vol. 6 • no.

6 SPORTS HEALTH

[ Primary Care ]

Stress Fractures of the Foot

and Ankle in Athletes
Stephanie W. Mayer, MD,† Patrick W. Joyner, MD,† Louis C. Almekinders, MD,‡
and Selene G. Parekh, MD, MBA*‡

Context: Stress fractures of the foot and ankle are a common problem encountered by athletes of all levels and ages.
These injuries can be difficult to diagnose and may be initially evaluated by all levels of medical personnel. Clinical suspi-
cion should be raised with certain history and physical examination findings.
Evidence Acquisition: Scientific and review articles were searched through PubMed (1930-2012) with search terms includ-
ing stress fractures and 1 of the following: foot ankle, medial malleolus, lateral malleolus, calcaneus, talus, metatarsal,
cuboid, cuneiform, sesamoid, or athlete.
Study Design: Clinical review.
Level of Evidence: Level 5.
Results: Stress fractures of the foot and ankle can be divided into low and high risk based upon their propensity to heal
without complication. A wide variety of nonoperative strategies are employed based on the duration of symptoms, type of
fracture, and patient factors, such as activity type, desire to return to sport, and compliance. Operative management has
proven superior in several high-risk types of stress fractures. Evidence on pharmacotherapy and physiologic therapy such as
bone stimulators is evolving.
Conclusion: A high index of suspicion for stress fractures is appropriate in many high-risk groups of athletes with lower extrem-
ity pain. Proper and timely work-up and treatment is successful in returning these athletes to sport in many cases. Low-risk stress
fracture generally requires only activity modification while high-risk stress fracture necessitates more aggressive intervention. The
specific treatment of these injuries varies with the location of the stress fracture and the goals of the patient.
Keywords: stress fracture; athlete; foot; ankle

Introduction, Epidemiology, true fracture line.12,13 If the repetitive loading continues, the
and Basic Science stress reaction can go on to a true stress fracture.12,13 This
mechanism of injury explains the higher incidence of stress
Stress fractures are relatively uncommon injuries, accounting for fractures among military recruits, runners, and those involved
approximately 1% to 7% of all athletic injuries.12,35 The incidence in jumping sports, though any activity with repetitive loading
of these injuries is rising due to earlier and longer participation can lead to stress fractures.8,12,13,17,35 Most bones have reported
in sports, the emergence of more extreme sporting activities, cases of stress fractures, but the lower extremities have the
and the heightened awareness of the diagnosis.55 highest prevalence.12 In a study of 320 athletes, the tibia (49.1%),
In contrast to acute fractures, which typically occur with a tarsals (25.3%), and metatarsals (8.8%) were the most frequently
single maximal load, stress fractures occur due to repetitive, involved bones affected by a stress fracture.58
submaximal loading of a bone, leading to microfractures that Intrinsic and extrinsic factors have been described when
are unable to heal due to bone resorption and bone formation determining the etiology of a stress fracture (Table 1). Intrinsic
imbalances.12 A bone responds to stress on a continuum from a factors consist of the patient’s anatomy and biology including
stress reaction to a fracture.12,13 The initial stage of bone failure cavus feet, leg length discrepancies, excessive forefoot varus
is generally called a stress reaction. This diagnosis is made in a tarsal coalitions, a prominent posterior calcaneal process,
symptomatic patient who has bone scan or magnetic resonance tight heel cords, poor bone density or vascular supply, and
imaging (MRI) evidence of bone reactive changes without a abnormal hormonal levels.35,46,55 Extrinsic factors such as type
From †Duke University Medical Center, Durham, North Carolina, and ‡North Carolina Orthopaedic Clinic, Durham, North Carolina
*Address correspondence to Selene G. Parekh, MD, MBA, North Carolina Orthopaedic Clinic, 3609 SW Durham Dr. Durham, NC 27707 (e-mail: [email protected]).
The following authors declared potential conflicts of interest: Selene G. Parekh, MD, MBA, is a consultant for Orthohelix.
DOI: 10.1177/1941738113486588
© 2013 The Author(s)
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Table 1. Intrinsic and extrinsic factors related to stress fractures of the foot and ankle34,44,51

