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Calcaneal Stress Fractures

General Considerations

  • Overuse injury seen in athletes, especially with running and aerobics, and military recruits
  • Most stress fractures are in lower extremities
  • Repetitive compressive loading

Clinical Findings

  • Increasing pain in the heel with exercise or activity
  • Tenderness to palpation over outer aspects of the heel
  • Pain may decrease or disappear with rest

Imaging Findings

  • Stress fractures may take up to 7-14 days to appear on conventional radiographs
  • Most occur in posterior half of calcaneus
  • Vertically oriented zone of increased density on lateral radiograph
  • Perpendicular to the trabecular lines
  • Usually oriented parallel to the curve of the posterior calcaneus
  • Fracture line usually disappears by 6 weeks
  • Radionuclide bones cans may be positive (increased uptake) within 72 hours
  • On MRI
    • Low signal on both T1 and T2
    • Surrounding marrow edema will show high signal
    • May be particularly helpful in setting of marked osteoporosis

MRI calcaneal stress fracture

T1 (left) and STIR MRI images show a stress fracture of the calcaneus (black arrow)
and the surrounding edema (white arrows)in another patient.

Differential Diagnosis

  • Heel pain may clinically be caused by plantar fasciitis


  • Avoiding aggravating activities like running for 4-8 weeks
  • Cushioning of the heel
  • Rarely, surgery 

Stress Fracture of the Calcaneus. Lateral view of calcaneus shows characteristic vertically-oriented dense band of sclerosis in calcaneus (white arrow), perpendicular to the orientation of the trabeculae. Lower tangential view also shows dense band of sclerosis (white arrow)
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Stress Fractures of the Calcaneus. JW Leabhart. The Journal of Bone and Joint Surgery; Vol L. 41-A, NO. 7, Oct 1959