Case Study: A Unique Presentation of Calcaneal Stress Fracture in a Pregnant Woman

Case Study: A Unique Presentation of Calcaneal Stress Fracture in a Pregnant Woman

As a sports doctor, I encounter a wide range of conditions affecting athletes and active individuals. Occasionally, cases arise that transcend the usual scope of sports medicine, demonstrating the intricate interplay between physical activity, systemic health, and underlying medical conditions. One such case involved a 32-year-old pregnant woman who presented with an unexpected diagnosis that underscores the importance of holistic patient evaluation.

Presentation

The patient, a healthy and active individual at 39 weeks of pregnancy, sought consultation for persistent pain in her heel. She described the pain as a dull ache that intensified during weight-bearing activities and persisted despite rest. She had no history of trauma, recent changes in activity levels, or footwear issues. The discomfort was starting to limit her mobility, prompting her to seek medical attention.

Examination and Initial Workup

Clinical examination revealed localised tenderness over the calcaneus, without swelling or visible deformity. A thorough assessment ruled out plantar fasciitis and other common causes of heel pain. Given her symptoms and pregnancy, imaging was performed with an MRI to avoid radiation exposure. The results confirmed a stress fracture of the calcaneus.

Delving Deeper: Identifying the Underlying Cause

Stress fractures typically arise from repetitive mechanical stress or a sudden increase in activity. However, in some cases stress fractures can be a sign of systemic illness. For this patient initial blood tests revealed an elevated parathyroid hormone (PTH) level of 13.5 and low levels of vitamin D, while her calcium and iron levels were normal. Her bone mineral density (BMD) scan showed a T-score of -2.5, indicating osteoporosis.

Recognising the potential for systemic contributors to her condition, further investigations were conducted. A serological test for coeliac disease returned positive for anti-tissue transglutaminase (tTG) antibodies, and a subsequent duodenal biopsy confirmed the diagnosis. Interestingly there was no family history of autoimmune disease.

Diagnosis and Management

The final diagnosis was a calcaneal stress fracture secondary to coeliac disease—a condition that had likely gone undiagnosed for years or potentially triggered during pregnancy, which is rare but has been reported in the literature. . Coeliac disease can lead to malabsorption of essential nutrients, including calcium and vitamin D, contributing to weakened bone structure and increased fracture risk.

Management included immediate offloading of the affected foot using a supportive boot to allow the fracture to heal. The patient was referred to a gastroenterologist for comprehensive management of her coeliac disease, which included a strict gluten-free diet. Nutritional support was initiated, focusing on correcting deficiencies in calcium, vitamin D, and iron. She was closely monitored throughout her pregnancy to ensure both maternal and foetal well-being.

Outcome

With interdisciplinary care, the patient’s fracture healed successfully within eight weeks. She delivered a healthy baby, and a follow-up BMD scan is pending but is expected to improve without the need for osteoporotic medication. She remains symptom-free, with ongoing monitoring for her coeliac disease.

Takeaway

This case highlights the importance of looking beyond the obvious when evaluating musculoskeletal injuries. As sports medicine practitioners, our role extends beyond managing physical injuries to recognising systemic conditions that can impact musculoskeletal health. By adopting a holistic and patient-centred approach, we can uncover hidden diagnoses and provide comprehensive care that benefits the whole patient.