Intrinsic Factors Extrinsic Factors

Cavus feet Type of activity
Leg length discrepancies Excessive/new training regimen
Excessive forefoot varus Poor equipment/footwear
Tarsal coalitions Improper technique
Prominent posterior calcaneal process Type of training surface
Tight heel cords Sleep deprivation
Osteopenia/osteoporosis  
Poor vascular supply  
Abnormal hormonal levels  

of activity, excessive or new training regimens, equipment and

footwear issues, training surfaces and techniques, and nutrition Table 2. High- and low-risk stress fractures of the foot and
can also play a role.35,46,55 Several studies have described the ankle12,13,34
biomechanical effects of muscle fatigue as a possible factor
High Risk Low Risk
in the development of stress fractures.96,102 Continued training
after muscle fatigue changes loading patterns of the foot based Medial malleolus Calcaneus
on force plate studies and is postulated to be a factor in stress-
related injuries.102 Talus Cuboid
Female individuals have a higher incidence of stress Navicular Cuneiforms
fractures.35,46,71,72,90 Anatomically, a wider pelvis and more
common genu valgum results in a compensatory increased Fifth metatarsal base Lateral malleolus
Q-angle and often foot pronation.5,55 On average, female Sesamoid  
individuals have 25% less muscle mass than male individuals,
which can focus forces on to a smaller area of bone with
less muscle protection.55 The “female athlete triad” (eating
disorder, amenorrhea, and osteoporosis) is found among
competitive female athletes, particularly those involved in long-
History, Physical ExamINATION, and
Imaging
distance running, figure skating, and gymnastics.5,28,30,35 High-
level endurance athletes from both sexes are in danger of Patients typically present with a progressive onset of pain
osteoporosis based on the effects of estrogen and testosterone with weightbearing activity over a period of days to weeks.43
on bone remodeling; low levels of sex steroids have been History may include a rapid increase in mileage, intensity,
measured following rigorous training sessions in both male or duration of activity; changes in playing surface or sport or
and female athletes.101 Sex steroids normally inhibit osteoclasts inadequate rest periods should raise the suspicion of a stress
and enhance osteoblasts, thereby slowing the resorption fracture.8,12,13,18,35,46,55,58,62,63,90,96 A thorough history including diet,
process; subphysiologic levels correlate with low bone mineral nutrition, medications, daily activities, footwear, and menstrual
density.101 cycles in female athletes should be discussed.5,8,12,13,24,35,46,90 On
Two main categories, low and high (Table 2), have been used physical examination, pain with weightbearing or range of
to determine the relative risk of either going on to complete motion of a joint near a stress fracture may be elicited, point
fracture or to nonunion and aid in guiding the work-up and tenderness is almost universal, and in more superficial areas,
treatment of stress fractures.12,13,35 Low-risk stress fractures, edema, warmth, ecchymosis, or even a palpable callus may
such as those of the calcaneus, have a better prognosis and be present.8,12,13,18,35,46,55,58,62,63,90,96 Assessment of limb alignment
can often be diagnosed clinically and treated with activity and length discrepancies, gait, passive range of motion, tendon
modification.12,13,35 Those at high risk, such as the navicular, function, and callosities provides information about repetitive
talus, medial malleolus, proximal fifth metatarsal, and stresses placed on the symptomatic area.16 Noting alignment of
sesamoids, will often need more advanced imaging, periods of the ankle in neutral, cavovarus, or planovalgus and determining
nonweightbearing, and possibly surgical fixation.12,13,35 fixed or flexible deformities can provide insight into the
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underlying causes of the pathology.16 Stiff joints as well as

