ConditionBones, joints & muscles
Calcaneal Stress Fracture (Heel Bone Stress Fracture)
A calcaneal stress fracture is a small crack in the heel bone (calcaneus) caused by repeated impact rather than a single injury. It typically affects runners, military recruits and people who suddenly increase walking or standing, especially if their bones are weakened. It causes heel pain that builds with activity and pain when the sides of the heel are squeezed. With rest from impact and protected walking, most heal in 6 to 12 weeks.
Also called: Heel bone stress fracture, calcaneus stress fracture, heel stress fracture, fatigue fracture of the calcaneus
At a glance
- What it is
- A hairline crack in the heel bone from repeated loading.
- Who gets it
- Runners, military recruits, people starting new activity, people with osteoporosis or low energy intake.
- Key signs
- Heel pain worse with weight-bearing, swelling, and pain on squeezing both sides of the heel.
- Diagnosis
- Clinical exam; X-ray (often normal early); MRI is the most sensitive test.
- Treatment
- Stop impact activities, walking boot or crutches if needed, gradual return over 6 to 12 weeks.
When to get help
See a doctor within a day or two
- Severe heel pain after a fall from height or a jump, with inability to walk (possible acute calcaneus fracture)
- Heel pain with swelling, warmth, redness and fever (possible infection)
- Heel pain with numbness or tingling in the foot
Book a routine appointment
- Heel pain that worsens with walking or running and has lasted more than 1 to 2 weeks
- Pain when squeezing the sides of the heel
- Repeated stress fractures, missed periods or significant weight loss in an athlete
- Heel pain in someone with osteoporosis or on long-term steroids
Usually safe to manage at home
- Mild heel soreness after a new activity that improves fully within a few days of rest
How a calcaneal stress fracture happens
Bone constantly remodels: small amounts of damage from activity are repaired over days to weeks. If loading increases faster than the bone can adapt, tiny cracks build up into a stress fracture. The calcaneus takes the full force of heel strike, which can be 2 to 3 times body weight with every running stride.
Two types:
- Fatigue fracture: normal bone overloaded by abnormal activity, such as a new running program or marching.
- Insufficiency fracture: weakened bone (osteoporosis, diabetes, rheumatoid arthritis, long-term steroids) breaking under normal activity, more common in older adults.
The fracture usually runs vertically through the back and upper part of the heel bone.
Symptoms
- heel pain that starts gradually, often over 1 to 3 weeks of increased activity
- pain that is worse with walking, running or standing and eases with rest
- in later stages, pain at rest or at night
- mild swelling at the back and sides of the heel
- tenderness over the sides of the heel bone
- limping or avoiding putting weight on the heel
The squeeze test
Pressing firmly on both sides of the heel at the same time with the palms (the calcaneal squeeze test) reproduces pain with a stress fracture. In plantar fasciitis, squeezing usually does not hurt; pain is under the heel instead.
Calcaneal stress fracture vs plantar fasciitis
| Calcaneal stress fracture | Plantar fasciitis | |
|---|---|---|
| Location of pain | Sides and back of the heel | Underside of the heel, toward the arch |
| Pattern | Worse with activity, builds through the day | Worst with the first steps in the morning, eases after warming up |
| Squeeze test | Painful | Usually not painful |
| Swelling | Sometimes | Rare |
| History | Recent jump in activity | Gradual onset, often with tight calves |
See plantar fasciitis and heel pain for other causes.
Risk factors
- sudden increases in running distance, speed or hill work
- military basic training and marching
- running on hard surfaces, worn-out shoes
- low energy availability in athletes (eating too little for training), with missed periods in women or low testosterone in men; this is called relative energy deficiency in sport (RED-S)
- low vitamin D and calcium
- osteoporosis, long-term steroid use, diabetes, smoking
- previous stress fractures
- flat or high-arched feet
Diagnosis
- History and examination: activity changes, location of pain, squeeze test, and checking for other causes.
- X-ray: often normal for the first 2 to 3 weeks; later may show a white line of healing bone (sclerosis) across the back of the heel.
- MRI: the most sensitive test; shows bone swelling and the fracture line early.
- CT or bone scan if MRI is not available.
- Blood tests for vitamin D, calcium and hormone problems, and a bone density scan if bone weakness is suspected or fractures recur.
Treatment
The calcaneus is a low-risk stress fracture site, which means it usually heals well with conservative treatment.
- Stop impact activity. No running or jumping until pain-free.
- Protected walking: a walking boot or cushioned shoes; crutches for a few weeks if walking is painful.
- Ice and elevation for swelling.
- Pain relief: acetaminophen (paracetamol) is often preferred. Ibuprofen and similar drugs are fine for short-term use; follow the label dose.
- Maintain fitness with swimming, cycling or deep-water running if pain-free.
- Correct risk factors: adequate calories, calcium and vitamin D; treat osteoporosis; address menstrual problems.
- Gradual return to running over several weeks once you can walk briskly and hop without pain, increasing load by no more than about 10 percent per week.
Surgery is almost never needed.
Healing time
Most calcaneal stress fractures heal in 6 to 8 weeks, with full return to running by about 8 to 12 weeks. Insufficiency fractures in older adults may take longer.
Preventing stress fractures
- increase training volume gradually
- replace running shoes every 500 to 800 km (300 to 500 miles)
- mix in low-impact cross-training
- eat enough to fuel training; include calcium and vitamin D
- get help early for heel pain rather than running through it
Frequently asked questions
How do I know if I have a heel stress fracture?
Suspect a stress fracture if heel pain started after an increase in activity, gets worse the longer you walk or run, and hurts when you squeeze both sides of the heel. X-rays can be normal early, so an MRI may be needed to confirm it.
Can you walk on a calcaneal stress fracture?
Usually yes, with protection. Most people can walk in a cushioned shoe or walking boot as long as it does not cause significant pain. Crutches help if walking hurts. Running and jumping must stop until the fracture has healed.
How long does a heel stress fracture take to heal?
Most heal in 6 to 8 weeks with rest from impact activities. A return to running usually takes 8 to 12 weeks, building up gradually. Healing may take longer in older adults or people with weakened bones.
Is it plantar fasciitis or a stress fracture?
Plantar fasciitis hurts under the heel, worst with the first steps in the morning. A stress fracture hurts on the sides of the heel, gets worse with continued activity, and is painful when the heel is squeezed. A doctor can examine and order imaging if unsure.
Why did I get a stress fracture?
Stress fractures happen when activity increases faster than bone can adapt, or when bones are weakened. Common contributors are sudden training increases, inadequate rest, eating too little for your activity, low vitamin D, missed periods and osteoporosis. Addressing these prevents recurrence.
Sources
This guide was written from current patient and clinical guidance, including:
- American Academy of Orthopaedic Surgeons: Stress Fractures of the Foot and Ankle
- American Academy of Family Physicians: Stress Fractures - Diagnosis, Treatment, and Prevention
- American College of Radiology: ACR Appropriateness Criteria Stress (Fatigue/Insufficiency) Fracture
- American Orthopaedic Foot and Ankle Society: Stress Fractures
- MedlinePlus: Stress fractures