In this video, I'm going to discuss stress fractures that you get in your heel bone – your
calcaneus. We're going to look at what causes it, how to diagnose it, what treatments work best,
and then lastly, how long can you expect your recovery to take? For those of you who
don't know me, my name is Maryke. I'm one of the physiotherapists from sports-injury-physio.com,
where you can get online physiotherapy assessment as well as treatment for your injuries.
Have a look at the description of this video if you want the link to my website.
OK, so what causes a calcaneal or heel stress fracture to develop? You've got to remember
that our bodies are constantly renewing cells. It's a process of breaking down the old ones and
rebuilding the new ones. Now, activities like … Weight bearing activities like walking, running,
jumping – those are the main ones – all load the skeletal system, the bones. And that ... They are
brilliant at building new bone. Because when we exercise, we accumulate micro damage in all the
parts of our body, including the bones. And if it's weight bearing exercise, you'll get more
micro damage in your bones, which is actually what we want, because the body then repairs this micro
damage, and it gives its stronger cells and more robust cells. And that's why, when you look at the
scans of athletes or anybody who does physical activity, their bones are always much thicker,
stronger, denser than people who don't do activity and who lead quite a sedentary lifestyle.
The problem comes in if you don't allow the bone to recover properly or there's a deficiency in
your body that doesn't allow it to build that bone. So, why may you develop stress fractures in
your heel? Now, the first and most common reason people develop stress fractures in their heels is
training errors. So, we're thinking of ... Something else to understand here is that, at any
moment in time, your body has a certain strength in its muscles, its ligaments, its tendons and
its bones, and that strength has been built up over the last few years of things you've done.
Now, if you do an activity that's too much … creates much higher forces than what you're
used to do, so it's either more intense or the volume is bigger, or it's just a strange
activity you've never done before, like for instance, if you're not used to jumping a lot
and suddenly you start jumping activity, it will likely overload the heel bone, because
it's not strong enough to deal with the amount of that activity or the intensity of that activity,
because you've not built its strength up. So, that's one reason why you may develop a stress
fracture. The second from a training error is if you ... You may be used to this type of training,
but you don't actually allow the body enough time to recover after each training session. So then,
this micro damage that we spoke about accumulates, because the body just goes, ‘Oh, mate! You're
doing a high intensity session again 24 hours after you've just done one. I haven't rebuilt
your heel bone yet!’ And then it accumulates, and that's when you can get a bone stress fracture.
Then, those are training errors, but there are also other things that can predispose you to that,
and one of them is if you have an energy deficiency in your body. What does that mean?
The research calls it RED-S, which stands for Relative Energy Deficiency Syndrome in athletes.
All that it means is, you do a high volume of exercise, but you don't take in enough calories
through your food to replace the energy that you burn in your exercise. Now, this is not an issue
if it's a once off or every now and again, but it becomes an issue if that's a general tendency over
a longer period of time. Because what happens is, your body needs energy – calories – to keep
all the processes going. Your brain eats a lot of calories in a day, for instance.
If your body doesn't get enough calories in every day to replace what you've just burnt, it
starts to think that you may be starving. And it reckons that, ‘OK, survival is my first priority.
How do I keep this person alive? Ah, I know! I’ll switch off the processes that we don't really
need for survival.’ And bone replenishing or replenishment – I'm not sure if that's a word – is
one of them. So, then what happens is, your bones don't renew, because you just don't have the
energy to do it, because it's saving the energy to keep your brain going or other functions going.
So, that is one of the first things to look at. So, if you … especially if you're an endurance
athlete that does a lot of cycling or lot of running or even a lot of swimming in that process.
So, it's not just people who run a lot. You may be burning your energy through other things and then
the running is the last kind of link in it. Have a look at that, because that's one of the main
things that can predispose athletes to developing stress fractures. And it's for men as well as
females. Females, a clear sign that this may be an issue for you, is if you've stopped
menstruating or your menstruation cycle is really haywire – then you have it, then you don't, that
type of thing – that can be an indication that actually your body's not getting enough energy.