ligamentous laxity are a sign of improper forces across a joint,
postulated to put the patient at higher risk of stress fracture.16
Imaging studies including radiographs, computed tomography
(CT) scans, MRI, and bone scintigraphy can be helpful when
the diagnosis is questionable or stress fracture is suspected in a
high-risk bone given the possible sequelae of a missed or late
diagnosis.12 Plain films will often be negative for the first
2 weeks following a stress fracture, until resorption, sclerosis,
or callus formation occurs.12,13 Radionuclide bone scan has
been shown to be a sensitive imaging modality since the
1970s.12,78,81 Changes can be seen within 48 to 72 hours
of injury.81 Uptake in all 3 phases of a technetium-99m
diphosphonate scan is characteristic of a stress reaction/
fracture and can be differentiated from soft tissue injury,
which will only show increased uptake in the first
phase (angiographic and blood pool/soft tissue imaging,
respectively).81 MRI has replaced bone scan as the imaging
modality of choice in many settings and gives superior
specificity and resolution over bone scintigraphy.73 CT scan
can be used to identify incomplete and complete fractures but
cannot aid in identification of stress reactions.73 However, CT Figure 1. T2-weighted MRI showing high signal in the
scan is thought to be more helpful than MRI in following the medial malleolus.
healing of stress fractures.91 Burne et al19 proposed that as a
stress fracture heals, the initial edema and hematoma seen well
on MRI for diagnosis is replaced by sclerosis, which is better
A patient with concerning symptoms but negative
seen on CT scan. This, in combination with a thick periosteum
radiographs should undergo a bone scan or MRI (Figure 1).
in some locations, impairs the ability of MRI to pick up some
An incomplete fracture on MRI or a positive bone scan can be
subtle fracture lines.91 Therapeutic ultrasound can also be used
treated with cast immobilization and nonweightbearing.75,89,91
as an adjunct to the physical examination. Although previously
Although most of these injuries will heal with appropriate
thought to have poor sensitivity and specificity, a recent trial
nonoperative treatments, internal fixation may be considered
found increased pain with the application of therapeutic
to allow earlier return to competitive sports, often within 1
ultrasound at the site of a stress injury to have a positive
to 2 months.52,75,89,91 Several series of medial malleolar stress
predictive value of 99% (sensitivity, 81.9%; specificity, 66.6.%).77
fractures in athletes showed that both time to healing and
return to sport were longer in the nonoperative group.89
High-Risk Stress Fractures
Some foot and ankle stress fractures have a relatively low Talus
propensity for spontaneous healing due to various factors
such as blood supply, shearing forces across their surface, and Talar stress fractures were first described in 1965 by McGlone.60
location.12,35,46 Strict nonweightbearing, immobilization, and, not It is a relatively rare injury; athletes and military recruits
uncommonly, surgery are frequently needed to obtain a solid performing repetitive axial loading activities are most prone
union.12,35,46 to this injury.82,93,94 Advanced imaging, particularly MRI, is
often required to obtain a diagnosis (Figure 2).14,93,94 Physical
examination findings are variable, including point tenderness,
Medial Malleolus
ankle effusion, or soft tissue swelling.14,60,93,94 Excessive subtalar
Stress fractures of the medial malleolus are uncommon and pronation or plantar flexion is noted clinically in many patients
generally found in athletes involved in running, jumping, and with lateral process stress injuries due to impingement of the
kicking sports, although abnormal forces at the ankle due to lateral process of the calcaneus on the posterolateral talus.14
tibial and talar osteophytes have also been implicated.42,89,91 The superior part of the talar head is most frequently involved,
The first series of 6 patients reported by Shelbourne in 1988 and the posterolateral talar body fracture will usually be seen
described medial malleolar tenderness, ankle effusion, pain extending into the subtalar joint.14,93
during running activities, and a vertical radiolucent line A retrospective review of Finnish military recruits found 56
extending from the plafond on radiographs.91 Although most talar stress injuries (reactions and fractures). Five patients had
medial malleolar stress fractures occur in skeletally mature bilateral injuries, and 44 had other associated lower extremity
patients, adolescent cases have been reported.89 stress injuries. Sixty-seven percent were in the talar head, 25%

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Figure 2. T2-weighted MRI showing high signal in the talus.

