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Stress fractures of the foot and ankle
Updated 2017 Mar 20 12:47:00 PM: ACR Appropriateness Criteria for stress
(fatigue/insufficiency) fractures, excluding other vertebrae (National Guideline Clearinghouse
2017 Mar 20) view update Show more updates
Topic Editor
Michelle Lin, MD
Recommendations Editor
Eddy Lang, MDCM, CCFP(EM), CSPQ
Deputy Editor
Alan Ehrlich, MD
Related Summaries:
Plantar fasciitis
Morton neuroma
Sesamoiditis
General Information
Description:
stress fractures are fractures that develop due to repetitive strain on healthy or unhealthy
bones, usually occurring in the lower extremities (1, 2)
fatigue fractures are stress fractures caused by repetitive or excessive stress on otherwise
healthy bones
pathologic or insufficiency fractures are stress fractures caused by the normal stress of
daily activities on unhealthy bones weakened by conditions including metabolic bone disease
and osteoporosis
stress fractures can occur in any of the bones in the foot and ankle, including(3, 4, 5)
metatarsal bones
navicular bone
talus bone
sesamoids
calcaneus bone
cuboid bone
cuneiform bones
lateral malleolus
medial malleolus
Also called:
march fracture
Definitions:
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typical grading system for severity of stress fractures (2)

grade 1
normal x-ray
mild unicortical uptake on bone scan
positive short T1 inversion recovery (STIR) images on magnetic resonance imaging
(MRI)
grade 2
normal x-ray
moderate unicortical uptake on bone scan
positive STIR and T2 images on MRI
grade 3
discrete line on x-ray
activity in 50% of bone width on bone scan
positive T1- and T2-weighted images on MRI
grade 4
fracture or periosteal reaction on x-ray
bicortical uptake on bone scan
fracture line on MRI
no standardized classification system available for stress fractures
based on systematic review of studies and/or review articles
systematic review of 43 studies and review articles evaluating stress or fatigue fractures
and their classification
27 different classification systems were identified
no classification system had statistical analysis of interobserver or intraobserver reliability
Reference - Phys Sportsmed 2011 Feb;39(1):93
Epidemiology
Who is most affected:

more common in women than men(1)
athletes or military recruits who participate in repetitive, high-impact activities (running, soccer,
track and field sports, basketball, gymnastics, or dance) are at increased risk(1)
Incidence/Prevalence:
1%-7% of athletic injuries are reported to be stress fractures (any kind)(4)
about 1% of athletic injuries are reported to be stress fractures of the foot and ankle(4)
rates of stress fractures of the foot and ankle in athletes and military recruits varies widely
across studies
about 10%-17% of professional athletes reported to have stress fractures of
the foot
based on systematic review of observational studies limited by clinical heterogeneity
systematic review of 89 articles evaluating epidemiology of ankle and foot overuse
injuries in athletes
reporting methods and definition of overuse injuries and stress fracture varied across
studies with many studies not adequately describing what counted as an overuse injury
stress fractures were evaluated in 16 articles but meta-analysis not performed due to
significant heterogeneity
stress fracture prevalence varied
10.2% in 6-year period reported in basketball players in 1 study with 49 male players
12.9% in sports career reported in runners in 1 study with 241 runners
16.7% in sports career reported in skating athletes in 1 study with 42 skaters
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incidence rates could not be summarized given varying time frames used across studies
Reference - Scand J Med Sci Sports 2013 Dec;23(6):669
3.5% of ultramarathon runners reported to have stress fractures of the foot
based on cross-sectional survey
1,212 active ultramarathon runners reported data on medical conditions including
exercise-related medical conditions for the year before the survey
3.5% reported stress fractures of the foot in the previous year
5.5% reported stress fracture in any location in the previous year
stress fractures were more common in women than men
Reference - PLoS One 2014;9(1):e83867 full-text
12.6 per 10,000 person-years reported incidence of bone stress injuries of the
ankle and foot in military conscripts
based on cohort study in Finland
131 military conscripts had 142 ankles and feet imaged by magnetic resonance imaging
(due to ankle or foot pain and negative plain x-rays)
378 ankle and foot bone stress injuries reported, resulting in an incidence of 12.6 bone
stress injuries per 10,000 person-years
58% injuries in tarsal bone, 36% injuries in metatarsal bone
63% cases had multiple bone stress injuries in 1 foot
talus and calcaneus were most commonly affected bones
calcaneus and fifth metatarsal usually affected alone, other bones usually associated
with at least 1 other stress injury
Reference - Am J Sports Med 2007 Apr;35(4):643
4.4 per 10,000 person-years reported incidence of talus stress injuries in
military recruits
based on retrospective cohort study
51 military recruits with exercise-induced ankle and/or foot pain had magnetic resonance
imaging (MRI) records evaluated
56 stress fractures reported over 96 months, resulting in an incidence of 4.4 talus stress
fractures per 10,000 person-years
40 in the head of the talus
15 in the body of the talus
5 in the posterior portion of the talus
fracture line was present in 18%
most patients had stress injuries in other bones of the foot also including the navicular
bone and the calcaneus
Reference - Bone 2006 Jul;39(1):199
2.6 per 10,000 person-years reported incidence of calcaneus stress injuries in
military recruits
30 military recruits with exercise-induced ankle and/or foot pain had MRI records
evaluated
34 calcaneus stress injuries reported over 96 months in population base of 117,149
person-years, resulting in an incidence of 2.6 per 10,000 person-years
19 occurred in posterior part of calcaneus
6 occurred in middle part of calcaneus
9 occurred in anterior part of calcaneus
15% had stress injury visible on x-ray
most patients had stress injuries in other bones of the foot also
