A calcaneal stress fracture is an overuse injury of the heel bone (the calcaneus). It’s a common cause of heel pain in runners, military recruits, and people who suddenly increase their activity. Because it can mimic more common causes of heel pain, such as plantar fasciitis, it’s often missed. So how does a heel stress fracture present, and how is it treated?
What is a calcaneal stress fracture?
The calcaneus (heel bone) is the largest bone in the foot and absorbs significant load during walking, running, and jumping. A stress fracture is a small crack that develops when repeated impact outpaces the bone’s ability to repair itself. In the calcaneus, this usually happens at the back of the heel.
What causes a heel stress fracture?
Calcaneal stress fractures are typically caused by repetitive overload, including:
- A sudden increase in running distance or intensity
- Long periods of marching or load-carrying (common in military recruits)
- Hard training surfaces or worn, unsupportive footwear
- Reduced bone strength — low vitamin D, low calcium, osteoporosis, or low energy availability (RED-S) in athletes
Symptoms of a calcaneus stress fracture
Symptoms usually build up gradually and include:
- Heel pain that worsens with weight-bearing activity, particularly running or walking
- Pain that eases with rest early on, but can progress to pain at rest or at night
- Swelling around the heel
- Tenderness when squeezing the heel bone from both sides — a positive calcaneal squeeze test
These symptoms overlap with those of other causes of heel pain, making an accurate diagnosis important.
How is a calcaneus stress fracture diagnosed?
We take a history and examine the heel, looking for tenderness and a positive squeeze test. Imaging then confirms the diagnosis:
- X-rays are often normal in the early stages, but they can help exclude other conditions.
- MRI is the most sensitive test for an early stress fracture, showing bone marrow oedema and the fracture line, and excluding other causes such as plantar fasciitis.
- CT can show the fracture line in more detail if needed.
A doctor’s assessment also looks for why it happened — training errors, footwear, biomechanics, and bone health (including vitamin D and, in athletes, energy availability).
How is a calcaneal stress fracture treated?
Most calcaneal stress fractures heal well with conservative treatment aimed at offloading the bone:
- Rest and activity modification — stopping the impact activity that caused it and switching to non-weight-bearing exercise, such as swimming or cycling, to maintain fitness.
- Offloading — a period in a walking boot, or, in more severe cases, on crutches — to reduce the load on the heel.
- Cushioned heel supports or orthotics to reduce impact while walking.
- Bone-healing measures — optimising calcium and vitamin D, and, in slow-healing cases, LIPUS therapy to help stimulate healing.
After the initial offloading period (usually around six weeks), physiotherapy restores calf and foot strength, and a graduated return-to-running programme follows. Most people return to full activity within about three months, though some take longer.
Frequently asked questions about a calcaneus stress fracture
How do you tell a calcaneal stress fracture from plantar fasciitis?
Both cause heel pain, but the pattern differs. Plantar fasciitis usually causes sharp pain under the heel with the first steps in the morning, easing as you warm up. A stress fracture causes pain that worsens with continued weight-bearing and is reproduced by squeezing the heel bone from both sides. MRI settles any doubt.
How is it different from heel fat pad pain?
Heel fat pad pain causes a deep bruise-like ache directly under the heel, worse on hard surfaces, without the positive squeeze test of a stress fracture. Again, imaging distinguishes the two if it’s unclear.
How long does a calcaneus stress fracture take to heal?
Most heal with around six weeks of offloading, followed by a graded return to running over several more weeks — roughly three months in total. Poor bone health or continued heel loading can prolong it.
Can you walk on a calcaneal stress fracture?
Usually, only in a protective boot early on, and sometimes with crutches for more significant fractures. Walking unprotected on a heel stress fracture risk worsens it, so offloading is the priority until it settles.
What causes a calcaneus stress fracture?
Repetitive impact that outstrips the bone’s ability to repair — usually a rapid increase in running or marching. Hard surfaces, worn footwear, low vitamin D, and low energy availability (RED-S) all increase the risk, which is why we look for an underlying cause and treat the fracture.
Final word from Sport Doctor London about a calcaneal stress fracture
A calcaneal stress fracture is an important cause of heel pain that’s often mistaken for plantar fasciitis. Early diagnosis, a period of offloading, attention to bone health, and a gradual return to activity lead to a full recovery in most cases.
If you have heel pain that isn’t settling, Dr Masci can assess you in London, including an ultrasound in the clinic. Contact the team here or call +44 (0) 203 488 0350.
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