Stress Fractures About the Tibia, Foot, and Ankle
1. Michael K. Shindle, MD,
2. Yoshimi Endo, MD,
3. Russell F. Warren, MD,
4. Joseph M. Lane, MD,
5. David L. Helfet, MD,
6. Elliott N. Schwartz, MD and
7. Scott J. Ellis, MD
From the Summit Medical Group, Morristown, NJ (Dr. Shindle), the Department of Radiology and
Imaging (Dr. Endo), the Department of Orthopedic Surgery (Dr. Warren and Dr. Ellis), and the
Orthopedic Trauma Service (Dr. Lane and Dr. Helfet), Hospital for Special Surgery, New York, NY,
and the Northern California Institute for Bone Health (Dr. Schwartz), Oakland, CA.
Dr. Warren or an immediate family member has received royalties from Biomet and Smith &
Nephew and has stock or stock options held in Cayenne, OrthoNet, and ReGen Biologics. Dr. Lane
or an immediate family member is a member of a speakers’ bureau or has made paid
presentations on behalf of Eli Lilly, Harvest Technologies, Novartis, and Weber Chilcott; serves as
a paid consultant to Amgen, CollPlant, Bone Therapeutics SA, BioMimetic, DFine, Graftys, and
Zimmer; has received research or institutional support from Amgen; and serves as a board
member, owner, officer, or committee member of the Orthopaedic Research Society, the
Musculoskeletal Tumor Society, the American Academy of Orthopaedic Surgeons, the Association
of Bone and Joint Surgeons, and the American Society for Bone and Mineral Research. Dr. Helfet or
an immediate family member has stock or stock options held in OHK Medical Devices and
FxDEVICES. Dr. Schwartz or an immediate family member is a member of a speakers’ bureau or
has made paid presentations on behalf of Amgen, Eli Lilly, and Novartis and has received research
or institutional support from Amgen, Eli Lilly, and Merck. None of the following authors or any
immediate family member has received anything of value from or owns stock in a commercial
company or institution related directly or indirectly to the subject of this article: Dr. Shindle, Dr.
Endo, and Dr. Ellis.
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Abstract
In competitive athletes, stress fractures of the tibia, foot, and ankle are common and lead to
considerable delay in return to play. Factors such as bone vascularity, training regimen, and
equipment can increase the risk of stress fracture. Management is based on the fracture site. In
some athletes, metabolic workup and medication are warranted. High-risk fractures, including
those of the anterior tibial diaphysis, navicular, proximal fifth metatarsal, and medial malleolus,
present management challenges and may require surgery, especially in high-level athletes who
need to return to play quickly. Noninvasive treatment modalities such as pulsed ultrasound and
extracorporeal shock wave therapy may have some benefit but require additional research.
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Risk Factors
A dynamic balance exists between the accumulation of microdamage and the host bone’s repair
processes. Intrinsic and/or extrinsic factors that disrupt this balance can increase the risk of
stress fracture. Intrinsic factors include metabolic state, menstrual patterns, level of fitness,
muscle endurance, anatomic alignment, microscopic bone structure, and bone vascularity.
Extrinsic factors include training regimen, dietary habits, and equipment (eg, footwear, playing
surface). Stress fractures commonly occur in poorly vascularized areas of bone. Bone in relative
watershed areas lacks the ability to respond to stress and heal. This is particularly true of highrisk stress fractures (ie, fractures of the navicular, fifth metatarsal, and anterior tibia). Poor blood
supply combined with high stress makes management of fractures in these areas challenging and
can delay an athlete’s return to play.1,2
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Diagnosis
Several history and physical examination findings are found in all types of stress fractures.
Typically, patients have an insidious onset of pain over a 2- to 3-week period. Onset of pain
often correlates with a recent change in training habits or equipment. A thorough history should
be obtained for all patients; medical history should include questions regarding known
endocrinopathies (eg, diabetes mellitus), autoimmune and eating disorders, depression,
malabsorption syndromes, bariatric surgery, and gastroesophageal reflux disease. Dietary history
should include questions regarding the intake of calcium, vitamin D, protein, and alcoholic and
caffeinated beverages. A medication history is helpful for detecting secondary causes of stress
fractures.
In the physical examination, the hallmark of a stress fracture is tenderness over the affected
bone. Percussion of the bone away from the site of the fracture may produce pain. Functional
testing such as hopping on one foot may also elicit pain.
