Ideal Timing of Starting WeightBearing After Calcaneal Insufficiency Fracture: A Case Report and Review of the Literature

Criteria for starting weightbearing on the heel with a symptomatic calcaneal insufficiency fracture have not yet been reported. We describe a rare case of a 52yearold woman with a calcaneal insufficiency fracture who sustained a second ipsilateral calcaneal insufficiency fracture within a short time span. The initial fracture was not evident radiographically, but was detected using magnetic resonance imaging (MRI). The patient rejected our advice to avoid weightbearing on the heel, instead opting to use a silicone heel orthosis. Although there were no abnormal local findings, the stand on heel test was positive at each subsequent visit until 2 months after her first medical examination. At this time, radiographs showed a sclerotic line; however, a second round of MRI showed a new calcaneal insufficiency fracture anterior to the initial calcaneal insufficiency fracture. The patient then agreed to stop weightbearing on the heel. Three months after the initial visit, radiographs showed two sclerotic lines, and the stand on heel test became negative for the first time; hence, weightbearing was permitted. There was radiographic evidence of fracture healing and complete resolution of symptoms 4 months after the initial visit. The callus formation seen on radiographs is helpful in determining when to start weightbearing; however, fresh insufficiency fractures of the ipsilateral calcaneus may not be detected by radiography. Since local findings such as tenderness, swelling, and heat are subjective, the criteria for starting weightbearing on the affected heel with an insufficiency fracture should be based on not only radiographs but also objective clinical findings such as the stand on heel test.