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Reference - J Bone Joint Surg Am 2006 Oct;88(10):2237

metatarsals, calcaneus, and navicular bone appear to be the most common
locations of stress fractures of the foot
based on 3 cohort studies
metatarsals and calcaneus bones reported to be most common locations of
stress fractures in soldiers in basic training
based on cohort study
109,296 soldiers in basic training were evaluated for stress fractures
0.96% developed stress fractures (1.09% of female recruits and 0.91% of male
recruits)
most common locations of stress fractures in men were
66% metatarsals
20% calcaneus
most common locations of stress fractures in women were
39% calcaneus
31% metatarsals
Reference - Orthop Rev 1992 Mar;21(3):297
metatarsals and navicular bone reported to be most common location of stress
fracture in the foot at a sports medicine clinic
180 patients (mean age 21.8 years) with stress fractures evaluated at a sports
medicine clinic were reviewed
most common locations of the stress fractures included
23.3% metatarsal bones
20% tibia
16.7% fibula
14.4% navicular bone
Reference - Clin J Sport Med 1996 Apr;6(2):85
navicular bone and metatarsals reported to be most common locations of stress
fractures in elite tennis players
139 elite tennis players were evaluated
10.8% developed stress fractures (18 stress fractures in 15 players)
location of stress fractures
27% navicular bone
16% metatarsals
Reference - Br J Sports Med 2006 May;40(5):454
uncommon locations of stress injuries of the foot and ankle include(3, 4, 5)
cuneiform bones
medial malleolus
cuboid bone
first metatarsal
Likely risk factors:
risk for stress fractures in general(1, 2)
intrinsic risk factors
female sex
women with female athlete triad (menstrual abnormalities, eating disorder, low bone
mineral density)
white race
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high bone turnover as can be seen in conditions such as Paget disease of bone and
renal osteodystrophy
external rotation of lower limb
bone anatomy
femoral anteversion
leg length discrepancy
genu varum and genu valgum
narrow tibia
less muscle mass in the lower limb
poor aerobic fitness before starting an intense exercise regimen
poor nutrition (low calcium intake and low overall energy intake)
age > 20 years
personal or family history of bone stress injury
smoking
consuming ≥ 10 alcoholic drinks/week
lower than average vitamin D levels
extrinsic risk factors (1, 2)
intense training regimen (such as military or athletic training)
increased running mileage
increased number of training cycles
inadequate recovery/rest periods and training with fatigued muscles
fast running pace
hill (particularly downhill) running
type of exercise (increased risk for running, soccer, track and field sports, basketball,
gymnastics, and dance)
harder training surface
improper footwear (however, weak evidence that shoes play any role)
previous stress fracture and female sex are reported to be the most strongly
supported risk factors for stress fractures of the lower extremity in runners
based on systematic review of observational studies
systematic review of 8 cohort studies evaluating risk factors for stress fractures of the
lower extremity in runners
increased risk of stress fracture associated with
history of previous stress fracture (odds ratio [OR] 5, 95% CI 2.9-8.6) in analysis of 3
studies
female sex (OR 2.3, 95% CI 1.2-4.3) in analysis of 3 studies
Reference - Br J Sports Med 2015 Dec;49(23):1517
increasing amounts of high-impact activity/week, running, basketball, and
cheerleading/gymnastics each associated with increased risk for stress fracture
in young girls
based on prospective cohort study (the Growing Up Today Study)
6,381 girls aged 9-15 years were followed for 7 years
3.9% developed stress fractures
factors associated with increased risk for stress fracture
increasing amounts of high-impact activity/week (compared to < 4 hours/week)
(adjusted hazard ratio [HR] 1.08, 95% CI 1.05-1.12)
running (adjusted HR 1.13, 95% CI 1.04-1.23)
basketball (adjusted HR 1.12, 95% CI 1.03-1.23)
cheerleading/gymnastics (adjusted HR 1.12, 95% CI 1.02-1.22)
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Reference - Arch Pediatr Adolesc Med 2011 Aug;165(8):723 full-text

Possible risk factors:
proposed risk factors for stress fractures of individual bones of foot and ankle
navicular bone(3, 4)
pes cavus (high arch)
limited ankle dorsiflexion
restricted subtalar motion
short first metatarsal
long second metatarsal
metatarsal adductus
metatarsal bones (3)
ankle and hindfoot varus
forefoot supination
metatarsal adductus
pes planus (flat arch)
pes cavus (for fifth metatarsal stress fracture)
Associated conditions:
female athlete triad in women (menstrual abnormalities, eating disorder, low bone mineral
density)(1, 2)
Etiology and Pathogenesis
Causes:
fatigue fractures are caused by repetitive or excessive stress on otherwise healthy bones (1, 2)
pathologic or insufficiency fractures are caused by the normal stress of daily activities on
weakened bones (1, 2)
Pathogenesis:
stress fractures occur due to bony microtrauma produced by repetitive submaximal loading(1,
2, 4)
bone fatigue develops when normal bone is unable to maintain repair when repeatedly
damaged or stressed, resulting in
acceleration of normal bone remodeling
production of microfractures (caused by insufficient time for bone to repair)
creation of bone stress injury (stress reaction)
eventual production of stress fracture
bone insufficiency develops when structurally abnormal bone unable to withstand normal
strain because of metabolic bone disease or osteoporosis
History and Physical
History:
Chief concern (CC):
typically present with pain in the affected bone(2)
pain gradually worsens and starts earlier during activity
eventually starts to be felt during regular activities
History of present illness (HPI):
location of pain will depend on stress fracture location
navicular stress fracture(3, 4, 5)
dorsal midfoot pain or pain along the medial longitudinal arch are the most common
locations of pain
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may present with mild and nonspecific symptoms

may be aggravated by standing on tiptoes (also known as plantar flexion)
