MKSAP Quiz: Left heel pain of 6 weeks' duration
A 36-year-old woman is evaluated for left heel pain of 6 weeks' duration. She is training for a half-marathon. Following a physical exam and radiograph, what is the most appropriate management?
A 36-year-old woman is evaluated for left heel pain of 6 weeks' duration. She is training for a half-marathon. The pain worsens with activity and improves after rest. She reports no morning stiffness, trauma, swelling, or paresthesia.
Percussion of the left heel, squeezing of the calcaneal tuberosity, and hopping on the foot elicit pain. No ecchymosis or edema is present; pulses, sensation, and strength are normal.
Radiograph of the left foot demonstrates a fracture line in the calcaneus.
Which of the following is the most appropriate management?
A. Casting
B. Electrical stimulation
C. MRI of the foot
D. Walking boot
MKSAP Answer and Critique
The correct answer is D. Walking boot. This content is available to MKSAP 19 subscribers as Question 104 in the General Internal Medicine 1 section. More information about MKSAP is available online.
The most appropriate management is a walking boot (Option D). The metatarsals, tarsals, and calcaneus are the most common sites of stress fracture in the foot. Physical examination may reveal bony tenderness, pain with percussion, or pain with hopping on a single leg. The calcaneal squeeze test may elicit pain in patients with calcaneal fracture. Management of foot and ankle stress fractures depends on the risk for nonunion, predominantly defined by the location of the fracture. Evaluation by an orthopedic surgeon is warranted in fractures at high risk for nonunion. Such risk factors include fracture at the base of the second metatarsal, fifth metatarsal diaphysis, and medial malleolus. Calcaneal fractures pose a low risk for nonunion and can be managed with rest, crutches, a walking boot, and/or footwear padding to achieve pain-free ambulation. Follow-up radiography at 4 weeks can help document healing. Once the patient can ambulate without pain and has no pain with provocative maneuvers on examination, activity can be gradually reintroduced. Most patients with low-risk injuries can resume running by 8 to 12 weeks.
In all cases of stress fracture, forces on the fracture site must be reduced to permit pain-free ambulation and to facilitate healing. Common examples of protective devices include a walking boot, leg splint, and hard-soled shoe. Casting (Option A) is not required in the management of most stress fractures.
Several treatment modalities of unproved benefit have been suggested for patients with stress fracture, including electrical stimulation (Option B), therapeutic ultrasonography, prostacyclin analogs (such as iloprost), and extracorporeal shockwave therapy. Clinical trials have demonstrated that electrical stimulation is no more effective than placebo in the healing of stress fracture and cannot be recommended.
MRI (Option C) is more sensitive than radiography for detection of stress fracture and can provide prognostic information about the risk for nonunion; it should be performed when plain radiographs are unrevealing but clinical probability is high. Because this patient's radiograph reveals a visible fracture in a low-risk location, MRI would not alter management at this point.
Key Points
- Stress fractures located at the base of the second metatarsal, fifth metatarsal diaphysis, and medial malleolus are associated with a high risk for nonunion, and orthopedic referral is recommended.
- Calcaneal fractures pose a low risk for nonunion and can be managed with rest, crutches, a walking boot, and/or footwear padding to achieve pain-free ambulation.