Just remember, if you’re also in the period where you may be going into the menopause,
it may just be the menopause that's messing with it – with your hormones and your menstrual cycle.
So, just keep all of that in mind. Another thing about diet is, you have to remember
that the building blocks of bones is calcium. But in order to absorb calcium from your gut,
you have to have enough Vitamin D in your system. So, if you have a deficiency in either of those,
your bones just may not have the right building blocks or can't use them
to rebuild your bones. So, Vitamin D, the best source for that is the sun. Most of us in,
especially around the UK area or in Europe, won't see enough sunshine in the winter to replenish our
Vitamin D levels. And they've shown that a lot of athletes are actually Vitamin D deficient
during those periods. But, say for instance, you live in a warm country like Israel, and you run,
you're not going to run in the middle of the day when the sun is really hot and sharp on you. You
may run early morning, or you may run indoors. So, you're not really getting a lot of sun exposure
then either. Or you might be whacking lots of sunscreen on so that you're not getting enough for
your bones. So, have a look at that. Your doctor can easily test your Vitamin D levels for you,
and if it's deficient, it may be useful to take a supplement. But have a chat with your doctor
about that. And also, look at your diet – are you actually getting enough calcium in your diet
for your bones? Then, if we think of other things that can predispose you to it,
it may be purely a genetic thing. Oops! My ... Ah, my iPad has just kicked off!
So, it may be purely a genetic thing that some people are predisposed to osteoporosis
or poor bone density. So, if you know that you have a family history from your mother's side or
your father's side, that there’s low bone density in the family, it may also be worth checking the
rest of your body to see if this is actually a wider problem, but it's just showing itself in
your heel at the moment. So, how do you know that you actually have a stress fracture in your heel?
Well, obviously you have to have the pain in and around the heel bone. There are other conditions
that can get confused with this, because they can give pain in very similar areas.
But a skilled clinician can easily distinguish between that, because when we listen to the
story you tell us and we make you do certain tests, we can see what the likely symptoms
or the diagnosis is. So, there's a squeeze test you can do that, if you take hold of the heel
bone and you squeeze it from the sides – if that causes pain that's similar to your pain,
that can be indication that it's a stress fracture of the heel bone. Just remember,
insertional Achilles tendinopathy can give you pain bang on the back of the heel,
but you usually can feel that it's something sore on the outside of the bone you’re pressing on.
There's also a condition called tarsal tunnel syndrome – made a video about that – that can
give you pain on the inner part of the heel, but usually you'll have an ache that goes up and down,
and there may even be tingling involved with that. Then, you get fat pad syndrome,
where you have a fat pad underneath your heel, and if you step on something sharp or you just give it
a lot of impact, that fat pad may become really painful. But again, it's pain more kind of under
the heel than what you’re feeling. And lastly, obviously, plantar fasciitis, which is a really
common condition, can cause pain also in the arch of the foot or just where it attaches to the heel.
So, those are things to keep in mind. Now, by far the best way to diagnose a stress fracture
in the heel is to get an MRI scan. X-rays aren't that useful, because X-rays don't show up stress
fractures within the first few weeks. It's only if it's been around for a while that you can perhaps
see a line on an X-ray for it. So, especially if yours is new,
an MRI scan is usually the best way to diagnose it. But a skilled clinician can help you make that
decision whether it's needed or not by listening to your history and making you do certain tests.
The other important thing with this is that a heel stress fracture will be painful when you weight
bear. Now, if it's just starting to develop and is not that painful, then standing may be absolutely
fine – walking may even be fine. It's only when you do high impact activities like running or
jumping and landing that you might feel it. However, if it's properly flared up,
then even standing for short periods of time may hurt, and it may even hurt while you’re
sitting down or lying in your bed. So, it just depends on how bad your injury is. If you're
getting pain while you’re lying in bed, it's definitely a sign you need to have it checked.
