Updated: 12/28/2021

Stress Fracture

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  • Snapshot
    • A 22-year-old woman presents with foot pain. She says that the pain worsens when running drills at her army base or when standing for prolonged periods of time. Her pain improves with rest. She denies any trauma to her foot or history of fracture. She recently joined the army and was mildly athletic before starting. On physical exam, there is pain upon palpation of the second and third metatarsal bone of the right foot.
  • Introduction
    • Clinical definition
      • overuse injury that commonly involves lower extremity structures such as
        • metatarsals
        • tibia
        • fibula
        • navicular bones
  • Epidemiology
    • Incidence
      • more common in athletes and military recruits
    • Risk factors
      • prior stress fractures
      • increasing intensity of physical activity
      • female gender
      • poor bone health
  • Etiology
    • Repeated tensile or compressive stress
    • Pathogenesis
      • increased physical activity without adequate rest results in pathological bone changes
        • this disrupts the balance between bone resorption and formation, which increases the risk of microfractures
  • Presentation
    • Symptoms
      • pain that worsens with
        • activity
        • repeated loading
          • should be suspected with tenderness or edema following a recent intensification of activity
    • Physical exam
      • tenderness upon palpation of the affected bone
      • loading the affected bone may result in pain
  • Imaging
    • Radiography
      • incidence
        • an initial imaging modality in the evaluation of stress fractures
          • specific but not sensitive
          • typically normal in the first 2-3 weeks after symptom onset
    • Magnetic resonance imaging (MRI)
      • incidence
        • obtained in patients with a negative stress fracture but symptoms are in a high-risk site
          • high-risk sites include
            • patella
            • talus
            • tarsal navicular
            • proximal 4th or 5th metatarsal
        • obtained in patients with negative stress fracture findings on repeat radiography with no symptom improvement
  • Differential
    • Tendinopathy
      • differentiating factor
        • localized tenderness in the affected tendon
    • Nerve entrapment syndromes
      • differentiating factor
        • patients will experience pain and neurologic symptoms such as
          • paresthesias
          • numbness
          • weakness
        • Morton neuroma
          • compressive neuropathy of 3rd and 4th interdigital nerves of foot between metatarsal heads
          • can present similarly to stress fracture
    • Fractures of the foot
      • Lisfranc injury
        • fracture/dislocation of the tarsal-metatarsal joint
  • DIAGNOSIS
    • Making the diagnosis
      • clinical diagnosis supported by imaging
  • Treatment
    • Conservative
      • activity reduction with or without analgesia
        • indication
          • an initial conservative approach for low-risk fractures
      • rehabilitative exercise
        • indication
          • an initial conservative approach for low-risk fractures
    • Casting/splinting
      • in particular needed for fractures of the 5th metatarsal
      • or following surgical intervention
      • should be performed in most stress fractures
    • Operative
      • orthopedic surgery
        • indication
          • recommended for high-risk fractures
  • Complications
    • Recurrent fractures
    • Malunion
  • Prognosis
    • With early treatment, patients have a quicker recovery
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(M2.OR.17.4752) A 17-year-old female presents to her primary care physician with right foot pain for the last 3 days. She states that the pain began gradually and is worse with weight bearing and activity. The patient states that she recently began to train for a marathon and is running much more than she did several months ago. She is healthy but has a 2-year history of irregular menstruation, with up to 3 months between periods. At this visit, her temperature is 98.5°F (36.9°C), blood pressure is 116/67 mmHg, pulse is 75/min, and respirations are 14/min. Her BMI is 17.1 kg/m^2, and she appears tired with a flat affect. Palpation of the dorsal surface of the right foot reveals point tenderness on the second metatarsal, though there is no redness, warmth, or swelling. The remainder of the exam is unremarkable. Plain radiograph of the right foot is performed and shown in Figure A. Which of the following is the best next step in management?

QID: 108763
FIGURES:

Obtain right foot MRI

9%

(2/23)

Ice and rest the right foot

78%

(18/23)

Perform surgical intervention

4%

(1/23)

Prescribe oxycodone-acetaminophen

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(0/23)

Refer the patient to psychiatry

4%

(1/23)

M 7 D

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(M2.OR.15.4672) A 25-year-old athlete comes into your office for pain in his right foot. He states that he has no prior medical history and takes no medications. He is an avid runner and runs in marathons, but recently switched to barefoot running from his normal shoes. He runs around 50 miles per week and states that his pain is getting worse and worse with each run. On exam, his vitals are within normal limits, but there is pain upon palpation of the second metatarsal of his right foot. His pulses and sensation are intact in all extremities. Figure A is an anteriorposterior (AP) radiograph of his right foot. What is the most likely diagnosis?

QID: 107182
FIGURES:

Stress fracture

100%

(11/11)

Degenerative joint disease

0%

(0/11)

Septic arthritis

0%

(0/11)

Gout

0%

(0/11)

Plantar fasciitis

0%

(0/11)

M 6 E

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EXPERT COMMENTS (5)
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