symptoms worsen over time and may start to affect regular activities
metatarsal stress fractures (3, 4, 5)
pain usually located in forefoot or midfoot
fifth metatarsal stress fractures present with lateral foot pain
may have sudden aggravation of chronic foot pain
also may have long history (at least several weeks) of aching pain worse with activity
calcaneus stress fractures (3, 5)
pain located in heel
may present as resting pain in a distance runner
talus fractures may present with ankle or heel pain(5)
medial malleolus stress fractures may present with medial ankle pain(5)
sesamoid stress fractures
may present with forefoot pain which is worsened by forced dorsiflexion(5)
may be uncomfortable to walk without orthotics or cushioned footwear(3)
cuneiform stress fractures may present with heel and midfoot pain(5)
Past medical history (PMH):
ask about(2)
personal history of stress fractures
irregular menstrual periods
eating disorders and poor nutrition intake
ask about history of bony injury (2)
Family history (FH):
ask about family history of stress fractures (2)
Social history (SH):
ask about activity level, including any recent increase in activity (2)
ask about(1, 2)
smoking
consuming ≥ 10 alcoholic drinks/week
Physical:
Extremities:
assess entire foot and lower extremity (3, 4)
assess gait
hindfoot alignment
assess ankle range of motion
assess tendon function
look for deformities
look for leg length discrepancies
look for callus formation
about 66%-100% of stress fractures present with focal tenderness over the fracture site(1, 3,
4)
for navicular fractures, tenderness may be appreciated over the dorsum of the navicular
bone between the tibialis anterior and extensor hallucis longus tendons
for metatarsal fractures, second and third metatarsals are most commonly involved
for calcaneus fractures, tenderness may be present with squeezing calcaneus
18%-44% of stress fractures reported to have swelling in the area of the fracture(1)
bruising and warmth might also be present on exam (2)
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hop test(1)
single-leg hop is often used and is considered positive for lower extremity fracture if it
produces severe localized pain, but positive results can also be seen in patients with other
disorders, such as shin splints
test has not been validated in literature
tuning fork appears to have limited utility for detecting lower limb stress fracture
(level 2 [mid-level] evidence)
based on systematic review of diagnostic studies with methodologic limitations
systematic review of 9 diagnostic cohort studies evaluating tuning fork or therapeutic
ultrasound for detection of lower limb stress fracture in 420 patients
all studies had unclear blinding of index and/or reference test, or had patients that were
not representative of patients who will receive test in practice
reference standard was x-ray, scintigraphy, or magnetic resonance imaging
diagnostic performance of tuning fork for detecting lower limb stress fracture in 2 studies
with 97 patients
sensitivity 35%-92%
specificity 19%-83%
positive likelihood ratio 0.6-3
negative likelihood ratio 0.4-1.6
Reference - J Orthop Sports Phys Ther 2012 Sep;42(9):760
Diagnosis
Making the diagnosis:

suspect stress fracture in patients with activity-induced foot pain that is relieved by rest,
especially if(1, 2, 3)
patient reports a recent increase in activity level, or performance of physical activity without
adequate rest periods
bony tenderness is present
diagnosis of stress fracture confirmed by visible fracture detected on imaging(2)
perform plain x-ray as the initial test to look for signs of stress fracture; however, this test
is often normal
consider performing magnetic resonance imaging (MRI) if a stress fracture is not visible on
plain x-ray (MRI is considered the most sensitive and specific test for stress fractures)
if MRI cannot be performed, consider
computed tomography scan (less sensitive for stress fractures)
radioisotope bone scan (less specific for stress fractures)
Differential diagnosis:
differential diagnosis for activity-related foot pain
stress reactions without fracture(3)
plantar fasciitis (4)
achilles tendinopathy and other tendinopathies (Curr Sports Med Rep 2011 Sep-
Oct;10(5):249)
osteoarthritis (Foot (Edinb) 2014 Sep;24(3):128)
osteochondritis dissecans (3)
metatarsalgia (Med Clin North Am 2014 Mar;98(2):233)
atrophic heel pad(4)
Sever disease(4)
bursitis (4)
sesamoiditis (Clin Imaging 2015 May-Jun;39(3):380)
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compartment syndrome(1)
traumatic injuries to the foot, such as
ankle sprains (Phys Med Rehabil Clin N Am 2014 Nov;25(4):829)
first metatarsophalangeal joint sprain ("turf toe") (Mil Med 2004 Nov;169(11):xix)
fracture of metatarsal (Clin Podiatr Med Surg 2006 Apr;23(2):283)
fracture of phalanges (Am Fam Physician 2003 Dec 15;68(12):2413)
avulsion fracture base of fifth metatarsal (Phys Med Rehabil Clin N Am 2014
Nov;25(4):829)
fracture of metaphyseal-diaphyseal junction of the fifth metatarsal (Jones fracture) (Phys
Med Rehabil Clin N Am 2014 Nov;25(4):829)
non-activity-related causes of foot pain include
Morton neuroma (Clin Podiatr Med Surg 2010 Oct;27(4):535)
nerve or artery entrapment(1)
tarsal tunnel syndrome (Foot Ankle Clin 2011 Jun;16(2):275)
Baxter nerve entrapment(4)
medial calcaneal nerve entrapment (Am J Sports Med 1984 Mar-Apr;12(2):152)
infection(1)
bone malignancy (1)
Testing overview:
imaging needed to confirm diagnosis of stress fracture
perform plain x-ray as the initial test to look for signs of stress fracture; however, this test
is often normal for ≥ 3 months from symptom onset
perform magnetic resonance imaging (MRI) if stress fracture is not visible on plain x-ray
can detect a stress response in the bone long before changes are apparent on plain x-
ray, and help exclude other causes of pain in the area
contrast not needed unless there is concern for another condition, such as
adjacent soft tissue mass
ambiguous findings
if MRI is not available or cannot be performed, consider
computed tomography scan
radioisotope bone scan (less specific than MRI for stress fractures)
Imaging studies:
perform x-ray as initial imaging modality
diagnosis confirmed if a fracture line is visible on the affected bone, and additional imaging