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Imaging
Plain radiography is the most useful imaging modality for initial radiographic assessment of
stress fractures of the lower extremity. It is readily available, is inexpensive, and may preclude the
need for additional imaging if the radiographic features are consistent with a stress fracture.
Radiographic appearance of the fracture is affected by whether cortical or cancellous bone is
involved and the acuity of the injury. In stress fractures that involve cortical bone such as that
found in the metatarsal shaft, the earliest radiographic findings may include a subtle radiolucency
or poor definition of the cortex.3 Later findings include thickening and sclerosis of the
endosteum and periosteal new bone formation, which may take weeks to months to form after
the onset of symptoms.4 Stress fractures that involve cancellous bone (eg, calcaneus) appear as a
band of sclerosis characteristically oriented perpendicular to the trabeculae4 (Figure 1).
Typically, radiographic findings lag behind clinical symptoms by weeks and may not appear at all
if activity has been modified.4 When a stress fracture is suspected and initial radiographs are
nondiagnostic, repeat radiographs obtained 2 weeks after initial imaging may reveal the
fracture.4 If urgent diagnosis is needed, bone scan and MRI are often helpful. Bone scan is
particularly useful for identifying potential areas of pathology in patients with noncontiguous,
simultaneous fractures (eg, fractures of the second metatarsal and midshaft of the tibia).
Technetium-99m–labeled diphosphonate bone scan is very sensitive and aids in early detection of
stress fractures; this scan is a valuable diagnostic tool when initial radiographs are negative.
Stress fractures are visible on bone scans days to weeks earlier than on radiographs5 (Figure 2).
Although bone scan has a high degree of sensitivity, it is not always specific. Focal tracer uptake
can be the result of any process that remodels bone (eg, tumor, infection, stress reaction without
fracture).
MRI has become indispensable for evaluation of radiographically occult stress fractures. This
modality allows evaluation of the soft tissues and provides greater anatomic detail than does
plain radiography. Fluid-sensitive sequences (eg, short-tau inversion recovery, fat-saturated T2weighted sequences) are highly sensitive for endosteal marrow edema and periosteal edema,
which are typically the earliest features of stress fractures6 (Figure 3). Muscle edema, cortical
thickening, and a hypointense fracture line through the cortex or medullary cavity are also visible
on MRI. It is considered to be at least as sensitive as and more specific than bone scan for
detection of stress fractures.7
Ultrasonography can be sensitive in identifying radiographically occult stress fractures in
relatively superficial bones such as the metatarsals.8 Although the ultrasound beam cannot
penetrate the cortex to facilitate evaluation of the endosteum or marrow below, ultrasonography
can be used to evaluate the outer surface of the cortex for step-off, a hypoechoic band,
periosteal reaction, and hyperechoic callus formation.8,9 Benefits of this modality include the
absence of ionizing radiation as well as the ability to perform a focused, real-time evaluation of
the fracture. Localized tenderness with transducer pressure at the injury site is an important
ancillary finding. Doppler can be used to identify hypervascularity and increase the diagnostic
accuracy as well as better define the acuity of ultrasonography (Figure 4).
CT is rarely indicated for initial evaluation of suspected stress fractures because it has a higher
radiation dose than conventional radiography and low sensitivity compared with MRI.10 However,
CT can be useful when a more accurate evaluation of the osseous anatomy is needed. For
example, when MRI is equivocal, the exquisite bony detail provided by CT allows differentiation of
complete versus incomplete fracture. CT may be used to identify a subtle fracture line not seen
on other modalities. Fracture complications such as nonunion may be better visualized on CT,
especially if susceptibility artifact from adjacent hardware limits MRI evaluation. Some authors
advocate using a CT classification to guide management of certain types of stress fractures,
particularly navicular fractures.10
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Nonsurgical Management
In general, management of stress fractures includes rest and immobilization. It is useful to
classify fractures as low risk or high risk to help determine the appropriate nonsurgical or
surgical management.
