Calcaneus Stress Fracture

Aka: Calcaneus Stress Fracture, Calcaneal Stress Fracture

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II. Epidemiology

  1. Second most common foot Stress Fracture (second to Metatarsal Stress Fracture)

III. Pathophysiology

  1. Repetitive heel overload
  2. Most commonly occurs posterior to the posterior facet of subtalar joint

IV. Risk Factors

  1. Beginning runner
  2. Runners on concrete surface
  3. Ballet dancers
  4. Increases in weight bearing on hard surfaces
  5. Relative Energy Deficiency in Sport (RED-S)

V. Symptoms

  1. Sudden onset of pain at base of foot
  2. Initially pain only with activity ultimately progresses to pain at rest

VI. Signs

  1. Localized Ecchymosis and swelling
  2. Point tenderness at the Fracture site
  3. Positive calcaneal Squeeze Test
    1. Pain on squeezing Calcaneus from medial and lateral aspects
  4. Single leg hop
    1. Reproduces pain and inability to repeat hopping when Stress Fracture present
    2. Contrast with calcaneal stress reaction in which patient may be able to continue hopping

VII. Differential diagnosis

  1. Acute Calcaneal Fracture with fall from height
  2. Plantar Fasciitis

VIII. Imaging

  1. Foot XRay
    1. High False Negative Rate
    2. Thin cortex makes Fracture identification difficult
  2. Bone Scan
  3. Foot CT
  4. Foot MRI
    1. Preferred test in early presentations (first few weeks after onset)

IX. Management

  1. Limit weight bearing activity for 6-8 weeks (up to 12 weeks)
    1. Consider complete non-weight bearing (Crutches)
    2. Consider CAM Walker boot
  2. Other measures
    1. Physical therapy
    2. Assess nutritional status (e.g. RED-S)

X. Prognosis

  1. Best outcomes with early diagnosis and management
  2. Delayed diagnosis risks kong-term Disability

XI. References

  1. Morancie (2025) Am Fam Physician 112(6): 648-56 [PubMed]
  2. Tu (2018) Am Fam Physician 97(2):86-93 [PubMed]

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