only needed for operative planning in fractures at high-risk stress fractures (2)
initial x-ray only has about 10% sensitivity for stress fracture(1)
after 2 weeks, bony changes may start to be visualized(4)
sensitivity increases to 30%-70% after 3 weeks (1)
x-rays are often normal for ≥ 3 months from time of symptom onset(2)
if initial x-ray is normal and urgent diagnosis not necessary, consider repeat x-ray in 2-3
weeks (1)
American College of Radiology considers x-ray usually appropriate as first imaging modality
for suspected stress test and recommends it be used before consideration of other
imaging (ACR 2016 PDF)
perform magnetic resonance imaging (MRI) if stress fracture is not visible on plain x-ray (2)
MRI considered best choice for imaging for stress fractures; contrast not needed unless
there is concern for another condition due to
adjacent soft tissue mass
ambiguous findings
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Reference - ACR 2016 PDF

benefits of MRI include(2)
can detect a stress response in the bone weeks before changes are apparent on plain
x-ray, and help exclude other causes of pain in the area
serial MRI can be used to monitor fracture resolution
computed tomography (CT) scan has limited utility for diagnosing stress fracture, but can be
considered in patients with claustrophobia or contradictions to MRI (2)
less sensitive than radioisotope scan(2)
positive MRI with negative CT may indicate stress response as opposed to a complete
fracture(2)
may be used to determine extent of the fracture distance and to plan surgery for
displaced fractures or navicular stress fractures (2)
some authors suggest CT scan before MRI if navicular stress fracture is suspected (Am J
Sports Med 2005 Dec;33(12):1875)
may be used to monitor healing of stress fracture(4)
axial and sagittal CT scan reported to detect all sesamoid stress fractures in 5 women
athletes when MRI only detected 2 of the fractures in case series (Foot Ankle Int 2003
Feb;24(2):137)
radioisotope bone scan(2)
sensitive for stress fractures but not specific
increased uptake can also be a sign of infection, inflammatory condition, or cancer
associated with a radiation dose 75 times greater than a normal chest x-ray
Society of Nuclear Medicine (SNM) procedure guideline for bone scintigraphy can be found
at SNM 2003 Jun 20 PDF
sensitivity and specificity of imaging tests for diagnosis of stress fractures of the
lower extremity vary across studies (level 2 [mid-level] evidence)
based on systematic review of mainly small diagnostic cohort studies with heterogeneity in
diagnostic standard
systematic review of 21 diagnostic cohort studies evaluating imaging modalities for
diagnosis of lower extremity stress fractures
diagnostic standard in studies varied with radioisotope bone scan, MRI, or radiography
being most commonly used
only 1 study had > 100 patients
ranges of sensitivity and specificity of the following tests were reported
in 4 studies evaluating MRI
sensitivity 68%-99%
specificity 4%-97%
in 6 studies evaluating bone scintigraphy
sensitivity 50%-97%
specificity 33%-98%
in 2 studies evaluating computed tomography
sensitivity 32%-38%
specificity 88%-98%
in 7 studies evaluating ultrasound
sensitivity 43%-99%
specificity 13%-79%
in 4 studies evaluating conventional x-ray
sensitivity 12%-56%
specificity 88%-96%
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in 2 studies evaluating thermography

sensitivity 78%-82%
sensitivity 83%-88%
Reference - Am J Sports Med 2016 Jan;44(1):255
positron emission tomography (PET)/MRI reported to identify stress fracture or stress
reaction in 8 of 20 patients with unclear foot or ankle pain in case series (Eur J Med Res 2015
Dec 23;20(1):99)
review of ultrasonography for fractures in sports medicine can be found in Br J Sports Med
2015 Feb;49(3):152
Other diagnostic testing:
pain during therapeutic ultrasound appears sensitive for high-grade stress injury
based on diagnostic cohort study without mention of blinding of reference standard in
therapists performing diagnostic test
113 elite track and field athletes suspected of having a bone stress injury had therapeutic
ultrasound performed at the point of tenderness on exam by a physical therapist
magnetic resonance imaging (MRI) used as reference standard for diagnosis of stress
injury
radiologists reading MRI were blinded to finding during therapeutic ultrasound but study did
not mention blinding of physical therapists to MRI results
97% had bony stress injury on MRI
73.5% had high-grade stress injuries (either discrete fracture line seen or extensive
periosteal edema and marrow signal abnormalities)
40% of bony stress injuries were in the foot
compared to reference standard, pain during therapeutic ultrasound had
sensitivity 95.1% for high-grade stress injury
specificity 66.6% for any stress injury
Reference - Am J Sports Med 2012 Apr;40(4):915
Treatment
Treatment overview:
treatment for stress fractures of foot and ankle vary depending on risk for nonunion
stress fractures at high risk for nonunion (such as stress fractures in the navicular bone or
fifth metatarsal)
refer to specialist such as an orthopedist or sports medicine physician
conservative treatment
consider 6-8 weeks of nonweight bearing with cast immobilization for incomplete
fractures or complete fractures that are nondisplaced
for sesamoid stress fractures, conservative treatment may include rest from sports,
period of partial or nonweight bearing, use of boots or orthotics, immobilization, and
possibly steroid injections
non-weight-bearing cast immobilization for 6 weeks or surgery reported to be more
effective than weight-bearing conservative treatment for navicular stress fractures (level
3 [lacking direct] evidence)
operative treatment reported to reduce time missed from activities compared to
nonoperative treatment in patients with medial malleolar stress fractures (level 3 [lacking
direct] evidence)
surgery
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for metatarsal fractures, consider surgery before conservative therapy if high-risk stress
fracture, especially in athletes wishing to return to activity as soon as possible
consider surgery if a complete fracture line is visible on x-ray, magnetic resonance
