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Stress Fractures of the Foot and Ankle

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Foot and Ankle Sports Orthopaedics

Abstract

Stress fractures were first described over 250 years ago and are believed to be the result of repetitive, prolonged muscular action on bone that has yet to accommodate or remodel. There is a close association with several well-known groups: military recruits, runners, and ballet dancers. Despite the easily identifiable populations, stress fractures are difficult to diagnose due to late appearance on standard radiograph. Therefore, a thorough history, a detailed physical exam, and a high level of suspicion are required to diagnose in a timely manner. Foot and ankle stress fractures make up a large percentage of the overall incidence of stress fractures with the tibia, fibula, metatarsals (MT), and calcaneus being more common and the navicular and sesamoid bones being less common. Although each bone has a slightly different etiology, presentation, and radiographic tendency, stress fractures of the foot and ankle are generally treated with activity modification and protected weight bearing, a difficult concept for the highly-active patient that usually presents. Prevention of stress fractures focuses on optimizing bone quality, sound training technique, and quality training equipment.

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References

  1. Breithaupt J. Zur pathologie des menschlichen fusses. Medizin Zeitung. 1855;24:169–77.

    Google Scholar 

  2. Daffner RH, Martinez S, Gehweiler JA, Harrelson JM. Stress fractures of the proximal tibia in runners. Radiology. 1982;142(1):63–5.

    Article  CAS  PubMed  Google Scholar 

  3. Beck BR. Tibial stress injuries. An aetiological review for the purposes of guiding management. Sports Med. 1998;26(4):265–79.

    Article  CAS  PubMed  Google Scholar 

  4. Daffner RH, Pavlov H. Stress fractures: current concepts. AJR Am J Roentgenol. 1992;159(2):245–52.

    Article  CAS  PubMed  Google Scholar 

  5. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987;15(1):46–58.

    Article  CAS  PubMed  Google Scholar 

  6. Brockwell J, Yeung Y, Griffith JF. Stress fractures of the foot and ankle. Sports Med Arthrosc. 2009;17(3):149–59.

    Article  PubMed  Google Scholar 

  7. Hoppenfeld S, Hutton RJA. Physical examination of the spine and extremities. New York: Appleton-Century-Crofts; 1976.

    Google Scholar 

  8. Gardner LI, Dziados JE, Jones BH, Brundage JF, Harris JM, Sullivan R, Gill P. Prevention of lower extremity stress fractures: a controlled trial of a shock absorbent insole. Am J Public Health. 1988;78(12):1563–7.

    Article  PubMed  PubMed Central  Google Scholar 

  9. McBryde AM. Stress fractures in runners. Clin Sports Med. 1985;4(4):737–52.

    PubMed  Google Scholar 

  10. Levy JM. Stress fractures of the first metatarsal. AJR Am J Roentgenol. 1978;130(4):679–81.

    Article  CAS  PubMed  Google Scholar 

  11. Spitz DJ, Newberg AH. Imaging of stress fractures in the athlete. Radiol Clin North Am. 2002;40(2):313–31.

    Article  PubMed  Google Scholar 

  12. Lee JK, Yao L. Stress fractures: MR imaging. Radiology. 1988;169(1):217–20.

    Article  CAS  PubMed  Google Scholar 

  13. LEABHART JW. Stress fractures of the calcaneus. J Bone Joint Surg Am. 1959;41-A:1285–90.

    Article  CAS  PubMed  Google Scholar 

  14. Kaeding CC, Miller T. The comprehensive description of stress fractures: a new classification system. J Bone Joint Surg Am. 2013;95(13):1214–20.

    Article  PubMed  Google Scholar 

  15. Harder AT, An YH. The mechanisms of the inhibitory effects of nonsteroidal anti-inflammatory drugs on bone healing: a concise review. J Clin Pharmacol. 2003;43(8):807–15.

    Article  CAS  PubMed  Google Scholar 

  16. Wentz L, Liu PY, Ilich JZ, Haymes EM. Dietary and training predictors of stress fractures in female runners. Int J Sport Nutr Exerc Metab. 2012;22(5):374–82.

    Article  PubMed  Google Scholar 

  17. Nieves JW, Melsop K, Curtis M, Kelsey JL, Bachrach LK. Nutritional factors that influence change in bone density and stress fracture risk among young female cross-country runners. PM R. 2010;2(8):740–50.

