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

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

Treatment

• 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