Treating Iatrogenic Calcaneal Osteomyelitis 
Following A Plantar Heel Injection

Michael Canales, DPM, FACFAS, Michael Bowen, DPM, and John Gerhard, DPM

Addressing questions of how to proceed when a calcanectomy is inappropriate, these authors detail how to treat a 24-year-old who experienced the rare complication of calcaneal osteomyelitis after an injection for plantar fasciitis.

Calcaneal osteomyelitis is a rare complication following injection treatment of plantar fasciitis. To date, there are two published reports documenting osteomyelitis following corticosteroid and local anesthetic injection for plantar fasciitis.1,2 With this in mind, we would like to discuss treatment options to consider when the physician deems calcanectomy inappropriate or the patient refuses it.

   Injection of local anesthetic in combination with corticosteroid is an accepted choice in the treatment of recalcitrant heel pain diagnosed as plantar fasciitis.3 When one performs the injection properly, post-injection infection is exceedingly rare.4

   This is a case of calcaneal osteomyelitis following injection in a patient with a calcaneal stress fracture misdiagnosed as plantar fasciitis. Authors have noted that subtotal and partial calcanectomy are effective treatment strategies for calcaneal osteomyelitis.5,6

A Closer Look At The Patient Presentation

A healthy 24-year-old female, employed as a pharmacy technician, visited her primary care physician with a complaint of unilateral heel pain. The patient reported a recent increase in activity in an effort to lose weight following the birth of her first child. The patient stated that her heel pain began after initiating a running program on a treadmill. Her primary care provider (PCP) diagnosed the etiology of the pain as plantar fasciitis and offered a treatment plan consisting of two injections of local anesthetic and corticosteroid within a six-day period.

   When this treatment did not resolve her symptoms, the patient got a referral to a podiatrist. The podiatrist added physiotherapy and cryotherapy to the treatment plan. These additional modalities did not alleviate her pain and the podiatrist obtained a magnetic resonance imaging (MRI) study. The MRI revealed a linear decrease in T1 signal intensity, suggestive of a stress fracture of the calcaneus (see figure 1). The patient received a subsequent referral to the senior author’s practice for further evaluation and treatment options.

   The examination revealed an edematous right rearfoot (see figure 2). No open lesions were present. The senior author applied a two-layer Jones compression bandage with a fiberglass shell in an attempt to reduce edema. The patient had instructions to be non-weightbearing on the right foot.

Treating The Repeated Complications

Five days later, the patient contacted the senior author with a complaint of numbness to her digits and 10/10 pain in the ankle. The patient reported bloody drainage seeping through the fiberglass shell of her compression cast. The patient immediately reported to the emergency department, where the senior author and residents met her.

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