History and Presenting Symptoms
A 25-year-old female presents with pain around her right ankle and heel. The pain has been present for about three weeks and gets worse upon weightbearing activity. She also relates running about six times per week for five miles a day, in preparation for her first half-marathon run in support of breast cancer awareness. She denies any specific injuries or direct trauma. Her medical doctor has diagnosed plantar fascitis, but she is not responding to the non-steroidal anti-inflammatory medications he prescribed.
Exam Findings
Vitals. This active young woman weighs 127 lbs. which, at 5’5’’, results in a BMI of 22; she is not overweight. She does not use tobacco products, and her blood pressure and pulse rate are within the normal range. Posture and gait. Standing postural evaluation reveals basically good alignment, but a decreased lumbar lordosis. She demonstrates bilateral calcaneal eversion, worse on the right, with a lower right arch. Gait evaluation finds obvious hyperpronation of the right foot and ankle when walking, which is accentuated when running. Chiropractic evaluation. The lumbar spine is moderately tender throughout, and she demonstrates a generalized loss of vertebral mobility, with few specific fixations. Orthopedic and neurological provocative testing of the spine and pelvis is negative. Primary complaint. Palpatory examination of the right foot elicits significant tenderness to medial/lateral squeezing of the right calcaneus. No point tenderness is noted at the insertion of the plantar fascia into the anterior aspect of the calcaneus. All right foot and ankle ranges of motion are full and pain free. Also, manual muscle testing reveals no evidence of weakness when compared to her left side.
Imaging
A lateral X-ray of the right foot demonstrates a calcaneus and talus that appear normal. There is no evidence of fracture, sclerosis or periosteal reaction.
Clinical Impression
Stress response in the right calcaneus bone, with moderate lumbar spine joint dysfunction. There is no evidence of plantar fascitis or subtalar joint malfunction.
Treatment Plan
Adjustments. Mobilization and adjustments were provided to the lumbopelvic region. The right calcaneus was adjusted anteriorly and both navicular bones were adjusted superiorly. Support. Flexible, stabilizing orthotics with shock-absorbing viscoelastic materials were custom made to support all three arches of each foot, in order to decrease calcaneal eversion and heel-strike shock. Rehabilitation. A foot-wheel device was recommended to improve the coordination of her foot intrinsic muscles. Once she had her orthotics, she also performed standing Achilles tendon stretches with knee straight, and then bent.
Response to Care
She was told to avoid walking as much as possible for the first week, and then only limited walking for two more weeks. She was permitted to increase her walking over the following three weeks and gradually incorporated short periods of running. At six weeks, she returned to her training program with no recurrence of heel pain, and she was released to a self-directed home stretching program after a total of 10 visits over two months.
Discussion
Stress fractures generally occur in the lower extremities, beginning as a stress response that can progress to a frank fracture. It is often said that a stress fracture is a normal response of bone to abnormal doses of stress. The rear foot or heel area of athletes is particularly susceptible to these overuse injuries, as most sports and training activities include a component of running, which places large amounts of stress on the anatomical structures of the foot and ankle. There is a higher incidence of stress fractures in young women (10:1), which is thought to be associated with their smaller bone structure, decreased lean body mass, and possible poor nutrition secondary to eating disorders.
Initial radiographs may be negative in up to 70% of patients with stress fractures. The radiographic evidence of stress fractures often lags two to three weeks behind the onset of symptoms. Typically, there will be a dense margin of sclerosis perpendicular to the trabecular meshwork and parallel to the posterior contour. Serial radiographs or radionuclide bone scans may be necessary when the initial diagnosis is questionable. In this case, the exam findings and response to treatment were clear, and no further imaging was needed.
Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation.