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Calcaneal Stress Fracture | Differential diagnosis of heel pain

Calcaneal Stress Fracture | Differential diagnosis of heel pain

Do I have a stress fracture of my heel bone?Calcaneal stress fracture

Differential diagnosis for calcaneal stress fractures

A stress fracture is a nondisplaced defect in a bone that occurs due to repetitive load or trauma.  A calcaneal stress fracture (fracture of the heel bone) is most often the result of a sudden abrupt injury but can occur without a history of trauma.

Confirming the diagnosis of calcaneal stress fractures can be difficult with just clinical testing. The appearance of a stress fracture on x-ray is not always evident. Quite often, the only x-ray findings seen are those signs that show up towards the end of the healing process, sometimes as long as several months after the onset of the stress fracture. The initial fracture may not be visualized but the healing bone will show evidence of a fracture 4-6 weeks after the onset of the injury. If the initial clinical findings of heel pain seem suggestive of a stress fracture, there are several tests that can be used to help determine the diagnosis. These tools include plain x-ray, bone scans, CT scanning, and MRI.

How do you differentiate a calcaneal stress fracture from other heel problems?  Let's take a look at a short list of common reasons for heel pain and their symptoms.

Calcaneal stress fracture

  • Onset varies - may or may not result from an injury such as a fall
  • Swelling is not common
  • Location of pain - pain found with side to side compression of the medial and lateral walls of the heel bone
  • Weight bearing with pain in the mid-body of the heel and is not relieved by rest

Plantar fasciitis

  • Onset varies and may be abrupt and associated with a specific event like a period of long standing (i.e. convention, seminar or sporting event)
  • Swelling is not common
  • Location of pain is specific to the bottom of the heel
  • Pain found with initial weight bearing and is relieved by rest

Baxter's nerve entrapment

  • Onset is usually insidious and not abrupt
  • Swelling is uncommon
  • Location of pain specific to the medial heel
  • Pain increases with the duration of time spent on the feet and is not relieved by rest

Achilles tendinitis

  • Onset is insidious or abrupt
  • Swelling is common and specific to the posterior heel
  • Pain occurs with the onset of activity - getting out of bed or at the onset of a run.  Pain is partially relieved with rest

The clinical symptoms of heel pain, particularly in cases of calcaneal stress fractures, can often be difficult to differentiate.  In my experience, calcaneal stress fractures are relatively rare injuries but need to be considered as a differential diagnosis for the more common heel pain problems like plantar fasciitis.

If your heel pain symptoms seem suspicious for a calcaneal stress fracture please be sure to check with your podiatrists or orthopedist.  Prompt diagnosis of a calcaneal fracture can significantly expedite healing.


Dr. Jeffrey Oster
Jeffrey A. Oster, DPM

Medical Advisor

Updated 3/18/2021

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