Updated: Feb 18
We'll start off this article by discussing the main causes of stress fractures in the heel bone (calcaneus), because if you know the cause, you'll be better able to choose the correct treatment and prevent the injury from recurring. Then we'll look at what signs and symptoms you may experience when you have a heel stress fracture and finally at what treatments work best. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call.
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What causes calcaneal/heel stress fractures?
Our bodies are constantly renewing the cells in our bodies. It breaks down the old ones and replaces them with strong healthy ones. When the body can't form new bone cells quick enough to replace the old or injured ones in your heel bone, you may end up with a stress fracture. These are some of the most common reasons why this may happen:
Weightbearing activities (standing, walking, running, jumping) can increase this turnover of bone cells and over time help to strengthen our bones. It does this by causing microdamage in our bones. This is absolutely normal. The body then repairs the microdamage with stronger cells, and that's how our bones grow stronger and denser over time.
High impact activities like running are brilliant for building strong bones and there are lots of studies that show that physically active people tend to have much stronger and healthier bones than sedentary people.
If, however, you don't allow your body enough time to repair and rebuild your bones between bouts of activity, then the microdamage may accumulate and you might end up with an overuse injury like a stress fracture in your heel. This is why recovery/rest days between training or exercise sessions are so important.
Heel or calcaneal stress fractures are more common in athletes who do jumping sports or runners with high weekly training volumes (90km+).
Suddenly increasing the intensity or volume of an activity, doing an activity that you're not used to, or switching the terrain you train on (soft surface vs. hard) can also predispose you to developing stress fractures.
Footwear may also play a role - running with a heel-strike running style in minimalist shoes (so high impact on the heel and not a lot of cushioning) can cause your heel bone to overstrain.
Vitamin D and calcium
The main building block for strong bones is calcium. To absorb calcium from the gut, you need an adequate supply of vitamin D. So if your diet is lacking in calcium or you have a vitamin D deficiency, your bones can't repair themselves properly. This makes them vulnerable to developing stress fractures.
Your GP can test your vitamin D and calcium levels for you. You can find more information about vitamin D deficiency and supplements for bone health in this blog post.
Not getting enough calories
Our bodies require energy (calories) to burn as fuel. If, over an extended period of time, we exercise and don't replace the calories we burn, our bodies may start to think that we're starving. To ensure that we have the best chance of survival, the body then starts shutting down less vital functions and saves the energy for the organs and processes that are crucial for our survival.
One of the processes that gets shut off is bone turnover/renewal. There is strong evidence that links this relative energy deficiency to a higher risk of stress fractures in athletes. You can read more about how low energy availability can lead to poor bone health here.
Heel stress fracture symptoms
When you have a stress fracture in your heel bone, the pain is usually felt around or inside the heel bone. Taking hold of the heel bone and squeezing it between your thumb and forefinger often hurts.
During the early stages, the pain may only be present when you're weight bearing, e.g. standing, walking, or running. However, if you've continued to train on it, it may even hurt when you're not weight bearing, e.g. sitting or lying down.
There are other conditions that can cause pain in and around your heel bone. Bruising of the fat pad, plantar fasciitis, insertional Achilles tendinopathy and tarsal tunnel syndrome are some conditions that may be worth excluding before you conclude that you have a stress fracture in your heel. An experienced doctor or physio can easily assess and differentiate between these injuries.
Heel stress fractures can often be missed on plain X-rays, especially during the first few weeks. If you've had your injury for more than three weeks, X-rays are more likely to pick it up. MRI scans are much more sensitive and therefore better at diagnosing a stress fracture.
What treatments work best for heel/calcaneal stress fractures?
Taking the load off
You will have to temporarily reduce the load on your heel bone if you want it to recover. The aim is to reduce all your standing and walking (you will definitely have to stop running and jumping) to a level that does not cause you pain. If you continue to push into pain, your heel bone will struggle to heal.
Boot and crutches
If you catch it early, you may be able to get away with just wearing really cushioned shoes and reducing your weight bearing activities for a while. In severe cases, you may need to wear a boot or walk with crutches.
Diet and nutrition
You also have to address all the other factors that may have combined to cause your specific stress fracture. Speak to your doctor about vitamin D and calcium, and consider consulting a nutritionist if you suspect that your diet may not have been optimal.
Correct training load
Think about how you can adapt your training habits to prevent this injury from recurring. Did you perhaps neglect your rest days or increase your running volume/intensity too quickly?
Very slow return to load bearing/sport
Once the pain has fully settled, it's important to ease back into activities really slowly. Your heel bone will need time to grow strong again. Stress fractures can easily recur if you jump back into full training too quickly. It can be really useful to work with a sports physio who can guide you in this process.
What's the recovery time for a heel/calcaneal stress fracture?
It can take between two and eight weeks of limiting weight bearing activities to get a calcaneal stress fracture to fully settle down. Then it can take another six to twelve weeks to slowly build your activities back up to your pre-injury levels. If you feel the pain creeping back, you have to reduce your activity, allow the heel to settle down, and then build it back up even slower. This is not an injury that you can train through.
How we can help
Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.
About the Author
Kaeding, C. C. and T. L. Miller (2020). Classification of stress fractures. Stress fractures in athletes, Springer: 65-75.