At our institution, patients with stress fractures have a consultation with a metabolic bone disease
specialist, who evaluates the need for serum and urine testing based on a thorough history and
physical examination. A complete metabolic panel, including serum calcium, albumin, alkaline
phosphatase, and serum vitamin D levels, as well as a calculated glomerular filtration rate, is
ordered for all patients. Hormonal levels are assessed if the patient has a history of amenorrhea,
oligomenorrhea,
sexual
dysfunction,
or
certain
endocrinopathies
(eg,
hyperthyroidism,
hyperparathryoidsim). In addition, bone densitometry is ordered for patients with a history of
multiple stress fractures or the female athletic triad (ie, eating disorder, osteoporosis,
amenorrhea). If an eating disorder is discovered, a multidisciplinary approach to treatment is
indicated.11
Medication
A slow healing process may interrupt participation in sports for a relatively long period of time. In
addition, nonsurgical treatment may result in delayed union or nonunion. In certain
circumstances, surgical management is indicated to promote union, thereby allowing a quicker
return to weight-bearing activity. However, inherent limitations in the ability of some fractures to
heal have sparked an interest in developing effective pharmacologic interventions to either
prevent stress fractures or accelerate recovery. If laboratory workup reveals low levels of calcium,
vitamin D, or phosphorus, underlying causes should be investigated and, at a minimum, a strict
regimen of supplementation should be instituted. The recommended daily allowances of calcium
and vitamin D are 1,000 mg and 800 to 1,000 IU, respectively.12 However, debate exists
regarding whether this amount is too low for athletes. At our institution, we recommend 1,200 to
1,500 mg/d of calcium and 800 to 3,000 IU/d of vitamin D.
A variety of medications that has been used to manage osteoporosis and osteopenia has also
been used to manage stress fractures. Diphosphonates prevent osteoclast-mediated bone
resorption and thus may prevent the initial bone loss observed in the remodeling response to
high bone strain, potentially preventing stress fracture.13 Stewart el al14 treated five collegiatelevel athletes with intravenous pamidronate weekly for 5 weeks. Four of five athletes were able to
continue training and compete within 1 week of therapy. The remaining patient missed only 3
weeks of training, which suggests that pamidronate may be useful when used as an adjuvant
therapy. Another study evaluated the prophylactic use of risedronate in a high-risk military
population.15 There was no statistically significant difference between the treatment and placebo
groups with regard to the total stress fracture incidence. Until the results of well-designed clinical
trials become available, it is prudent to limit use of diphosphonates for management of stress
fractures. The risks and benefits of any prescribed medication must be considered.
Diphosphonates should not be used in patients of childbearing age.
Teriparatide (Forteo, Eli Lilly, Indianapolis, IN) is a 1-34 amino acid moiety of the N-terminal
portion of the 1-84 amino acid parathyroid molecule and is produced by recombinant DNA
technology. Like the full parathyroid molecule, bursts of teriparatide are anabolic to bone and
result in additional osteoblast formation from precursor stem cells, which results in earlier and
increased formation of callus, thereby improving fracture healing. This effect has been reported
in numerous preclinical studies.16-19 These data have led to the use of teriparatide in numerous
anecdotal situations and in patients with acute traumatic, osteoporotic, and stress fractures and
delayed fracture healing or nonunion. Forteo has been approved by the FDA for treatment of
osteoporosis in women with a high risk of fracture. It is used off label to increase bone mass in
men who are at high risk of fracture (ie, those with osteoporosis, those taking glucocorticoids). In
addition, one must be cognizant of the contraindications and warnings associated with this drug;
Forteo has a black box warning because its use was associated with osteosarcoma in a rat
model.18 Further research is needed to determine the effect of teriparatide on fracture healing in
humans. The use of anabolic agents (eg, anti-sclerostin antibody) for fracture prevention and
acute fracture healing requires additional research, as well. It is likely that over the next 5 to 10
years, the role of platelet-rich plasma, mesenchymal stem cells, bone morphogenetic proteins,
and other modalities will be further clarified.
Pulsed Ultrasound
Use of other modalities such as pulsed ultrasound has been proposed for management of stress
fractures. Although the exact mechanism remains unknown, pulsed ultrasound is thought to
induce aggrecan and proteoglycan synthesis in chondrocytes, leading to increased endochondral
ossification.20 In a recent prospective, randomized, double-blind study, 43 tibial stress fractures
were randomized to treatment with either placebo or pulsed ultrasound. There was no significant
reduction in healing time between the two groups. However, other studies have shown that
pulsed ultrasound may decrease the time to clinical healing; therefore, additional studies are
warranted.21
Extracorporeal Shock Wave Therapy
Extracorporeal shock wave therapy (ESWT), another noninvasive technique, has proved to be
effective for fracture healing and management of delayed union and nonunion in an animal
model.22 ESWT is thought to induce periosteal detachment and microfractures of the trabeculae,
which in turn can stimulate fracture healing.23 Taki et al23 reported on five athletes with
recalcitrant stress fractures treated with ESWT and suggested that it is an effective treatment
method for intractable stress fractures in athletes. Additional basic science and clinical studies
are necessary to determine the effectiveness of ESWT as well as optimal energy density levels and
impulse rates.
