An Unusual Case Of A Calcaneal Stress Fracture

Abstract

HISTORY: A 56-year-old healthy female presented to clinic with several weeks of left heel pain. No inciting injury, patient is generally active but had not done any recent strenuous activity, however after the onset of the pain any slight bump of the heel produced severe pain. She also had mild swelling around the distal ankle, without any warmth or erythema. The pain gradually worsened to the point the patient started using crutches due to the pain she experienced with weight-bearing. She denied any radiation of the pain as well as any numbness, tingling, or weakness of the foot. PHYSICAL EXAMINATION: Examination revealed mild swelling over the lateral calcaneus, without erythema or induration. Patient had severe tenderness to palpation of the lateral aspect of the calcaneal tuberosity. No tenderness was noted over either malleolus or the Achilles tendon. Range of motion revealed normal inversion, eversion, and plantar flexion but dorsiflexion limited to 10 degrees due to pain. Sensation was intact and strength testing was normal. Talar tilt testing and squeeze test of the calcaneus were negative. DIFFERENTIAL DIAGNOSIS:1. Septic arthritis2. Calcaneal fracture3. GoutTEST AND RESULTS:Labs:-Normal WBC, ESR, CRP, RF, ANA, uric acid, and Lyme and anaplasma titersImaging:-Left ankle radiographs: no acute osseous abnormality-Left ankle MRI without contrast:1.Nondisplaced fracture along the posterior dorsal surface of the calcaneus2.Trace ankle joint effusion3. Mild tibialis posterior tenosynovitis FINAL DIAGNOSIS:Nondisplaced stress fracture of posterior calcaneus TREATMENT AND OUTCOMES:1. Patient was referred to Infectious Disease (ruled out infectious origin including tick-borne infection) and Orthopedics.2. Initial treatment consisted of limited weight-bearing with walking boot, however pain worsened in the boot and she developed numbness of her foot with symptoms suggestive of tarsal tunnel syndrome.3. Patient transitioned to non-weight bearing status without boot, and after approximately two months of slow improvement progressed to limited weight-bearing and physical therapy.5. Due to prolonged recovery, patient still undergoing work-up for less common risk factors for stress fractures and bone infections, including Celiac disease, Bartonella, and Rickettsia testing.