    Patient Address
    City
    County
    Postal Code
    Country
    Orla Mulligan
    Administration and Social Media Manager
    Administration, LBSM

    Orla Mulligan is the administration and social media manager for LBSM. She has a strong background in sport having herself played netball at an elite standard for the U21s Northern Ireland team in the European Championships as well as the U21s competition for Saracen Mavericks.

    She understands youth sport pathways having herself played and training in the netball Kent regional pathway. She has a keen interest in most sports and a good understanding of how injury and illness can impact on the mind and body, as well as rehabilitation pathways.

    She looks forward to speaking and assisting LBSM patients and gives her best support to them during their treatment pathway.

    A day in the life of Orla involves communicating with patients via phone and email, managing and organising clinics, operations and media management.

    Outside of work, Orla is a gym enthusiast, enjoys tennis and still finds the time for an occasional game of netball.

    Maddie Tait
    BSc, MSc
    Associate, LBSM
    Musculoskeletal and Sports Podiatrist

    Maddie treats and manages complex foot and ankle injuries in London and Surrey.

    She is particularly interested in helping her patients improve their quality of life and achieve their personal goals, working closely with Foot and Ankle Consultants, Sports Medicine Doctors and Physiotherapists.

    Maddie has a sporting background herself having previously represented England in Hockey. She understands the demands of elite sport and the importance of physical and mental health. In her spare time, Maddie continues to enjoy an active lifestyle by running, cycling and attending a Pilates class.

    Having graduated from University of Brighton with a MSc (hons) in Podiatry, Maddie focused her career in Podiatric Sports Injuries and Biomechanics. Previously she completed a BSc (hons) in Sport Science at Loughborough University.

    A day in the life of Maddie involves consulting patients in clinic, performing gait and biomechanical assessments, measuring and fitting orthotics and braces. She also regularly teaches and presents at sports medicine and podiatry conferences.

    Outside of work, Maddie still finds time to play hockey and enjoys running and skiing.

    Mr Prakash Saha
    MBBS, PhD, FRCS
    Consultant Partner, LBSM
    Consultant in Vascular Surgery

    Mr Prakash Saha is a Consultant Vascular Surgeon at LBSM. He takes pride in providing the best possible results for his patients by using the most appropriate non-surgical and surgical methods based on clinical evidence, patient results and satisfaction.

    He treats fit and active people suffering with a range of cardiovascular issues, from painful leg swelling associated with exercise to venous insufficiency, post-thrombotic syndrome and leg ulcers. He also treats people with arterial system problems including poor circulation, compression syndromes and aneurysms. He carries out both endovascular and open aortic repair and has some of the best outcomes in the country.

    Mr Saha studied medicine at the United Medical & Dental Schools at Guy’s and St. Thomas’ Hospitals before completing his higher surgical training in London and the South East. During this time, he was awarded the prestigious NIHR Clinical Lectureship in Vascular Surgery at St. Thomas’ Hospital, giving him comprehensive training in open and endovascular techniques for treating arterial and venous disease. Prakash completed his aortic surgery training at the St. George’s Vascular Institute before carrying out a specialist fellowship at the Royal Prince Alfred Hospital, Sydney.

    Mr Saha regularly lectures and runs workshops across the globe on the latest surgical techniques to treat vascular disease. He has also been awarded a number of research grants from the Royal College of Surgeons, the Circulation Foundation, the Wellcome Trust, the Academy of Medical Sciences, and the British Heart Foundation, which has led to over 80 publications and the development of innovative technologies to help treat patients. For this work, Prakash has received a number of prizes, including the Venous Forum prize from the Vascular Society of Great Britain and Ireland, an International Young Investigator Award, and an Early Career Investigator Award from the American Heart Association.

    A day in the life of Mr Saha involves seeing patients in clinic, operating in surgical theatre or lecturing at his university. He also regularly teaches and presents at vascular and sports medicine conferences.

    Mr Saha is an avid cyclist and tennis player (although yet to get a set of Dr Seth!). Outside of work, he spends time with his family who consists of 3 children and enjoys travelling.

    Dr Gajan Rajeswaran
    MBBS, FRCR
    Consultant Partner, LBSM
    Consultant in Sports and Musculoskeletal Radiology

    Dr Gajan Rajeswaran is a Consultant Musculoskeletal Radiologist at LBSM, with an extensive background of working in elite sport. He is one of the most recognised radiologists in the sports medicine field. He provides top level imaging and medical diagnostic services for patients and athletes.

    Dr Gajan Rajeswaran completed his undergraduate medical training at Imperial College London and his radiology training at Chelsea & Westminster Hospital. He has obtained two post-CCT fellowships in musculoskeletal imaging. He was appointed as a consultant at Chelsea & Westminster Hospital in 2011.

    He has a passion for all sports having worked as a radiologist at the Glasgow Commonwealth Games and London World Athletic Championships and continues to support The Championships, Wimbledon. He also continues to work with a number of Premier League and Championship Football Clubs, Premier League Rugby Clubs, England Sevens Rugby, British Athletics and the Lawn Tennis Association.

    A day in the life of Dr Rajeswaran involves giving his expert opinion on investigations such as MRI and CT scans, x-rays and ultrasound. He also performs injection lists under ultrasound, CT and X-ray including spinal injections. He also regularly teaches and presents at sports medicine conferences.

    Dr Gajan Rajeswaran is an avid football fan and life-long fan of Tottenham Hotspur (for which he offers no apologies!). Outside of work, he spends time with his family and has a keen passion for photography.

    Dr Ajai Seth
    MBBS, BSc, MSc, MRCS, MRCGP, FFSEM
    Medical Director, LBSM
    Consultant in Sport and Exercise Medicine

    Dr Ajai Seth is a Sport and Exercise Medicine Physician. He has dedicated his career to helping people with sport and exercise related injury and illness. He consults and treats everyone from the elite athlete to the weekend warrior.

    Dr Ajai Seth is part of the British Tennis Sports Physician team at the LTA and has also provided cover to elite athletes at Wimbledon Tennis, European Tour Golf, Premier League Football, British Athletics, and the Men’s England Football academies as part of the FA.

    He also prides himself for working in disability sport and is currently the Chief Medical Officer for Team GB Wheelchair Tennis which has taken him to the Olympics and Paralympics.

    Dr Ajai Seth is dedicated to education, training and research and is a Senior Lecturer in Sports Medicine at King’s College London where he lectures in all aspects of Sports Medicine and Science.

    He also has a passion for travel and Expedition Medicine, which has seen him accompany medical, scientific and charity expeditions all around the world. He also has vast experience in treating musculoskeletal injuries from children and adolescents to veteran exercisers, both male and female.

    Dr Seth also has positions in leading Sport Medicine organisations, including the non-executive board for the UK’s largest Sports Medicine charity, BASEM and Past President for the Royal Society of Medicine. 

    A day in the working life of Dr Seth involves consulting his patients in clinic, performing diagnostics and ultrasound guided injections. He also regularly lectures and tutors students and presents at sports medicine conferences internationally. He also spends part of the working week at the National Tennis Centre, LTA, supporting British Tennis players.

    Outside of work, Dr Seth enjoys playing club tennis, triathlon, golf, running and skiing (but will give any sport a go!). He enjoys keeping fit and active and good quality family time with his wife and three children.