imaging (MRI), or computed tomography (CT)
offer surgery for displaced fractures, fractures with delayed union or nonunion, or
fractures that failed to heal after conservative therapy
surgery might be associated with shorter time to return to play compared to
conservative therapy with non-weight-bearing cast for > 6 weeks in patients with
navicular stress fractures (level 2 [mid-level] evidence)
stress fractures at lower risk for nonunion (such as stress fractures in the distal part of the
second to fifth metatarsals)
often heal with conservative treatment
may include activity modification alone or partial nonweight bearing until pain has
resolved
discomfort during activity should help guide which activity should be limited
maintaining a pain-free level for 4-8 weeks is often sufficient to have stress fracture heal
consider surgery for displaced fractures or fracture with signs of delayed union or nonunion,
or if conservative therapy fails
after appropriate rest period, consider gradually increasing activity (no more than 10%
increase in activity per week) as long as athlete is pain free and site of stress fracture is
not tender
return to full activity
for high-risk stress fractures
patients can return to full activity when they have normal examination and have no pain
with functional activity
for navicular stress fracture, CT scan or MRI showing healing suggested before athletes
return to sports
for low-risk stress fractures
if injury is during the competitive season, modify activity to a stable or decreased pain
level and monitor closely
if injury is during off-season, consider gradually increasing activity (no more than 10%
increase in activity per week) after 4- to 8-week period of decreased activity, as long as
athlete is pain free and site of stress fracture is not tender
Activity:
Activity modification for high-risk fractures:
navicular stress fractures
consider 6-8 weeks of nonweight bearing with cast immobilization for incomplete fractures
or complete fractures that are nondisplaced(3)
limited weight bearing is not recommended(3)
if no tenderness after 6-8 weeks of treatment, rehabilitation can be started with gradual
return to sports (3)
proposed conservative regimen for navicular stress fractures (each step should only occur
if patient remains symptom free)(3)
nonweight bearing in cast for 6 weeks followed by
weight bearing as able in a removable cast for 2 weeks followed by
weight bearing out of cast with resistive strengthening and light jogging for 2 weeks
followed by
full running and start of sports specific training for 2 week followed by
full return to sports
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many patients treated for navicular stress fracture without non-weight-bearing

cast immobilization for ≥ 6 weeks reported to not be able return to sports at
previous level
based on retrospective case series
11 patients with navicular stress fracture followed for median 3.7 years
18% were treated with ≥ 6-week non-weight-bearing activity
55% returned to sports at their previous level
Reference - Am J Sports Med 2005 Dec;33(12):1875
high-risk metatarsal fractures
high-risk metatarsal fractures include(2, 3, 4)
fifth metatarsal stress fractures at the diaphyseal-metaphyseal junction (some authors
also state stress fractures are similar to fifth metatarsal stress fractures)
stress fractures of the second metatarsal base (some authors also state stress
fractures of the third metatarsal base are similar to second metatarsal base stress
fractures)
fifth metatarsal fractures - if no signs of nonunion or delayed union, consider a 6- to 8-
week trial of nonweight bearing in a short leg cast unless the patient is high-level athlete
needing return to play as soon as possible(3, 4)
for second or third metatarsal base fracture - nonweight bearing or weight bearing in
regular shoes or short leg casts have all been reported to lead to good outcomes (3)
sesamoid fractures (3, 4)
conservative treatment should be first approach
conservative treatment options include
rest from sports
period of partial or nonweight bearing
use of boots or orthotics
immobilization
possible steroid injections
medial malleolus fractures
incomplete fracture can be treated conservatively with cast immobilization and non-weight-
bearing activity (4)
nonsurgical treatment has been reported to lead to 100% return to play, but return to play
appeared to take longer compared to surgical treatment of medial malleolus fractures in
systematic review of 6 retrospective case series (Sports Health 2014 Nov;6(6):527 full-
text)
talus fractures
no established treatment algorithm for talar stress fractures (4, 5)
some experts suggest 6 weeks of nonweight bearing (Clin J Sport Med 1996 Jan;6(1):48)
only 44% of patients with talar stress fracture and pain on walking reported to
have complete symptoms resolution following decreased activity with crutch
use (level 3 [lacking direct] evidence)
based on case series
9 military recruits with 10 talus stress fracture who were followed for a mean 45 months
patients were suspended from military training for median 39 days and performed
reduced exercise
patients were also given crutches to use if they noted pain with walking
nonsteroidal anti-inflammatory medications were given
no casts or orthotics were used and no patients had surgery
4 of 9 (44.4%) patients did not have any symptoms at last follow-up
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6 of 10 stress fractures at last follow-up were still causing either minor or moderate
symptoms during exercise
5 of 10 stress fractures showed degeneration on magnetic resonance imaging (MRI) at
last follow-up
Reference - Am J Sports Med 2006 Nov;34(11):1809
Activity modification for low-risk fractures:
general treatment considerations for low-risk fractures
can usually be managed with relative rest, which can include decreasing intensity or
frequency of activity to a pain-free level
discuss risks and benefits of continued sports participation with modification compared to
stopping activity with complete rest to allow healing
discomfort during activity should help guide which activity should be limited
if fracture not healing with relative rest, nonweight bearing or surgery can be considered