    Article  PubMed  Google Scholar 

  18. Tenforde AS, Sayres LC, Sainani KL, Fredericson M. Evaluating the relationship of calcium and vitamin D in the prevention of stress fracture injuries in the young athlete: a review of the literature. PM R. 2010;2(10):945–9.

    Article  PubMed  Google Scholar 

  19. Lappe J, Cullen D, Haynatzki G, Recker R, Ahlf R, Thompson K. Calcium and vitamin d supplementation decreases incidence of stress fractures in female navy recruits. J Bone Miner Res. 2008;23(5):741–9.

    Article  CAS  PubMed  Google Scholar 

  20. Altarac M, Gardner JW, Popovich RM, Potter R, Knapik JJ, Jones BH. Cigarette smoking and exercise-related injuries among young men and women. Am J Prev Med. 2000;18(3 Suppl):96–102.

    Article  CAS  PubMed  Google Scholar 

  21. Jones BH, Cowan DN, Tomlinson JP, Robinson JR, Polly DW, Frykman PN. Epidemiology of injuries associated with physical training among young men in the army. Med Sci Sports Exerc. 1993;25(2):197–203.

    Article  CAS  PubMed  Google Scholar 

  22. Reynolds KL, Heckel HA, Witt CE, Martin JW, Pollard JA, Knapik JJ, Jones BH. Cigarette smoking, physical fitness, and injuries in infantry soldiers. Am J Prev Med. 1993;10(3):145–50.

    Google Scholar 

  23. Greaney RB, Gerber FH, Laughlin RL, Kmet JP, Metz CD, Kilcheski TS, et al. Distribution and natural history of stress fractures in U.S. Marine recruits. Radiology. 1983;146(2):339–46.

    Article  CAS  PubMed  Google Scholar 

  24. D’Ambrosia RD, Drez D. Prevention and treatment of running injuries. Thorofare: C.B. Slack; 1982.

    Google Scholar 

  25. Anderson RB, McBryde AM. Autogenous bone grafting of hallux sesamoid nonunions. Foot Ankle Int. 1997;18(5):293–6.

    Article  CAS  PubMed  Google Scholar 

  26. Griffin NL, Richmond BG. Cross-sectional geometry of the human forefoot. Bone. 2005;37(2):253–60.

    Article  PubMed  Google Scholar 

  27. Milgrom C, Finestone A, Sharkey N, Hamel A, Mandes V, Burr D, et al. Metatarsal strains are sufficient to cause fatigue fracture during cyclic overloading. Foot Ankle Int. 2002;23(3):230–5.

    Article  CAS  PubMed  Google Scholar 

  28. Donahue SW, Sharkey NA. Strains in the metatarsals during the stance phase of gait: implications for stress fractures. J Bone Joint Surg Am. 1999;81(9):1236–44.

    Article  CAS  PubMed  Google Scholar 

  29. Drez D, Young JC, Johnston RD, Parker WD. Metatarsal stress fractures. Am J Sports Med. 1980;8(2):123–5.

    Article  PubMed  Google Scholar 

  30. HARRIS RI, BEATH T. The short first metatarsal; its incidence and clinical significance. J Bone Joint Surg Am. 1949;31A(3):553–65.

    Article  CAS  PubMed  Google Scholar 

  31. Chuckpaiwong B, Cook C, Pietrobon R, Nunley JA. Second metatarsal stress fracture in sport: comparative risk factors between proximal and non-proximal locations. Br J Sports Med. 2007;41(8):510–4.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Lucas MJ, Baxter DE. Stress fracture of the first metatarsal. Foot Ankle Int. 1997;18(6):373–4.

    Article  CAS  PubMed  Google Scholar 

  33. Meurman KO. Less common stress fractures in the foot. Br J Radiol. 1981;54(637):1–7.

    Article  CAS  PubMed  Google Scholar 

  34. Porter DA, Foulk DM, Rund AM. Intramedullary screw fixation for chronic proximal fourth metatarsal stress fractures: a new technique for the fourth metatarsal jones. Tech Foot Ankle Surg. 2010;9(3):147–53.

    Article  Google Scholar 

  35. O’Malley MJ, Hamilton WG, Munyak J, DeFranco MJ. Stress fractures at the base of the second metatarsal in ballet dancers. Foot Ankle Int. 1996;17(2):89–94.