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Management of Specific High-Risk Stress Fractures
Anterior Tibial Diaphysis
Anterior tibial (ie, so-called dreaded black line) stress fractures are less common but more
concerning than posteromedial tibial stress fractures. Radiographic findings associated with
stress fracture of the anterior tibia include a thickened anterior cortex with a lucent line in the
anterior midshaft of the tibia (Figure 5). Management of this fracture is challenging, especially in
the high-performance athlete. Constant tension from posterior muscle forces and poor
vascularity may predispose to delayed union and nonunion and even complete fracture.
Beals and Cook24 reported poor results with nonsurgical management of stress fractures of the
anterior tibial diaphysis. Five of eight patients with these fractures who were allowed full activity
went on to complete fracture. Only 8 of 20 patients (40%) treated with rest alone were able to
return to full activity after an average of 4.4 months. Batt et al25 treated four delayed-union
stress fractures of the anterior midshaft of the tibia with bracing and modified rest; the mean
time to return to full activity was 12 months. Such long periods of convalescence may end a
professional athlete’s career.
Other authors have reported better success with nonsurgical management of these fractures.
Rettig et al26 reported that seven of eight basketball players with anterior stress fractures
achieved union with rest and electrical stimulation. Mean treatment time was 8.7 months. The
players returned to sport at a mean of 12.5 months.
Intramedullary (IM) nailing of chronic anterior tibial stress fractures is effective in many cases, but
it does not uniformly lead to healing.27 The pain relief promoted by the nail may allow return to
sport before complete bone healing.
Borens et al28 used an anterior tension band plating technique to treat four high-performance
female athletes with anterior tibial stress fractures. Compression plating of the anterolateral
aspect of the tibia was done with a 3.5-mm 6-hole locking compression plate (Figure 6). All four
patients underwent bone grafting with demineralized bone matrix. Immediately postoperatively,
patients began range-of-motion exercises for the knee and ankle as well as isometric exercises
without resistance. Physical therapy was initiated, with weight bearing of the affected extremity
limited to 20 lbs for 8 weeks, followed by progression to full weight bearing and return to sport
as tolerated over the next 2 to 4 weeks. All four athletes returned to full activity at a mean of 10
weeks. The authors postulated that anterior tension band plating may be superior to IM nailing
because (1) biomechanically, a plate that is placed at a distance from the central axis of the bone
has a mechanical advantage over an IM device in neutralizing tensile forces and fracture
micromotion, (2) an anterior plate has the added advantage of being ideally placed to resist the
tensile forces that lead to anterior stress fractures, and (3) plating avoids disruption of the knee
extensor mechanism and the anterior knee pain frequently associated with IM nailing of the
tibia.29
Navicular
The navicular is susceptible to stress fracture based on specific vascular and biomechanical
properties. The central one third of the navicular body has been identified as a zone of maximum
shear stress.30 During the foot-strike phase of running, and especially in the equinus foot,
compression forces are generated from distal to proximal across the medial and lateral aspects of
the navicular via the first and second metatarsocuneiform joints. The talar head resists the forces
across the first metatarsal and medial cuneiform, whereas forces across the second metatarsal
and middle cuneiform are not resisted. Because of these forces, the navicular experiences a zone
of maximal shear stress just lateral to the center of the talar head in the talonavicular articulation.
In addition, the central zone of the navicular body is devoid of a direct blood supply and has
difficulty healing30 (Figure 7).
Often, there is a considerable delay in the diagnosis of navicular fracture; therefore, a high index
of suspicion should be maintained for this stress fracture in the athlete with foot pain (Figure 8).
Physical examination may reveal focal dorsal pain over the midportion of the navicular, which is
also referred to as the N spot.31,32
Management of navicular stress fractures continues to evolve. These fractures can heal without
surgery; however, such healing comes at the cost of prolonged immobilization and limitation of
activity. These fractures are high risk; therefore, aggressive management is necessary.