Reference - Clin J Sport Med 2005 Nov;15(6):442
additional considerations in athletes
if injury is during an off-season
decrease activity to pain-free level for 4-8 weeks
after 4- to 8-week period of decreased activity, consider gradually increasing activity
(no more than 10% increase in activity per week) as long as athlete is pain free and
site of stress fracture is not tender
if injury is during the competitive season
if no functional limitations - monitor closely and modify activity to a stable or
decreased pain level
if function limitations - modify activity to a level where pain not limiting function and
then titrate activity to a level of stable or decreased pain
Reference - Clin Sports Med 2006 Jan;25(1):17
distal metatarsal stress fractures (3, 4)
activity modification suggested until symptoms have resolved (typically 6-8 weeks),
including limited weight bearing using crutches for first 1-3 weeks
gradually increase weight bearing as tolerated, and consider addition of lower extremity
exercises, such as towel toe curl and ankle isometrics
stiff-soled shoes, midfoot taping, a walker boot, or a short leg walking cast may be used
initially to increase comfort
after pain resolves, general conditioning and strengthening specific to the injured extremity
is advised, with goal to be able to be fully weight bearing without pain for ≥ 30 minutes 3
times/week
consider alternating between periods of strengthening exercises and rest as it may help the
osteocytes and periosteum to mature more quickly
calcaneus (4, 5)
usually improve with activity modification alone
casting or surgery not usually required
cuneiform, cuboid, and lateral malleolus (4)
2-6 weeks of partial weight bearing advised until pain has resolved
can be performed with or without periods of immobilization
Medications:
analgesia(1)
consider acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control
some authors suggest caution with NSAIDs due to potential risk for nonunion seen in
animal studies on traumatic fractures
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Surgery and procedures:

Surgery for high-risk fractures:
consider surgery if a complete fracture line is visible on x-ray, magnetic resonance imaging, or
computed tomography (Clin J Sport Med 2005 Nov;15(6):442)
high-risk fractures that are displaced should be managed surgically (Clin J Sport Med 2005
Nov;15(6):442)
navicular stress fracture
surgery for navicular stress fracture(3, 5)
surgery considered treatment of choice if displaced fracture, delayed union, or nonunion,
and also recommended if conservative treatment fails
some experts suggest surgery as first-line treatment if stress fracture extends from the
dorsum onto the navicular body, or if there is complete bicortical disruption seen on
imaging
surgery involves fixation performed either percutaneously or by open approach
after surgery, patients should be nonweight bearing for 6-8 weeks followed by
rehabilitation
evidence for navicular stress fractures
surgery or non-weight-bearing cast immobilization for 6 weeks reported to
be more effective than weight-bearing conservative treatment for navicular
stress fractures (level 3 [lacking direct] evidence)
based on systematic review of observational studies with indirect comparisons
systematic review of 23 studies (12 case reports, 4 case series, and 7 cohort
studies) evaluating management of navicular stress fractures in 313 patients
patients were divided into 3 groups for analysis (non-weight-bearing treatment,
weight-bearing treatment, and surgical treatment)
the term successful outcome was used to describe patient if all of the following met
pain free
able to return to sport at previous activity level
no fracture recurrence
reported successful outcomes by modality
96% with non-weight-bearing cast immobilization for 6 weeks (p < 0.0001
compared to weight bearing, not significant compared to surgery)
82% with surgical treatment (p = 0.0003 compared to weight bearing)
47% with weight-bearing conservative treatment
Reference - Am J Sports Med 2010 May;38(5):1048, commentary can be found in
Am J Sports Med 2010 Oct;38(10):NP3
surgery might be associated with reduced time to return to play compared to
conservative therapy with non-weight-bearing cast for > 6 weeks in patients
with navicular stress fractures (level 2 [mid-level] evidence)
based on systematic review of low-quality observational studies and case
reports/case series
systematic review of 18 studies evaluating treatment approaches for navicular, fifth
metatarsal, or anterior tibial stress fractures in 477 patients
8 studies evaluated navicular stress fractures in 200 patients, including 6 studies
evaluating time to healing/return to sports (4 retrospective cohort studies and 2 case
series)
mean time to return to sports was 16.4 weeks with surgery vs. 21.7 weeks with
conservative treatment with non-weight-bearing cast for > 6 weeks (no p value
reported) in analysis of 4 retrospective cohort studies
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Reference - Br J Sports Med 2015 Mar;49(6):370

high-risk metatarsal fractures
high-risk metatarsal fractures include(2, 3, 4)
fifth metatarsal stress fractures at the diaphyseal-metaphyseal junction (some authors
also state stress fractures are similar to fifth metatarsal stress fractures)
stress fractures of the second metatarsal base (some authors also state stress
fractures of the third metatarsal base are similar to second metatarsal base stress
fractures)
surgery for high-risk metatarsal stress fractures (3, 4, 5)
recommended if delayed union or nonunion
may also be option for fifth metatarsal fractures displaced by > 2 mm or if conservative
therapy has failed
may be considered before conservative therapy if high-risk stress fracture, especially in
athletes wishing to return to activity as soon as possible
surgery appears to reduce time to return to play compared to conservative
therapy in patients with fifth metatarsal stress fractures (level 2 [mid-level]
evidence)
based on systematic review of low-quality observational studies and case reports/case
series
systematic review of 18 studies evaluating treatment approaches for navicular, fifth
metatarsal, or anterior tibial stress fractures in 477 patients