in the body, and 8% in the posterior portion, similar to previous

reports.93 Talar head injury was associated with navicular stress
injury, upper talar body with calcaneal injury, and posterior talus
with posterior impingement and a symptomatic os trigonum.93
Patients treated nonoperatively (NSAIDs, relative rest, partial
weightbearing as tolerated) until asymptomatic did well, with Figure 3. T2-weighted MRI showing high signal in the
a mean duration of treatment of 64 days.94 In contrast, others navicular.
recommended a minimum of 6 weeks of nonweightbearing for
this injury due to concern for delayed healing and avascular
necrosis.14 There is no established treatment algorithm for
talar stress fractures given the lack of scientific analysis and first and second metatarsals (through the cuneiforms) along
outcomes. Although orthotics are not used for treatment, the convex surface distally and the talus at the concave surface
patients with excessive pronation may benefit from orthotics to proximally.33,35 Anatomical risk factors include a relatively long
reduce lateral loading, given the coincidence of pronation and second metatarsal, pes cavus, metatarsus adductus, medial
lateral talar stress fractures in some series.14,16 narrowing of the talonavicular joint, talar beaking, and limited
subtalar or ankle motion.44
Small studies have supported both nonoperative and
Navicular
operative treatment.33,35,43,87,99 Nonoperative treatment typically
Navicular stress fractures are currently considered high risk includes nonweightbearing in a short leg cast.33,35,43,87,99
due to the rate of nonunion.12,35 Patients are usually involved in Operative treatment entails open reduction and internal
explosive sprinting or jumping activities and complain of pain fixation with or without bone grafting.33,35,43,87,99 One of the first
at the dorsum of the midfoot or along the medial longitudinal studies reviewing this injury found good results in patients
arch with activity.99 Swelling, erythema, and ecchymosis are treated with nonweightbearing in a short leg cast.99 In a review
less reliable, but point tenderness at the dorsal aspect of the of 86 navicular stress fractures in athletes, only 26% treated
navicular known as N-spot tenderness is the most consistent with activity modification versus 86% with nonweightbearing
finding.12,35 Clinical suspicion should prompt radiographic in a short leg cast returned to sports.43 Six patients initially
evaluation, and advanced imaging should be obtained if initial underwent surgical treatment, and 5 returned to sports at an
radiographs are negative.33,99 MRI (Figure 3) and bone scan average of 3.8 months. They concluded that nonweightbearing
provide no additional benefit over CT.19,31 The fracture line in a short leg cast was the standard of care, though
usually extends from the proximal dorsal border in a plantar acknowledged that time to return to sport was shorter with
and distal direction in the sagittal plane.19,33 The central third initial surgical intervention. In an evaluation of 22 patients, 11
of the navicular is a watershed area between blood supplies of 13 navicular stress fractures healed with nonweightbearing
coming from medial and lateral vessels.99 This may lead to in short leg cast, and 8 returned to sport at an average of
slower healing of physiologic microfractures in this central area 4.3 months.87 All 9 treated with initial internal fixation, with
and increase the risk of a stress fracture.99 During walking and or without bone grafting, returned to sport at an average of
running, this region is also subjected to shear forces from the 3.1 months.87 In 19 navicular stress fractures, 6 treated with

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a nonweightbearing short leg cast healed and returned to

sports at 4 months; all 13 undergoing open reduction internal
fixation (ORIF) returned at 4.1 months.86 In these 2 studies,
they found no significant difference in outcome or time to
return to sports.86 In a recent systematic review, outcomes
including radiographic healing, clinical healing, and time from
onset of symptoms to return to activity were compared for 3
different treatment strategies.98 Regimens of weightbearing,
nonweightbearing in short leg cast, and surgical intervention
were analyzed, with no statistically significant difference
between nonweightbearing in short leg cast and surgical
intervention. Weightbearing treatments were inferior in all
outcome measurements. This study concluded that an initial 6
to 8 weeks of nonweightbearing in a short leg cast should be
the standard of care for navicular stress fractures.98 Despite this
recommendation, it should be noted that displaced fractures
may have a higher risk of nonunion and poorer outcomes even
with surgical treatment.59

