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Calcaneal stress fractures in minimalist/barefoot runners

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Craig Payne, Oct 11, 2012.

  1. Craig Payne

    Craig Payne Moderator


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    I have been seeing more chatter on stress fractures of the calcaneus in forefoot strikers.

    Who said stress fractures are impact related?
  2. Athol Thomson

    Athol Thomson Active Member

    Had an experienced marathon runner with a confirmed calcaneal stress fracture (MRI) in today. Started using a 4mm drop shoe after running in traditional running shoes (12-14mm drop) for 10 years+ with no bone pathology.

    Also developed a rip-roaring FHL tendinopathy bilaterally which he had never had before.

    He had no pain until the long run was > 16 miles.

    I have a query........

    If the Pete Larson foot-strike study indicated that the majority of runners moved to a rearfoot strike after the 32KM mark.


    The American council exercise (ACE) study showed the average loading rate to be twice as much when heel striking in vibrams compared to heel striking in traditional running shoes. see attached image.

    Are these calcaneal stress fractures the result of increased bone strain from the huge achilles eccentric loading demand with the forefoot strike....


    are these calcaneal stress fractures impact related due to the change back to rearfoot striking with fatigue on long runs in shoes that are not designed to alter impact loading at heel strike??

    Attached Files:

  3. toomoon

    toomoon Well-Known Member

    This from Ross Tucker's blog, thesportsscientist..
    Thank you for this. I made the switch to forefoot running a few years back. Slowly, however, I developed calf issues, then plantar fascitis, culminating in two stress fractures (one for each heel). I'd had several "experts" tell me I don't heel strike, and indeed I do not. However, what they failed to tell me was that I ran too far forward on my toes.
  4. Craig Payne

    Craig Payne Moderator

    Thanks Simon; that was my exact point in starting the thread; there are more and more anecdotal comments turning up in forums and on blogs about calcaneal stress fractures in minimalist/barefoot/forefoot runners.
  5. Craig:

    These are not even just mild stress fractures. When Simon Bartold and I were talking to Joe Hamill in Manchester in June at BSS 2012, Joe told us about a barefoot or Vibram runner-friend of his that had just developed a non-displaced calcaneal fracture (clearly visible on x-ray initially) in such an orientation that he felt it must have been caused by Achilles tendon tension forces, not plantar heel compression forces, from forefoot striking There is a published study describing such an injury from minimalist shoes.
  6. Craig Payne

    Craig Payne Moderator

    I forgot about that one:
    Discussed here

    Calcaneal stress fractures are not common, but given that they are happening in those who do not heel strike, it does raise a question if they are really due to impact loads or bending moments.
  7. The calcaneal stress fractures could very well be due to shear stresses, and not either to impact loads or bending moments. Time for a little finite element analysis study to determine why stress fractures are increasingly being reported in individuals running in Vibram Fivefingers and barefoot.
  8. CraigT

    CraigT Well-Known Member

    We have 2 experienced recreational runners who have been diagnosed with this- both sub 3 hr marathon PBs doing consistent high mileage. Number 1- after trying to run up on toes with Newton shoes; Number 2 switching from Nike Free to NB minimist zero drop shoes…
    Both of these cases the fracture line is postero lateral, on the superior margin of the body of the calc. Suggests increased traction loading...
    I have not found a definitive article on the location where calc stress fractures occur, but this does not seem typical in my experience
  9. blinda

    blinda MVP

    I'm sure Joe used that example in one of his lectures. I'll ask him if we can see a copy of that x-ray here. It was remarkable.
  10. Craig:

    This is exactly what Joe Hamill described to me with the calcaneal fracture he saw in his friend.

    But remember what the latest "headlines" will now show, forefoot strikers get fewer injuries than rearfoot strikers....:bash::bang::craig:
  11. blinda

    blinda MVP

    Unfortunately, I cannot post the x-ray as it forms part of a study (waiting for permission to do so). However, Joe did say; I thought the cause of the fracture was a taut plantar fascia along with a large Achilles tendon force. Both of these are seen in forefoot running...."
  12. Blaise Dubois

    Blaise Dubois Active Member

    I'm back, month is finish...;)

    - Since more than 10 years many health professionals prescribe minimalist shoes to thousands of runners in the province of Quebec...
    - We observe that minimalist shoes change the biomechanics for more forefoot striking (some still rear foot strike... but less. Sensitive-proprioceptive rear foot striking?).
    - In this 10 years of practice I see just some calcaneum stress fracture... (even if I agree that is more a traction than impact related injury)... and it was, for most of them, on maximalist/traditional running shoes (remember one in a ASICS Nimbus shoes)
    - I observe less overall injuries with runners in minimalist shoes when the transition from big bulky shoes is properly coached... especially for recreational runners.
    - Tones of knee problem are resolve with more minimalist shoes / more forefoot striking
    - Please don't just look the foot... look the entire body.
  13. Craig Payne

    Craig Payne Moderator

    Which was my point in starting this thread, that maybe calc stress fractures are not necessarily impact related, but traction related. ie If minimalist or forefoot strikers get them as well as heel strikers, then we have to entertain that possibility that shoes or foot strike pattern are possibly not the problem or issue for calc stress fractures.
  14. Jenene Lovell

    Jenene Lovell Active Member

    Has there been a specific study done to determine if it is "possible" for the tensile forces between the plantar fascia and gastroc-soleal complex to cause a calcaneal stress fracture?
  15. Craig Payne

    Craig Payne Moderator


    Calc stress fractures are not common; I have probably only seen a dozen or so over the last 20 or so years and they were all in heel strikers (at least if I recall correctly, they were!) - but that could have been misleading as most runners heel strike, BUT I think the assumption has been that they were probably impact related and I think most people would have agreed with that assumption. (I have not done any sort of evidence review to see what is said).