8 studies evaluated fifth metatarsal stress fractures in 246 patients
data pooled for patients treated conservatively compared to patients treated surgically
return to play occurred at mean 13.8 weeks with surgery compared to 19.2 weeks with
conservative treatment (no p value reported)
of 2 studies that directly compared surgery vs. conservative therapy, 1 found
significantly shorter time to return to play with surgery
Reference - Br J Sports Med 2015 Mar;49(6):370
for sesamoid stress fractures (3, 4)
sesamoidectomy may be used if conservative treatment fails
other surgical options include partial sesamoidectomy, closed reduction and percutaneous
screw placement, curettage, and bone grafting
all surgical methods have been reported to have a high success rate and return to sports
rate
medial malleolus stress fractures
consider internal fixation in athletes to allow earlier return to play (4)
operative treatment reported to reduce time missed from activities compared to
nonoperative treatment in patients with medial malleolar stress fractures
(level 3 [lacking direct] evidence)
based on systematic review of small, retrospective case series
systematic review of 6 case series describing treatment for medial malleolar stress
fractures in 31 patients (16 treated nonoperatively and 15 treated operatively)
therapies were heterogenous (nonoperative treatment ranged from activity as tolerated
to full nonweight bearing)
decision regarding surgery was based on factors including higher level of competition,
proximity to competitive season, visibility of a fracture line on x-ray, and displacement of
the fracture
81% were men and mean age was 24.5 years
time from diagnosis to radiographic healing varied from 4 weeks to 8 months
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all patients who were participating in sports were able to return to play
time missed from activities ranged from 2-4 weeks with operative treatment vs. 3-12
weeks with nonoperative treatment (no p value reported)
nonunion of fracture occurred in 1 patient
Reference - Sports Health 2014 Nov;6(6):527 full-text
Surgery for low-risk fractures:
consider surgery for low-risk stress fractures if
delayed union or nonunion(3)
conservative treatment fails (Clin J Sport Med 2005 Nov;15(6):442)
Consultation and referral:
refer high-risk fractures to orthopedics or sports medicine specialist(1)
Other management:
BMJ rapid recommendations recommends against the use of low-intensity pulsed utrasound
(LIPUS) in adults and children with fracture or osteotomy (GRADE Strong recommendation)
(BMJ 2017 Feb 21;356:j576 full-text, full details at MAGICapp 2017 April 20)
low-intensity pulsed ultrasound does not appear to improve symptoms or healing
in patients with stress injuries of the lower extremity (level 2 [mid-level]
evidence)
based on small randomized trial
23 patients with lower extremity stress injuries (11 tibia, 5 fibula, 7 metatarsal other than
fifth or first metatarsal) were randomized to low-intensity pulsed ultrasound vs. placebo
machine for 20 minutes daily for 4 weeks
no significant differences between groups for
6 clinical measures including nigh pain, pain at rest, pain on walking, pain with running,
tenderness, and pain with single-leg hop
magnetic resonance imaging (MRI) grading at 4-week follow-up
bone marrow edema size
Reference - Clin J Sport Med 2014 Nov;24(6):457
Follow-up:
return to activity
for high-risk stress fractures
patients should not return to full activity until they have a normal examination and no
pain with functional activity (Clin J Sport Med 2005 Nov;15(6):442)
for navicular stress fracture, computed tomography (CT) scan or magnetic resonance
imaging (MRI) showing healing suggested before athletes return to sports (Foot Ankle
Clin 2009 Jun;14(2):187)
for low-risk stress fractures
if injury is during the competitive season
if no functional limitations caused by pain from stress fracture
modify activity to a stable or decreased pain level
monitor closely
if function limitations caused by pain from stress fracture
modify activity to a level where pain not limiting function
titrate activity to a level of stable or decreased pain
if pain worsens despite activity modifications, complete rest or immobilization should
be considered
if injury is during off-season, consider gradually increasing activity (no more than 10%
increase in activity per week) after 4- to 8-week period of decreased activity, as long as
21/05/2019 DynaMed
athlete is pain free and site of stress fracture is not tender

Reference - Clin Sports Med 2006 Jan;25(1):17
Complications and Prognosis
Complications:
complications can include(3)
delayed union and nonunion
refracture
persistent pain
degenerative arthritis
Prognosis:
risk for nonunion varies by the location of the stress fracture
stress fractures at high-risk stress for nonunion include(2, 3, 4)
talus
navicular
fifth metatarsal
proximal fractures of second metatarsal
sesamoid
medial malleolus
stress fractures at lower-risk stress of nonunion include(2, 3, 4)
calcaneus
cuboid
cuneiform
lateral malleolus
distal fractures of the second to fifth metatarsals
time to return to sports may depend on whether stress fracture is at a high-risk
site, and severity of stress fracture on imaging (level 2 [mid-level] evidence)
52 athletes with stress fractures seen on either magnetic resonance imaging (MRI) or
bone scintigraphy who had been treated with non-weight-bearing activity were evaluated
23 fractures were at high-risk site (most commonly navicular bone and fifth metatarsal)
29 fractures were at low-risk sites (most commonly other metatarsal bones)
52 stress fractures were graded as high risk by severity on imaging
high grade on MRI defined as bone marrow edema in T1- and T2-weighted image with
or without a fracture line
high grade on bone scintigraphy defined as sharply marginated area of increased activity
rather than a poorly defined area of increased activity
comparing time to return to sports
143 days if high-grade lesion compared to 95 days if low-grade lesion (p = 0.01)
132 days if high-risk location compared to 119 days if low-risk location (not significant)
61 days if low-risk site and low-grade lesion (p < 0.02) compared to
135 days if high-risk site and low-grade lesion
