What is the appropriate management for a calcaneal stress fracture?

Management of Calcaneal Stress Fractures

Calcaneal stress fractures should be treated with protected weight-bearing using a walking boot or cast, activity modification, and immobilization for 6-8 weeks minimum until the patient is pain-free on palpation, as this is a low-risk fracture that responds well to conservative management. 1, 2, 3

Initial Diagnosis and Confirmation

• Plain radiographs are the first-line imaging, though they have limited sensitivity (30-70%) and symptoms often occur before fractures are visible on x-rays. 1, 2
• MRI without contrast is the definitive diagnostic study when radiographs are negative but clinical suspicion remains high, offering excellent sensitivity and providing prognostic information for return-to-activity timelines. 1, 2, 3
• Key clinical finding: Pain on compression of the calcaneus is highly suspicious for stress fracture, with tenderness at the lateral calcaneal wall slightly posterior to the subtalar facet. 1
• Swelling and warmth may be present at the injury site. 1

Risk Stratification

Calcaneal stress fractures are classified as low-risk, meaning they are not prone to delayed union, nonunion, or avascular necrosis—unlike high-risk foot stress fractures (navicular, talus, medial malleolus, proximal fifth metatarsal, hallux sesamoids). 2, 4

This distinction is critical because it allows for less aggressive management compared to high-risk fractures.

Conservative Treatment Protocol

Immobilization and Weight-Bearing

• Immobilize with a walking boot or cast for a minimum of 6-8 weeks until the patient is completely pain-free on palpation. 1, 2, 3
• Protected weight-bearing is appropriate for calcaneal stress fractures (as opposed to complete non-weight-bearing required for high-risk fractures). 2
• Initial immobilization may involve 4 weeks of non-weight-bearing, followed by progressive weight-bearing between weeks 4-8. 5

Pain Management

• NSAIDs are appropriate for pain relief in calcaneal stress fractures. 2
• Paracetamol can be used regularly unless contraindicated. 6

Activity Modification

• Complete cessation of the inciting activity (running, jumping, repetitive impact) is mandatory during the healing phase. 1, 5, 7
• Sports activity should not resume before 12 weeks, with full return to unrestricted activity typically by 24 weeks. 5

Return-to-Activity Algorithm

Follow this specific progression to avoid re-injury:

1. Achieve pain-free walking for 45-60 minutes daily before any running. 2
2. Begin a graded run-walk program:
   • Start with 1-minute running intervals alternating with walking
   • Increase running duration by 1-2 minutes each session
   • Perform sessions on alternating days for the first 2-4 weeks
   • If pain occurs, rest and resume at the previous lower intensity 2
3. Overall timeline: Expect approximately 12 weeks before initiating sports activity, with full return by 24 weeks. 5

Special Populations Requiring Modified Management

Patients with Osteoporosis or on Bisphosphonates

These patients have significantly higher risk of progression from incomplete to complete fracture and require:

• Longer immobilization periods than standard 6-8 weeks 2, 3
• More conservative approach with extended protected weight-bearing 2
• Evaluation of vitamin D and calcium levels with supplementation if deficient 2

Bilateral Calcaneal Stress Fractures

• Metabolic and nutritional issues must be investigated, including screening for female athlete triad, vitamin D deficiency, and underlying bone quality disorders. 2, 5, 8
• Consider carbamazepine or other antiepileptic drug use as a cause of poor bone quality. 8

Follow-Up and Monitoring

• Clinical follow-up should continue until the patient is pain-free on palpation; thereafter, controlled increase in activity is permitted. 2
• For uncomplicated calcaneal stress fractures, additional imaging is generally unnecessary when clinical improvement is evident. 2
• If symptoms persist despite 6-8 weeks of adequate conservative therapy, obtain repeat MRI to assess for delayed union or other complications. 2
• If symptoms recur with increased activity, repeat imaging and re-evaluation of the original diagnosis are recommended. 2

Critical Pitfalls to Avoid

• Do not confuse calcaneal stress fractures with acute traumatic calcaneal fractures (which result from falls from height and require CT imaging and often surgical intervention). 1, 6
• Do not allow early return to high-impact activities before achieving pain-free palpation and completing the minimum 6-8 week immobilization period, as this leads to re-injury. 2, 3
• Do not miss bilateral fractures or underlying metabolic disease—always inquire about training intensity changes, nutritional status, and medication history (especially antiepileptics). 5, 8
• Requiring complete resolution of bony tenderness can unnecessarily delay return to activity; functional pain-free walking is the adequate benchmark for low-risk fractures like the calcaneus. 2