Good! So, what is the best treatment for this thing? The good news is, if you catch this early
on, you probably don't need any fancy treatments and not even a boot. So, the most important thing
is to offload that injured area to the point where it can actually start to recover.
So, you definitely want to reduce your load bearing sports. Stop all running, stop all
jumping activities. Yes, you may be able to do some running without pain, but I can tell you,
if you want this thing to recover quickly and not escalate, it's best to stop it for a short
period of time and reintroduce it later on. Now, you may be able to cross train
and do things like cycling or swimming that don't directly load the heel bone. But again,
I want to caution you against doing high volumes of that while you're waiting for this to recover,
because remember, I spoke about the energy availability in your body. So, if you do lots of
cycling or swimming in that period to keep your fitness going, you may end up actually starving
that heel bone of the nutrients it needs and then it doesn't recover as well. So, it's really good
to bring it right down for a couple of weeks to just give it the best kind of chance to recover.
Now, like I said, if you catch it early, it's not too bad, you may be able to get away with
just wearing really cushioned running shoes and not spending too much time on your feet.
However, if you've been neglecting it for a while, it's really quite painful, your doctor
may suggest that you wear a boot, as well as use crutches for a while to really offload it.
So, it just depends on that. Speak to your doc – they'll be able to guide you on that better. Then,
coming back from that, people always want to know, ‘Oh, what strengthening exercises I should do for
this.’ There's nothing you can strengthen to help that heel bone at this point. It was total overuse
that caused it or lack of nutrients, and that needs to be sorted. So, don't just think about the
load bearing in your training. It's important to identify your training errors, if there were any,
because you want to prevent this from happening again. But have your Vitamin D tested, have a
chat with your doctor – see if your diet has enough calcium in it. And also, if you suspect
there may be a family link with this, have the rest of your body checked for bone density.
Good! So then, how do we get back to training after a stress fracture? For how long do you
have to offload it? What are the healing times? If you have a mild stress fracture, it takes about
two weeks of total offloading before you can start reloading it again. But most of them take between
two to eight weeks. So, eight weeks is two months – it's a long period of time that you sometimes
have to not do any load bearing activity before it fully calms down. But now, you've got to remember,
when you've reached that point where you don't get pain with walking anymore and you don't get pain
with standing anymore, that heel bone is not yet strong enough to 'bang!' go back into your running
again. It lost some of its strength when you injured it, so you now have to slowly reload it
over time and introduce load bearing activities at small volumes to rebuild that strength.
It can be tricky, because there's no way of telling how strong that heel bone is. You can
do scans till the cows come home, it can't tell you anything about the tolerance and the endurance
of that piece of bone. So, the best way to go about it is, work with a physio who can help you
figure out, OK, what's the load it can bear at the moment? How do we increase this on a week-on-week
basis? And how do we allow the bone enough recovery time during this period? Now, this is
one of those injuries where it's not OK if you get pain when you do the activity and it's not okay
if the pain lingers after the activity. So, if you find that, ‘Uh-huh, my pain symptoms are being
stirred up again!’, you have to bring your rehab back down a little bit again. And that's where
people go wrong. They've put all this period of time into resting it and getting the pain to shut
up, and now they start to reload it, and it goes well for about two weeks. And then the third week,
their heel is starting to get painful again. Now they feel they've invested so much time
that they don't want to go back, so they start pushing to just continue with their rehab,
and then they end up making it worse. Whereas, if they just took a few days off and loaded it a bit
more slowly and adjusted their program, they may have been OK. So, please don't try to push
through pain. You've got to adjust your rehab if it flares up. Good! Hope you found this useful!
If you've got any questions, let us know. But if you need more help with your injury, you're
welcome to consult one of us via video call – link is in the description of this video. Take care!