Metatarsal
These stress fractures occur most frequently in the second and
third metatarsals and are relatively common.12,13,35,46 They are consid-
ered high or low risk, depending on location.12,13,35,46 Common in Figure 4. T2-weighted MRI showing high signal in the distal
runners, military recruits, ballet dancers, and basketball fourth metatarsal.
players, like most, patients will report a recent increase in
training.1,8,12,13,16,17,21-23,29,31,32,35,38,39,46,48,55,58,62,64,67,74,77,79,85,90,97,102,104
Forefoot pain with weightbearing, inability to toe walk,
point tenderness, and swelling are present on examina-
Second and Third Metatarsal Base
tion.1,8,12,13,16,17,21-23,29,31,32,35,38,39,46,48,55,58,62,64,67,74,77,79,85,90,97,102,104
Radiographic work-up with plain films of the foot may Metatarsal base stress fractures are most common in female
show callus formation about the metatarsal at around ballet dancers.1,22 The insidious onset of vague midfoot pain is
2 weeks.1,12,13,16,17,22,23,29,34,38,39,46,55,58,62,67,74,85 As with other stress frac- often overlooked or misdiagnosed.1,22,39,64,67,74,85 The second and
tures, increased uptake on bone scan should be isolated to the third metatarsals are most at risk during ballet in the en pointe
affected bone; MRI (Figure 4) can differentiate between stress position due to the locking of the second metatarsal base and
reaction or fracture and soft tissue abnormalities.35,46,85 cuneiforms in extreme plantar flexion.1,22,39,64,67,74,85 Intrinsic risk
Distal second metatarsal stress fractures are most common.16 factors include a pronated foot and poor ankle plantarflexion
During walking and running, the second metatarsal assumes causing a so-called over-pointe foot with compensatory
the highest bending strain and shear force.38 The fixed bases plantarflexion through the Lisfranc joint.1 This shifts the center
and proximal hinged metatarsophalangeal joints create a of gravity anterior to the metatarsal shaft, creating more force
bending moment at the proximal diaphysis during the stance at the base. Four female ballet dancers with midfoot pain were
phase of gait.38,61 A relatively long second metatarsal and treated successfully with a short period of immobilization and
an excessively mobile first ray (Morton foot) increase this rest, and 1 required operative debridement of necrotic bone.64
force even further.38,55,61 Additionally women have a higher Several subsequent studies have also reported good results
middle forefoot loading force than men.79 These anatomical and return to dancing with nonoperative management, ranging
and biomechanical characteristics may play a role in the from a wooden-soled shoe to short leg walking cast.67,74 The
development of stress fractures.38,79 A recent cadaveric incidence of nonunion is low.22,67,85 Comorbidities including
biomechanical study showed that both custom and semicustom diabetes, chronic steroid use, the female athlete triad, cancer,
orthotics decrease tension and shear strain on the second and metabolic bone disease are associated with a higher rate
metatarsal, with custom orthotics being superior.61 Clinical of nonunion.22 Ballet trainees treated with medium energy
studies from military recruits show benefit from orthotics.31,66 external shock wave and ultrasound along with a period of 3
Treatment of established distal metatarsal stress fractures is to 5 weeks of weightbearing rest had a 100% return to dancing
usually initially conservative with activity modification for 6 to at a mean 4.6 weeks and return to full pointe at a mean
8 weeks with gradual return to sports when asymptomatic.16 18 days later without subsequent pain or nonunion.1 Overall,
The addition of a stiff-soled shoe, midfoot taping, walker boot, nonsurgical management seems to yield good results with
or short leg walking cast can increase comfort.13,16,35 nonweightbearing or weightbearing in a regular shoe or short