    But in the last few yrs, there have been more than a few blog comments; forum posts, tweets etc ...ie social media comments (and obviously see the cases above) ... ie anecdotes of them occurring in forefoot strikers. Obviously we all should be aware of the issues surrounding 'anecdotes'.

    Why I started the thread is at what stage do we start taking into account all the social media comments, especially if you are an 'evidence' based clinician? .... there are more than enough 'anecdotes' to start questioning the assumption that calcaneal stress fractures are impact related.
    Last edited by a moderator: Dec 5, 2012
  16. Craig Payne

    Craig Payne Moderator

    I just checked the latest edition of Brukner & Khan which is on my desk at the moment:
  17. NewsBot

    NewsBot The Admin that posts the news.

    Calcaneal Stress Fracture in a Competitive Runner After Incorporating Minimalist Footwear
    Reuteman, Paul F.; Kernozek, Tom; Durall, Chris; Meardon, Stacey A.
    Combined Societies Mtg; American Physical Therapy Association; San Diego January 21-24. 2013
  18. NewsBot

    NewsBot The Admin that posts the news.

    Bilateral calcaneal stress fractures: a case report.
    Imerci A, Incesu M, Bozoglan M, Canbek U, Ursavas HT.
    Ortop Traumatol Rehabil. 2012 Aug 31;14(5):477-81.
  19. Athol Thomson

    Athol Thomson Active Member

    A quick update.

    Today I had my 8th confirmed (MRI) Calcaneal stress fracture in a runner/triathlete since the start of 2013. The athlete had transitioned to using minimalist running shoes after reading "born to run" and a triathlon blog about the 180 steps/minute cadence concept. This has been the case with almost every confirmed case so far.

    I think adding a question to initial history-taking asking athletes if they have tried to change their foot-strike, cadence or footwear after reading about "barefoot running" is now mandatory.

    Interestingly, the stress fractures are usually not the most painful pathology at presentation due to the various tendinopathies and boney stress reactions at other sites about the foot and ankle that are also causing major grief to the patient. This lines up with the findings of this study


    The Musculoskeletal radiologist who reports on my referrals has said he really enjoys doing them because there is usually so many structures to report on!

    Any books that inspire people to exercise must have some merit but it is terrible to see another talented young athlete in an aircast boot (cam walker) today for very silly and most likely avoidable reasons.
  20. I've been asking this as part of my work up for about 18 months now. Sometimes they initially state that they haven't changed their gait, yet later on during the physical exam when they have relaxed a little they admit that they have because of something they read on t'interweb.

    I had a chap in last week wit a confirmed stress fracture of the fifth metatarsal. While he admitted to wearing Vibram five fingers (VFF), he claimed he didn't run in them. So, do VFF increase the risk of stress fracture even in a walking population?
  21. Blaise Dubois

    Blaise Dubois Active Member

    So, he need a big bulky shoes?
  22. Athol Thomson

    Athol Thomson Active Member

    Can you see anywhere in my post that said that?

    Do you think a drastic change in loading volume or intensity may be an issue here Blaise? You wouldn't go from doing no plyometric training to suddenly doing it every session for the whole session.

    The point was not about footwear.... It was about making a decision to change some aspect of your training after reading a book or blog and not using some common sense. He tried to change his steps/minute also or cadence but you only ask me about "big bulky shoes"

    You are barking up the wrong tree here Blaise..... My patients use lots of different footwear depending on the desired task and their injury history or current status.. And I do use gait retraining, an alterG treadmill, real time feedback with motion analysis and accelerometers if the literature supports a change in running kinematics for that athletes specific injury. EG chronic exertional compartment syndrome at the anterior leg (bio mechanical overload syndrome)

    Is that an adequate response to your condescending question?
  23. Blaise Dubois

    Blaise Dubois Active Member

    Like you answer. Agree with.
    It was not condescending.

    ... just see last week a patient with calcaneus stress fracture : a heelstiker running with a Nimbus. My first recommendation was the 'mechanical stress quantification' (like you)... but I will also recommend, for this case, most of the other things (like increasing the cadence) that you were accusing as a cause of the problem...

    I forget : to my point of view it was not the shoes (run with since some years now... but he start to wear orthotics since 2 months (for prevention)
  24. NewsBot

    NewsBot The Admin that posts the news.

    Fatigue Fracture of the Calcaneus: From Early Diagnosis to Treatment: A Case Report of a Triathlon Athlete.
    Serrano, Sim?o MD; Figueiredo, Pedro MD; P?scoa Pinheiro, Jo?o MD, PhD
    American Journal of Physical Medicine & Rehabilitation: March 4, 2016
  25. NewsBot

    NewsBot The Admin that posts the news.

    Stress Fractures of the Calcaneus Diagnosed by Sonography: Report of 8 Cases.
    Bianchi S, Luong DH
    J Ultrasound Med. 2017 Jun 12. doi: 10.1002/jum.14276

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