Nonsurgical management should include use of a nonweight-bearing cast until the fracture has
healed. Torg et al33 performed a systematic review of nonsurgical and surgical management of
tarsal navicular stress fractures and concluded that nonsurgical non-weight–bearing management
is the standard of care for initial treatment of both partial and complete stress fractures of the
tarsal navicular. In a separate study, Torg et al34 reported a 100% success rate in 10 patients
treated with non-weight–bearing cast immobilization for 6 to 8 weeks, with an average return to
activity at 3.8 months.
In a study of 82 patients with navicular stress fractures managed nonsurgically, Khan et al32
reported that 19 of 22 patients (86%) treated for 6 weeks in a non-weight–bearing cast returned
to full activity at an average of 5.6 months postinjury. Only 9 of 13 patients (69%) managed with
casting for a shorter duration (ie, 2 to 5 weeks) returned to full activity. In five patients with no
activity restrictions, only one returned to full activity. This study demonstrates the importance of
strict non-weight–bearing restrictions with casting for a minimum of 6 weeks.
Surgical management of navicular stress fractures includes screw fixation with or without
exposure of the fracture site (Figure 9). Elite athletes with type I navicular stress fractures may
choose to undergo percutaneous screw fixation to return to competition quickly and to reduce
the risk of recurrent stress fracture. At our institution, the preferred technique is to expose the
fracture site and use compression screw fixation with two screws placed such that the threads
gain as much purchase in the larger fragment of bone as possible, which usually entails placing
the screws from lateral to medial. However, screw placement depends on the exact location of the
fracture. Partially threaded cannulated screws are the easiest to place and can deliver
compression but are weaker than solid screws. Postoperative rehabilitation includes non-weight–
bearing ambulation with a removable walking cast for 4 weeks, partial weight bearing for 2
weeks, and gradual return to activity at 8 weeks. Some authors recommend repeat imaging to
confirm healing before permitting return to full sporting activities.30
Proximal Fifth Metatarsal
Stress fracture of the proximal fifth metatarsal typically occurs just distal to the metaphysealdiaphyseal junction of the fifth metatarsal (Figure 10). These fractures are common in basketball,
football, and soccer players, and are considered high risk because of the high incidence of
nonunion due to poor blood supply. We suggest nonsurgical management with strict non-weight–
bearing ambulation in a short leg cast for 6 to 8 weeks. Because of the high incidence of delayed
union and nonunion, surgeons may consider more aggressive management of these fractures. If
the patient is an elite-level athlete, has persistent unresolved pain, or develops an established
pseudarthrosis, then surgical intervention is indicated.
Torg et al35 reported on 15 acute fractures of the base of the fifth metatarsal treated with
protected weight bearing and cast immobilization; 93% healed at an average of 6.5 weeks. One
patient had a nonunion that required surgery. The authors concluded that non-weight– bearing
and cast immobilization for 6 to 8 weeks is successful in patients in which IM sclerosis is not
present on radiographs. However, surgical intervention should be considered in patients with
radiographic evidence of IM sclerosis that partially obliterates the medullary cavity or in patients
who engage in high-level athletic activity. Clapper et al36 reported on 100 acute fractures divided
into three groups: avulsion fractures, which were treated with a hard-soled shoe or walking cast
with weight bearing as tolerated; proximal stress fractures, which were treated with a nonweight–bearing cast for 8 weeks and then progressive weight bearing in a walking cast; and (3)
shaft or neck fractures, which were treated with a short-leg walking cast and weight bearing as
tolerated. The cast was removed 4 weeks postinjury; if symptoms persisted, the cast was
reapplied and worn for an additional 2 to 4 weeks. Twenty-five patients had proximal stress
fractures of the fifth metatarsal. In this group, union occurred in only 18 patients (72%), and 7
had clinical and radiographic evidence of nonunion 25 weeks after injury. These patients
underwent IM screw fixation and had a union rate of 100% at an average of 12.1 weeks.
Goals of early surgical management are to minimize the risk of nonunion and refracture and to
decrease the time to return to sport. Foot anatomy must be taken into consideration, and
additional procedures, such as lateralizing calcaneal osteotomy for a cavovarus foot, should be
considered. At our institution, internal fixation with a solid stainless steel IM screw has become
the procedure of choice (Figure 10, B). The patient is kept non-weight–bearing for 3 weeks; then
partial weight bearing is allowed with a removable boot, and stationary bicycle and pool therapy
is begun. Transition to full weight bearing begins at 5 weeks. In general, return to activity is
allowed 2 months after surgery, depending on the resolution of pain and radiographic evidence of
healing. Porter et al37 reported on 23 consecutive athletes treated with fixation using a 4.5-mm
cannulated screw; all athletes returned to sport at an average of 7.5 weeks.
