An X-Ray Suggested a Broken Foot but the Player Had Been Carrying That Extra Bone His Whole Life

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The first two X-rays, the standard front and side views, showed nothing. It was a third image, taken at an oblique angle, that produced the alarming finding: a small, well-defined piece of bone sitting next to the front of his heel bone, exactly where an avulsion fracture would appear.

A CT scan settled it: there was no injury. The case appears in a report in Radiology Case Reports published in 2026.

The CT showed a small oval structure sitting near the anterior process of the calcaneus, the forward-projecting shelf at the front of the heel bone. Its surfaces were smooth, its edges rounded, and its cortex, the dense outer shell of bone, was continuous all the way around.

That last detail is the giveaway. A fracture fragment has a sharp, irregular break where the cortex is torn open, and a matching defect in the parent bone. This piece had neither. It was fully corticated, meaning it had spent years as a finished, independent bone.

The diagnosis was os calcaneus secundarius, an accessory ossicle that forms from a secondary ossification center near the front of the heel bone and never merges with the calcaneus during development. It was described in 1869 by the anatomist Ludwig Stieda. The player had almost certainly had it since childhood without knowing.

The foot is unusually prone to leftover ossification centers. In a review of foot and ankle radiographs from 1,000 adult patients referred to a foot and ankle clinic, published in Medicina, accessory ossicles of some kind appeared in 40.2% of images.

Os calcaneus secundarius specifically is one of the rarer members of that family, and estimates of how rare vary a lot. That review found it in 0.3% of feet. A study of a Portuguese skeletal collection published in Scientific Reports found it in 6.0% of 486 individuals. A systematic review and meta-analysis presented in Orthopedic Proceedings in 2025 described the epidemiology as not established and poorly understood, with published estimates spanning 0.1% to 15.2%.

The clinically relevant number from the survey of 1,000 patients is a different one: 2.7% of the accessory ossicles identified had initially been misdiagnosed as avulsion fractures in emergency departments.

The confusion is not one-sided, and that is what makes this corner of the foot genuinely difficult.

Researchers at a German level-one trauma center reviewed 611 foot CT scans taken after acute injury and published their findings in Surgical and Radiologic Anatomy. They found accessory ossicles at the anterior calcaneal process in 14 scans and real pathology (fractures or non-healing fractures) in 56.

Then came the uncomfortable part. Seven of the 12 typical accessory ossicles and 25 of the 56 genuine fractures and pseudarthroses were not mentioned at all in the original CT reports. Both the harmless variant and the actual injury were being overlooked at broadly similar rates.

The features that separated them were consistent: the accessory ossicle sat toward the inner side of the joint in a concave notch on the calcaneal surface and showed continuous corticalization, while fractures did not. An earlier case in Case Reports in Radiology describing a 20-year-old with a nearly identical presentation reached the same conclusion, recommending that clinicians learn the standard locations of accessory bones specifically to avoid misdiagnosis and unnecessary surgery.

Comparing the opposite foot is often suggested, but it is not reliable. Accessory ossicles of this type are usually one-sided, and the absence of a matching bone on the other side proves nothing.

The distinction matters clinically, but the ossicle is not always innocent.

Although usually silent, the os calcaneum secundarium can become symptomatic after trauma or repeated mechanical stress. Reported presentations include chronic pain on the outer side of the foot and limited inward rolling of the ankle after an inversion sprain. When conservative treatment fails, the ossicle can be surgically removed, including through a keyhole endoscopic approach.

A report in the Journal of Clinical Medicine published in 2026 described a 19-year-old soldier with progressive front-of-foot pain after playing soccer, with no clear injury event. CT showed two separate, well-corticated accessory ossicles at the same site, a rare variant with even greater potential for diagnostic confusion.

For readers, the takeaway is not to self-diagnose from an X-ray report. It is that an unexpected bone fragment near the heel after an ankle sprain has more than one explanation, that CT is usually the test that settles the question, and that persistent pain after a sprain labeled a fracture, or dismissed as nothing, is worth revisiting with a clinician. Most ankle sprains heal. The ones that do not deserve a second look at the imaging.

What is os calcaneus secundarius? It is an accessory bone near the front of the heel bone, formed from an ossification center that never fused with the calcaneus during development. Most people who have one never know.

Why does it look like a fracture? On plain X-rays, it appears as a separate bone fragment sitting exactly where an avulsion fracture of the anterior calcaneal process would be, especially on oblique views.

How do doctors tell the difference? CT is the deciding test. The accessory bone has smooth, rounded margins and a continuous outer cortex, while a fracture fragment has sharp, irregular edges and a matching defect in the parent bone.

How often are these bones mistaken for injuries? One review of 1,000 adults found that 2.7% of accessory ossicles had been initially misdiagnosed as avulsion fractures in emergency departments. A separate CT review found that real fractures at this site were also frequently missed.

What should someone do if pain persists after an ankle sprain? Continued pain, swelling or instability weeks after a sprain warrants review by a clinician, who can decide whether further imaging is appropriate.