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leg cast.1,22,39,64,67,74,85 Surgical treatment of nonunion following intramedullary fixation is possible, and returning too soon is
nonoperative treatment may include drilling procedures and a risk factor.48,104 Functional bracing or orthotics upon return
open reduction internal fixation.85 to sports may reduce the high rate of refracture seen in that
series.48,104
Fifth Metatarsal
Sesamoid
The typical presentation of fifth metatarsal stress fractures
differs from acute fractures clinically and radiographically. Pain The medial sesamoid is more commonly injured because of
has usually been present for several weeks, and the fracture its position directly under the first metatarsal head.9 Activities
is classically located at the diaphyseal-metaphyseal junction.97 involving repetitive, forceful dorsiflexion of the toes are
Repetitive adduction force with the ankle in plantarflexion most commonly associated.9,16 Swelling or even bulging
often causes these stress fractures due to the pull of the soft tissues may be present, and pain is reproduced with
plantar fascia. As such, they are frequently seen in basketball forced dorsiflexion.9,16 Radiographic differential includes
players.12,29,35,77,104 A description of lateral foot pain, tenderness bipartite sesamoid, which is difficult to distinguish on plain
about the fifth metatarsal base, and pain with passive inversion films but is seen in 5% to 30% of the general population.9,16
stretch are clues to the diagnosis.12,29,35,77,104 A cavovarus foot or Sagittal cuts on CT scan may be superior to MRI or bone
restricted hindfoot eversion is thought to predispose patients to scan when advanced imaging is needed.9 Initial treatments
fifth metatarsal base stress fractures by increasing the force on include shoe modification, immobilization, cessation of sport,
the lateral aspect of the foot.35 Torg et al created a classification partial or nonweightbearing, systemic anti-inflammatories,
system for these more distal fifth metatarsal base stress and steroid injections.9,16,76,100 Operative treatment including
fractures based on history and radiographic appearance that sesamoidectomy,88,100 partial sesamoidectomy,9,80 closed
helps to guide treatment.97 Type I fractures are acute fractures reduction and percutaneous screw placement,11 curettage, and
by history and have sharp fracture lines with no radiographic bone grafting3 with success rates of 90% to 100% union and
signs of healing. Type II fractures are considered delayed 100% return to sports.3,9,11,80,88,100 Surgical complications include
unions. There is no history of previous fracture, but radiographs hallux valgus and flexor hallucis brevis tendon dysfunction,
show periosteal new bone, resorption, and sclerosis at the so careful dissection of the sesamoid out of the flexor tendon
fracture line. Type III fractures are considered nonunions. sheath is important.9,76,88,100
History reveals history of pain with recurrent symptoms, likely
representing repetitive insults, and on plain films, the fracture
line is widened with medullary canal replaced by sclerosis. Low-Risk Stress Fractures
Initial treatment recommendations of nonweightbearing in Low-risk stress fractures of the foot include those of
a short leg cast for Type I injuries and curettage and bone the calcaneus cuboid, cuneiform bones, and the lateral
grafting for Type II and III injuries were based on Torg’s malleolus, each of which usually heals with nonoperative
experience with 46 fractures.97 Operative treatment has yielded management.13,16,18,21,35,46,57,58,63,105 Low-risk stress fractures of the
good results using an intramedullary malleolar screw, and foot are common in patients undergoing new occupations or
tension band wiring has been used with similar outcomes.29,51 physical training regimens involving repetitive motion.13,18,58,62,63
Placement of these screws can be technically challenging as
the surgeon inserts a straight screw into the curved proximal Calcaneus
metatarsal. Intraoperative fracture of the metatarsal shaft,
bicortical penetration, and skin irritation proximally are The incidence of calcaneal stress fractures is highest in mili-
potential complications of intramedullary fixation. Seven to 10 tary recruits and long-distance runners.35,40,95,106 A positive calca-
weeks postoperatively is a reasonable goal for return to full neal compression test with some amount of swelling is usually
sport activity following screw fixation and has led to screw present.35,40,49,103 The diagnosis is often missed initially because
fixation for not only Torg Type II and III, but also Type I for of similarity to plantar fasciitis, Baxter nerve entrapment and
a faster return to sports.29,77 Curettage and bone grafting in insertional achilles tendonitis, atrophic heel pad and retrocal-
addition to screw fixation is also an option for Type II and caneal bursitis, and in adolescents, Sever disease or calcaneal
III surgical treatment.12,35 In a study of elite athletes, a plantar apophysitis.35 Plain films will often show a sclerotic or radiolu-
gapping of the fracture of >1 mm increases time to union (71 vs cent line after 2 to 3 weeks of symptoms, and a bone scan or
126 days) postsurgical fixation.50 Currently, it is recommended MRI could be helpful to rule out soft tissue diagnoses (Figure
that Type I injuries undergo a 6- to 8-week trial of 5).35,95,106 Calcaneal stress fractures can be adequately treated
nonweightbearing in a short leg cast and Type II and III injuries with activity modification without casting or surgical interven-
undergo surgical fixation.77,97 An exception is a high-level athlete tion.40,49,103 In a more recent Finnish military study of 34 stress
who wishes to return to sport sooner, in which case surgical injuries (reactions and fractures), 65% were associated with
fixation of an acute stress fracture may be considered.77 These talar, cuboid, or navicular stress injuries. Nonoperative manage-
patients must be warned though that refracture in spite of ment was used in all patients; recruits were asymptomatic at an

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those receiving prophylactic risedronate and placebo.65 There

was a trend toward a harmful effect of alendronate treatment
in an animal study, possibly due to inhibition of remodeling
of microfractures from woven to lamellar bone.4 The 25-year
experience of the Israeli Army on prevention of stress fractures
showed sleep minimums and training modifications, but not
bisphosphonate treatment, decreased the incidence of stress
fractures.32