Great Toe Sesamoids
Stress fractures of the great toe sesamoids are not uncommon in athletes, particularly football
players, runners, golfers, and gymnasts. The medial sesamoid bone is more likely to develop a
stress fracture because it is larger than the lateral sesamoid and lies directly under the head of
the first metatarsal. Repeated dorsiflexion of the great toe during running and jumping can result
in tensile forces on the sesamoid sufficient to cause a transverse stress fracture. Patients typically
present with pain on palpation of the plantar aspect of the sesamoid bones as well as pain with
dorsiflexion of the metatarsophalangeal joint of the great toe. Plain radiographs, particularly AP
and sesamoid views, may be helpful, and MRI can be used to identify areas of edema or necrosis
(Figure 11).
Stress fracture of the sesamoid must be differentiated from bipartite sesamoid. In the general
population, the reported incidence of bipartite sesamoid ranges from 5% to 30%, and the
incidence of bilaterality is approximately 80%.38,39 Bipartite sesamoid occurs more commonly in
the medial sesamoid, and radiographs typically reveal a sesamoid with smooth margins.
Radiographically, a stress fracture can be differentiated from a bipartite sesamoid by the presence
of a transverse fracture line with jagged margins. Nuclear imaging can be useful to help
differentiate acute or stress fractures from a bipartite sesamoid.
Nonsurgical management is the standard of care and should include a non-weight–bearing cast
that extends to the distal tip of the toe to prevent dorsiflexion. After initial casting, an orthosis
with a dancer’s pad or a stiff-soled running shoe with a built-in metatarsal bar may be used.
Other conditions may place additional force on the sesamoids (eg, plantar flexed first ray,
isolated gastrocnemius contracture, pes cavus alignment; these should be considered in the
treatment plan.
Early surgical intervention may be required for stress fractures in the sesamoids of the great toe
because of the high incidence of delayed union, nonunion, or refracture associated with these
fractures. Surgery may consist of bone grafting, cast immobilization, and open reduction and
internal fixation, or excision of the offending sesamoid bone and reconstruction of the flexor
hallucis brevis and intersesamoid ligament.
Medial Malleolus
Stress fractures of the medial malleolus are relatively uncommon. They can occur during running
and jumping activities. Etiology of these stress fractures may be secondary to repetitive
impingement of the talus on the medial malleolus during ankle dorsiflexion and tibial rotation.40
In patients with negative plain radiographs and evidence of incomplete fracture line on advanced
imaging such as MRI, treatment is individualized based on the patient’s prior level of activity
(Figure 12). Most patients can be treated successfully with activity modification and cast
immobilization or ankle bracing. However, nonunion has been reported with high shear forces
exerted at the fracture site.40 We recommend internal fixation with two 4.0-mm cancellous
screws or a plate in patients with a complete fracture line visible on radiographs or in patients
with nonunion. Bone grafting should be considered for management of nonunion.
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Summary
Stress fractures most commonly occur in the tibia, foot, and ankle and may result in considerable
delay in return to play. Many factors can affect these injuries, including metabolic state, blood
supply, training regimen, and foot anatomy (eg, varus or valgus hindfoot, plantar flexed first ray).
The location of the injury can help in predicting the rate of healing and dictating treatment.
Nonsurgical management of these fractures with medication such as teriparatide and other
anabolic agents (eg, anti-sclerostin antibody) is promising, but further research is warranted.
Additional research is also needed on other nonsurgical treatment options, including pulsed
ultrasound and ESWT. In general, good results have been reported with weight-bearing
restrictions and cast immobilization; however, surgical intervention may be required to manage
high-risk stress fractures in athletes who must return to sport quickly.
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Figures
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Figure 1
Lateral radiograph of the foot demonstrating a stress fracture of the calcaneus. The arrow marks
a linear band of sclerosis perpendicular to the trabeculae.
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Figure 2
Technetium-99m-methylene diphosphonate bone scan of anterior tibias demonstrating focal
tracer uptake in the lateral aspect of the midshaft of the right tibia, which is consistent with a
stress fracture.
