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ACP InternistMKSAP Quiz: Left Heel Pain of 6 Weeks’ Duration

A 36-year-old woman is examined for 6 weeks of left heel pain. She’s getting ready to run a half-marathon. What is the best course of action after a physical examination and radiograph?

Addressing the issue of stress fractures, particularly in the foot, this case study provides critical insights into the effective management of this common athletic injury. Physicians are encouraged to delve into the nuances of treatment methods, their efficacy, and the determining factors for selection.

Key Points:

  • Stress fractures can occur commonly in the foot, specifically in the metatarsals, tarsals, and calcaneus.
  • Certain locations of stress fractures, such as the base of the second metatarsal, fifth metatarsal diaphysis, and medial malleolus, have a high risk of nonunion, warranting an orthopedic referral.
  • Calcaneal fractures pose a low risk for nonunion, and their management can include rest, crutches, a walking boot, and/or footwear padding to achieve pain-free ambulation.

Additional Points:

  • Follow-up radiography at 4 weeks can help document healing of the fracture.
  • Once a patient has no pain with provocative maneuvers and can ambulate without pain, activity can gradually be reintroduced.
  • Most patients with low-risk injuries can resume running in 8 to 12 weeks.


  • Protective devices such as a walking boot, leg splint, and hard-soled shoe can reduce forces on the fracture site, permitting pain-free ambulation and facilitating healing. Casting is typically not required for most stress fractures.

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Did You Know?
According to a 2012 study published in “Current Sports Medicine Reports,” stress fractures are estimated to account for up to 20% of athletic injuries, with foot fractures being particularly prevalent in runners.

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