Bone Stimulators
There are 2 types of stimulators, electromagnetic stimulators
and ultrasound stimulators.
Electromagnetic stimulators generate electromagnetic fields
with coils on either side of the fracture.15 Mechanical stresses
cause fluid flow around and through bones that induces
Figure 5. T2-weighted MRI showing high signal in the electrical currents around cells, which can open calcium
calcaneus. channels in cell membranes increasing calmodulin, thus
increasing cell proliferation.15 Very few controlled studies are
available that evaluate the efficacy of these stimulators in
stress fractures. One such study found no significant difference
average of 77 days. They concluded that these injuries can be
in time to healing between placebo and those using an
treated nonoperatively with suspension from activity only.106
electromagnetic stimulator.6 However, when higher grade stress
fractures were compared exclusively, there was significantly
Cuneiforms, Cuboid, Lateral Malleolus
shorter time to healing noted, though power was not sufficient
Cuneiform stress fractures were first reported in 1936 as a to draw conclusions.6 When compliance was adequate,
march fracture of the medial cuneiform.18,62,63 Stress fractures of electromagnetic stimulators correlated to shorter healing
the middle and lateral cuneiform have also been reported.21,63 time.6 Despite some early promising results, electromagnetic
Unlike bones with a diaphysis, the cuneiform and cuboid may stimulators have not been shown conclusively to enhance
not display the usual periosteal callus.18,62,63 Instead, stress healing in stress fractures.
fractures may appear as a transverse sclerotic zone.18,62,63 MRI is Pulsed ultrasound bone stimulators can increase vascular
the imaging of choice if plain films are unremarkable.18 These endothelial growth factor (VEGF) and fibroblast growth factor
injuries will demonstrate the fracture line with bone marrow (FGF), which promote angiogenesis, and increase alkaline
edema on both T2- and T1-weighted images.13,18,35,62 phosphatase, bone sialoprotein, and intracellular calcium
The 2 forces responsible for cuneiform stress fractures are (markers of bone metabolism).45 Most studies report on acute
bending and compression.18,63 Bending forces are applied across fractures. A systematic review of pulsed ultrasound showed
the cuneiforms due to their location in the midfoot. The medial low to moderate grade evidence for a positive effect: there
cuneiform lies in the axis of the first metatarsal and is susceptible was a 33.6% decrease in radiographic healing time.20 Stress
to compression-type stress fractures.18,63 Body weight passes fractures may respond differently to pulsed ultrasound because
through this axis, and muscular insertions on each side of the they heal through intramembranous remodeling instead of
first cuneiform exert strong opposing forces across a small endochondral remodeling as acute fractures do. Literature
area.18,63 The lateral cuneiform is the keystone of the arch with 6 specifically on stress fractures treated with pulsed ultrasound is
articulations leading to several force vectors across this bone.18,63 sparse.53,83 In a military study of 43 tibial shaft stress fractures,
The mainstay of treatment of low-risk stress fractures is there was no significant difference in time to healing using
nonoperative.13,35,46,58,62,63 Initially, partial weightbearing from 2 low-intensity pulsed ultrasound.83 In a rat ulnar stress fracture
to 6 weeks with or without immobilization is recommended model, low-intensity pulsed ultrasound alone produced better
until pain has abated during weightbearing activities.13,35,46,58,63 results than ultrasound and NSAIDs combined as well as
controls.53
Other Treatments
Bisphosphonates Oral Contraceptives
Bisphosphonates have the potential to decrease the incidence Low levels of sex steroids are associated with low bone
of stress fractures by decreasing bone turnover by inhibiting mineral density.26,101 Abnormally low levels of sex hormones
osteoclast function.4,32,65 However, a prospective, randomized are seen for 24 to 48 hours in endurance athletes following
trial of 324 military recruits showed no difference in the rigorous training sessions, and secondary amenorrhea causes
incidence of stress fractures of the lower extremities between a hormone deficient state.26,101 Hormone replacement therapy