    Article  PubMed  Google Scholar 

  36. Towne LC, Blazina ME, Cozen LN. Fatigue fracture of the tarsal navicular. J Bone Joint Surg Am. 1970;52(2):376–8.

    Article  CAS  PubMed  Google Scholar 

  37. Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24(2):211–7.

    Article  CAS  PubMed  Google Scholar 

  38. Khan KM, Fuller PJ, Brukner PD, Kearney C, Burry HC. Outcome of conservative and surgical management of navicular stress fracture in athletes. Eighty-six cases proven with computerized tomography. Am J Sports Med. 1992;20(6):657–66.

    Article  CAS  PubMed  Google Scholar 

  39. Fitch KD, Blackwell JB, Gilmour WN. Operation for non-union of stress fracture of the tarsal navicular. J Bone Joint Surg Br. 1989;71(1):105–10.

    Article  CAS  PubMed  Google Scholar 

  40. Torg JS, Pavlov H, Cooley LH, Bryant MH, Arnoczky SP, Bergfeld J, Hunter LY. Stress fractures of the tarsal navicular. A retrospective review of twenty-one cases. J Bone Joint Surg Am. 1982;64(5):700–12.

    Article  CAS  PubMed  Google Scholar 

  41. Pavlov H, Torg JS, Freiberger RH. Tarsal navicular stress fractures: radiographic evaluation. Radiology. 1983;148(3):641–5.

    Article  CAS  PubMed  Google Scholar 

  42. Khan KM, Brukner PD, Kearney C, Fuller PJ, Bradshaw CJ, Kiss ZS. Tarsal navicular stress fracture in athletes. Sports Med. 1994;17(1):65–76.

    Article  CAS  PubMed  Google Scholar 

  43. Saxena A, Fullem B. Comment on torg et al, “management of tarsal navicular stress fractures: conservative versus surgical treatment”. Am J Sports Med. 2010;38(10):NP3.

    Article  PubMed  Google Scholar 

  44. McCormick F, Nwachukwu BU, Provencher MT. Stress fractures in runners. Clin Sports Med. 2012;31(2):291–306.

    Article  PubMed  Google Scholar 

  45. Kiss ZS, Khan KM, Fuller PJ. Stress fractures of the tarsal navicular bone: CT findings in 55 cases. AJR Am J Roentgenol. 1993;160(1):111–5.

    Article  CAS  PubMed  Google Scholar 

  46. Gould JS. Operative foot surgery. Philadelphia: W.B. Saunders Co; 1994.

    Google Scholar 

  47. McBryde AM, Anderson RB. Sesamoid foot problems in the athlete. Clin Sports Med. 1988;7(1):51–60.

    PubMed  Google Scholar 

  48. Aper RL, Saltzman CL, Brown TD. The effect of hallux sesamoid resection on the effective moment of the flexor hallucis brevis. Foot Ankle Int. 1994;15(9):462–70.

    Article  CAS  PubMed  Google Scholar 

  49. Aper RL, Saltzman CL, Brown TD. The effect of hallux sesamoid excision on the flexor hallucis longus moment arm. Clin Orthop Relat Res. 1996;325:209–17.

    Article  Google Scholar 

  50. BURROWS HJ. Fatigue fractures of the fibula. J Bone Joint Surg Br. 1948;30B(2):266–79.

    CAS  PubMed  Google Scholar 

  51. Richmond DA, Shafar J. A case of bilateral fatigue fracture of the fibula. Br Med J. 1955;1(4908):264.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  52. DEVAS MB. Stress fractures of the tibia in athletes or shin soreness. J Bone Joint Surg Br. 1958;40-B(2):227–39.

    CAS  PubMed  Google Scholar 

  53. Miller MD, Marks PH, Fu FH. Bilateral stress fractures of the distal fibula in a 35-year-old woman. Foot Ankle Int. 1994;15(8):450–3.

    Article  CAS  PubMed  Google Scholar 

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Correspondence to J. Benjamin Jackson III MD .

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Melton, W., Jackson, J.B. (2016). Stress Fractures of the Foot and Ankle. In: Valderrabano, V., Easley, M. (eds) Foot and Ankle Sports Orthopaedics. Springer, Cham. https://doi.org/10.1007/978-3-319-15735-1_17

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  • DOI: https://doi.org/10.1007/978-3-319-15735-1_17

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