38 - Stress Fractures of the Foot and Ankle

Abstract

Lower extremity stress fractures occur most frequently in the tibia, navicular, calcaneus, metatarsals, and sesamoids, causing disability and interrupting training in endurance athletes, jumping athletes, and military enlistees. Stress fractures begin as a stress reaction, typically accompanied by vague activity-related aching that can be difficult to localize. Plain radiographs are almost uniformly unremarkable, especially in early stages of injury. MRI is generally the most sensitive imaging modality to assist in diagnosis, especially early. Prevention begins with a well-balanced, tailored diet specific to the athlete's training regimen and goals. Calcium and vitamin D supplementation may help prevent injury during training by increasing bone mineral density in response to training. Once a stress injury occurs, treatment is typically conservative, with protected weight bearing and immobilization. Navicular stress fractures, in particular, should be treated with 6 weeks of non–weight bearing upon presentation. Nonselective nonsteroidal antiinflammatory medications (e.g., ibuprofen) are safe for postfracture use. It is paramount that sources of relative energy deficiency (RED syndrome) are appropriately evaluated, especially in the young female athlete. Surgical intervention is typically reserved for fractures that inadequately respond to conservative treatment, with few exceptions. Anterior tibial, complete navicular, and fifth metatarsal stress fractures are most frequently indicated for surgical treatment.