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via oral contraceptive pills (OCPs) is controversial. Data Calcitonin

suggest that hormone replacement in amenorrheic women
Calcitonin inhibits osteoclasts, the offending agent in the
and endurance athletes improves bone mineral density.25-27
imbalanced remodeling process of stress fractures.40,41,54,56
A randomized study of 150 young female runners with low-
Increased BMD and biomechanical properties has been shown
dose OCP or no treatment showed that oligo- and amenorrheic
with calcitonin, but its role in stress fracture prevention or
runners who used OCPs gained 1% bone mineral density
healing is controversial.40,41,54,56
(BMD) per year.24 Stress fracture incidence trended lower in the
OCP group, but was not significant. A military study of female
recruits found a fivefold increase in lower extremity stress Orthotics
fractures in women who had been amenorrheic, though OCP Several biomechanical studies have shown predictable,
use did not have a significant protective effect.100 repetitive stress patterns in the foot and ankle with
If OCPs are used in exercise-induced hypoestrogenic weightbearing.61,79 However, there is inconclusive data to
amenorrhea, other factors such as nutrition status or other support orthotics for prevention of stress fractures of the
hypothalamic perturbations should be worked up and may foot and ankle.31,32,66,92 A systematic review of 5 articles on
require treatment, as energy status, calcium intake, and body orthotics and stress fractures concluded that orthotic use
mass index have proven to be independent predictors of reduced the overall rate of stress fractures of the proximal
improved BMD and normal bone turnover.24,25,34 femur and tibia in military personnel; no conclusion could be
made regarding prevention in stress fractures of the foot and
Calcium and Vitamin D ankle.92
Calcium and vitamin D can improve BMD but are not
definitively proven to prevent stress fractures.8,23,24,47,68,72,84 In
Conclusion
track and field athletes and military recruits, no significant
difference was found with increased calcium and vitamin D Stress fractures of the foot and ankle in athletes are relatively
intake and incidence of all types of stress fractures.8 One of uncommon at 1% of all athletic injuries.12 However, a
the largest studies on the topic showed that in female military heightened awareness of this condition by coaches, athletic
recruits, 2000 mg of calcium and 800 IU of vitamin D daily trainers, therapists, and physicians along with more rigorous
had a 20% lower incidence of stress fractures during basic training has contributed to an increasing incidence of stress
training than those taking a placebo.47 Another group found fractures.55 A change in training conditions, such as increased
that each cup of skim milk consumed daily by female distance time or distance, new impact activities, training surface,
runners lowered the rate of stress fracture by 62%.72 These technique, and poor nutrition, is a contributing factor in the
reports support several previous studies suggesting that low development of stress fractures.35 Additionally, in the female
dietary calcium and vitamin D is associated with increased athletic population, coaches, athletes, and families should be
risk of stress fracture, and adequate intake or supplementation educated and alerted to the adverse effects of eating disorders
can reduce the risk of stress fractures.68,94 The recommended and hormonal abnormalities.5,24,26,101 The type of injury (high
daily dose of calcium depends on age, while vitamin D intake and low risk) as well as the demands of the patient will drive
is more controversial.2,37,69,70 A specific amount of calcium and nonoperative versus operative treatment.12,13,35 There are mixed
vitamin D needed to prevent stress fractures has not been results with bone stimulators,6,7,20,45,53,83 bisphosphonates,4,32,65
determined. In some studies, daily supplementation of 500 to hormone replacement,24-27,90,101 and dietary supplementation
800 mg of calcium and 400 to 800 IU vitamin D improves BMD of calcium and vitamin D8,48,68,72,84 for prevention or treatment
and decreases fracture (not specifically stress fracture) risk of stress fractures of the foot and ankle. There are no data to
significantly.10,36 support or refute the use of calcitonin.

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vol. 6 • no. 6 SPORTS HEALTH

Clinical Recommendations
SORT: Strength of Recommendation Taxonomy
A: consistent, good-quality patient-oriented evidence
B: inconsistent or limited-quality patient-oriented evidence
C: consensus, disease-oriented evidence, usual practice, expert opinion, or case series

SORT Evidence
Clinical Recommendation Rating
Strength of recommendation taxonomy. B
Navicular stress fractures should be treated initially with nonweightbearing.33,35,43,87,99 B
Nonoperative treatment of talar stress fractures with partial weightbearing to tolerance is effective.93 B

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