Stress fractures

Last updated: February 24, 2023

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A stress fracture is a fracture of structurally normal bone due to the coalescence of microfractures caused by repetitive activity. Risk factors include female sex, calcium deficiency, and highly repetitive activity. Clinical manifestations include pain that worsens with activity and improves with rest and tenderness over the affected bone. High-risk stress fractures are stress fractures in locations (e.g., lateral femoral neck, anterior tibia, 5th metatarsal) that are prone to complications (e.g., fracture progression, nonunion). Stress fractures may be managed based on a clinical diagnosis, but x-rays are typically obtained for confirmation. Because x-rays are often normal, an MRI is indicated if there is a concern for a high-risk stress fracture. Treatment is mainly conservative and focuses on cessation of the inciting activity, but high-risk stress fractures are managed as acute fractures, with immobilization, avoidance of weight-bearing activities, and referral to orthopedics. Calcaneal stress fractures are a low-risk type of stress fracture. They are most commonly caused by repetitive microstress and/or prolonged loadbearing on the heel (e.g., jumping, marching) and can usually be managed conservatively.


Normal bone develops a fracture as a result of bone remodeling due to repetitive microtrauma. [1][2]

Risk factors [2][3]

The female athlete triad syndrome is associated with an increased risk of stress fractures. [5]

Stress fractures are classified according to the risk of healing complications. [2][3][5]

Low-risk stress fractures

High-risk stress fractures

A preliminary clinical diagnosis guides early management, but imaging of the affected region is indicated for confirmation. [5][8]

Stress fractures may be difficult to see on plain films and should be treated empirically based on the clinical diagnosis. [8]

The differential diagnoses listed here are not exhaustive.

Initial therapy of stress fractures is typically conservative. Surgical management is reserved for refractory cases and fractures in high-risk locations (e.g. anterior tibia, proximal 5th metatarsal, patella, talus, superolateral femoral neck), which are prone to fracture progression, delayed union, or nonunion.

Low-risk stress fractures [6][8]

Up to one-third of low-risk stress fractures do not heal with conservative management. Refer patients with refractory fractures to orthopedic surgery. [2]

High-risk stress fractures [5][8]

High-risk stress fractures should be managed like acute fractures. [5]

We list the most important complications. The selection is not exhaustive.

Calcaneal stress fractures are most commonly found in individuals who run, jump, and/or march for extended periods of time (e.g., athletes, dancers, soldiers). For acute fractures of the calcaneus, see “Calcaneal fractures.” [11]

Etiology [11]

  • Repetitive microstress to the calcaneus (e.g., weight overload, increase in physical activity)
  • Inadequate footwear and activity on hard surfaces increase risk.
  • See also “Etiology of stress fractures.”

Clinical features [11]

  • Heel pain on activity (e.g., weight-bearing activities, walking on hard surfaces)
  • Point tenderness on palpation of the posterior calcaneus
  • Swelling, warmth, and/or ecchymosis of the heel (uncommon)
  • Positive calcaneal squeeze test: pain elicited by mediolateral compression of the heel between thumb and index finger


Differential diagnosis of chronic heel pain

Treatment [11][12]

Calcaneal stress fractures are considered low-risk and can usually be managed conservatively.

Calcaneal stress fractures are often misdiagnosed as soft tissue injuries and undertreated. [#27519

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  4. Bencardino JT, Stone TJ, Roberts CC, et al. ACR Appropriateness Criteria ® Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae. J Am Coll Radiology. 2017; 14 (5): p.S293-S306. doi: 10.1016/j.jacr.2017.02.035 . | Open in Read by QxMD
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  8. McInnis KC, Ramey LN. High‐Risk Stress Fractures: Diagnosis and Management. PM&R. 2016; 8 (3S): p.S113-S124. doi: 10.1016/j.pmrj.2015.09.019 . | Open in Read by QxMD
  9. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  10. Kahanov L, Eberman L, Games K, Wasik M. Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open Access J Sports Med. 2015 : p.87. doi: 10.2147/oajsm.s39512 . | Open in Read by QxMD
  11. Brewer RB, Gregory AJM. Chronic Lower Leg Pain in Athletes. Sports Health. 2011; 4 (2): p.121-127. doi: 10.1177/1941738111426115 . | Open in Read by QxMD
  12. Kiuru MJ, Niva M, Reponen A, Pihlajamäki HK. Bone Stress Injuries in Asymptomatic Elite Recruits. Am J Sports Med. 2005; 33 (2): p.272-276. doi: 10.1177/0363546504267153 . | Open in Read by QxMD

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