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Figure 3
Axial short-tau inversion recovery magnetic resonance image through the midshaft of the tibia
demonstrating endosteal marrow edema (arrow) and periosteal edema (arrowhead) associated
with a tibial stress fracture.
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Figure 4
Ultrasound with power Doppler of the dorsum of the second metatarsal bone demonstrating
callus formation along the metatarsal diaphysis, with associated hyperemia consistent with a
healing stress fracture.
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Figure 5
Plain AP (A) and lateral (B) radiographs of the tibia and fibula in a 23-year-old female professional
basketball player with an anterior tibial stress fracture. The fracture is not visible on the AP
radiograph, but the black line (arrow) that represents an anterior tibial stress fracture can be seen
on the lateral radiograph. C, Magnification of the lateral radiograph demonstrating the black line
(arrow).
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Figure 6
Management of an anterior tibial stress fracture with compression plating. A, The preoperative
plan outlines patient position, exposure, and equipment to be used. B, Intraoperative photograph
demonstrating the stress fracture following débridement. AP (C) and lateral (D) intraoperative
fluoroscopic images demonstrating the position and appearance of the plate. Postoperative AP (E)
and lateral (F) radiographs demonstrating a healed tibial stress fracture at 8 weeks.
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Figure 7
Multiplanar reformatted axial CT scan of the foot demonstrating subchondral sclerosis along the
proximal articular surface of the navicular with a central linear fracture line and lucent cavity
(arrow) in the cancellous bone that is consistent with a chronic stress fracture.
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Figure 8
Coronal fast spin-echo magnetic resonance image demonstrating a navicular fracture (arrow).
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Figure 9
Intraoperative AP fluoroscopic image demonstrating medial to lateral placement of two 4.0-mm
cannulated screws. Stronger, solid screws can also be used for compression fixation.
Compression can be obtained using partially threaded screws or by overdrilling the medial
fragment.
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Figure 10
A, Preoperative AP radiograph of the foot demonstrating a stress fracture of the fifth metatarsal
base in a 20-year-old collegiate soccer player. The fracture is located just distal to the fourth and
fifth metatarsal articulation. The large degree of sclerosis is suggestive of the chronic nature of
the fracture. B, Postoperative AP radiograph of the foot obtained 2.5 months after fixation of the
fracture. A solid, partially threaded screw was used to bypass and compress the fracture site.
Healing is observed on all sides of the fracture.
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Figure 11
A, Coronal short-tau inversion recovery magnetic resonance image of the foot demonstrating
marrow edema within the lateral hallux sesamoid (arrow). B, Sagittal proton density sequence
demonstrating a hypointense signal within the lateral hallux sesamoid with a central linear signal
that represents a fracture (arrow). C, Sesamoid radiograph demonstrating sclerosis of the lateral
sesamoid and the irregular contour of the plantar surface (arrow) secondary to a chronic stress
fracture.
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Figure 12
Axial (A) and coronal (B) proton density sequences of the ankle demonstrating linear hypointense
focus (arrows) in the anterior medial malleolus that represents a stress fracture that extends to
the tibiotalar articular surface. (Courtesy of Carolyn M. Sofka, MD, New York, NY.)
Previous Section
References
1. Evidence-based Medicine: Levels of evidence are listed in the table of contents. In
this article, references 6, 15, 17-20, and 22 are level I studies. References 5, 7, and
8 are level III studies. References 10, 14, 23-29, 32-37, and 40 are level IV studies.
References 1-4, 9, 11-13, 16, 30, 31, 38, and 39 are level V expert
opinion.References printed in bold type are those published within the past 5 years.
2. 1.↵
1. Boden BP,
2. Osbahr DC
BodenBP, OsbahrDC: High-risk stress fractures: Evaluation and treatment. J Am Acad
Orthop Surg 2000;8(6):344-353.pmid:11104398
Abstract/FREE Full Text
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1. Anderson RB,
2. Hunt KJ,
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This Article
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doi: 10.5435/JAAOS-20-03-167 J Am Acad Orthop Surg March 2012 vol. 20 no. 3 167-176
1.
AbstractFree
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» Full Text
3.
Full Text (PDF)
Navigate This Article
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Abstract
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Risk Factors
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Imaging
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Nonsurgical Management
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Management of Specific High-Risk Stress Fractures
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Summary
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Figures
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