153 days if low-risk site and high-grade lesion
131 days if high-risk site and high-risk lesion
Reference - BMC Musculoskelet Disord 2012 Aug 6;13:139 full-text
patients treated for navicular stress fractures with either nonweight bearing for > 6 weeks or
surgery tend to have a good prognosis (Am J Sports Med 2010 May;38(5):1048)
low-risk stress fractures usually heal when the patient is limited to pain-free activity for 4-8
weeks (Clin Sports Med 2006 Jan;25(1):17, Am Fam Physician 2007 Sep 15;76(6):817 full-
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text)
nonunion reported in 50% of 12 patients with stress fractures of the second metatarsal base
in retrospective cohort study (Clin Orthop Relat Res 2007 Aug;461:197)
Prevention and Screening
Prevention:
limited evidence suggests insoles and orthotics do not appear to prevent stress
fractures or stress reactions of the foot (level 2 [mid-level] evidence)
based on Cochrane review with limited evidence from trials with methodologic limitations
systematic review of 16 trials evaluating interventions for treating and preventing stress
fractures of lower limbs in active young adults
all studies had inadequate discussion of allocation concealment and most did not have
adequate blinding of outcomes assessors
13 studies evaluated preventative interventions
preventative measures not shown to clearly prevent stress fracture or stress reactions in
the foot included
insoles or orthotics compared to no insoles in 2 trials
cushioned compared to standard insoles in 1 trial
vesico-elastic polymer compared to standard mesh insoles in 1 trial
orthotics (semirigid or soft foot) compared to mesh insoles in 1 trial
urethane compared to special grid-like mesh insoles in 1 trial
semirigid compared to soft foot orthotics in 1 trial
custom-made mechanical compared to prefabricated semirigid foot orthoses in 1 trial
modified basketball shoe compared to standard infantry boot in 1 trial
preexercise stretching in 2 trials
calcium supplements in 1 trial
Reference - Cochrane Database Syst Rev 2005 Apr 18;(2):CD000450 (review updated
2008 Oct 22)
calcium and vitamin D supplement may reduce risk of stress fractures in female
military recruits (level 2 [mid-level] evidence)
based on randomized trial with high dropout rates
5,201 female Navy recruits randomized to calcium 2,000 mg and vitamin D 800 units vs.
placebo and followed through 8 weeks of basic training
5.9% developed stress fracture
71% completed study
stress fracture occurred in 5.3% with supplement vs. 6.6% with placebo (p = 0.03, NNT
77)
Reference - J Bone Miner Res 2008 May;23(5):741 full-text
higher dietary calcium intake and dairy intake each associated with decreased
risk of stress fractures in young female competitive distance runners (level 2
[mid-level] evidence)
based on prospective cohort study
125 female competitive distance runners (aged 18-26 years) had nutrition intake data
collected and were monitored for stress fractures for 2 years
13.6% developed ≥ 1 stress fracture
lower rates of stress fracture associated with
higher calcium intake (hazard ratio [HR] 0.53, 95% CI 0.29-0.97)
higher skim milk intake (HR 0.38, 95% CI 0.16-0.9)
higher dairy product intake (HR 0.6, 95% CI 0.4-0.89)
21/05/2019 DynaMed
Reference - PM R 2010 Aug;2(8):740

higher vitamin D intake might be associated with decreased stress fracture risk in
adolescent girls (level 2 [mid-level] evidence)
based on prospective cohort study with borderline statistical significance
6,712 girls aged 9-15 years at baseline, were followed for 7 years
3.9% developed stress fractures
highest vitamin D intake had borderline association with decreased risk of stress fracture
(adjusted hazard ratio 0.49, 95% CI 0.24-1.01) compared to lowest vitamin D intake
in subgroup of patients with ≥ 1 hour of high-impact activity per day, the trend for higher
vitamin D intakes association with lower risk of stress fracture became significant (p =
0.04)
dairy and calcium intake was not related to stress fracture risk
Reference - Arch Pediatr Adolesc Med 2012 Jul 1;166(7):595 full-text
preventive osteopathic manipulation associated with decreased risk for stress
fractures in male cross-country athletes (level 2 [mid-level] evidence)
based on before-and-after study
annual incidence of stress fractures in athletes on the cross-country team of 1 college were
compared for the 8 years before osteopathic manipulation therapy was regularly
performed on the team and compared to the 5 years after therapy was regularly
performed
in the men, yearly incidence of stress fracture decreased from 13.9% to 1% (p = 0.019)
the yearly incidence did not significantly change in women (12.9% before vs. 12% after)
Reference - J Am Osteopath Assoc 2013 Dec;113(12):882
oral contraception might not decrease stress fracture risk in female runners
based on randomized trial with inadequate statistical power and with high crossover rates
150 competitive female runners randomized to oral contraception (ethinyl estradiol 30 mcg
and norgestrel 0.3 mg) vs. no intervention and followed for 2 years
33% of patients switched groups during the study period
12% had a stress fracture during the study period
stress fracture occurred in 8.7% with oral contraception vs. 14.8% with no intervention
(not significant)
study was powered assuming a stress fracture rate of 20% would occur in the control
group
Reference - Med Sci Sports Exerc 2007 Sep;39(9):1464
prophylactic risedronate may not lower risk of stress fractures in infantry
recruits (level 2 [mid-level] evidence)
based on randomized trial without reporting of allocation concealment
324 infantry recruits randomized to risedronate 30 mg/day vs. placebo for 10 days during
the first 2 weeks of basic training followed by once weekly dosing for 12 weeks
comparing risedronate vs. placebo, no significant differences in
stress fracture (in 14.5% vs. 13.2%)
stress fracture of metatarsus (in 4.8% vs. 2.5%)
stress fracture of tibia (in 9.1% vs. 5.7%)
stress fracture of femur (in 6.7% vs. 6.3%)
Reference - Bone 2004 Aug;35(2):418
Guidelines and Resources
Guidelines:
21/05/2019 DynaMed
United States guidelines:

American College of Radiology (ACR) Appropriateness Criteria for stress (fatigue/insufficiency)
fractures, excluding other vertebrae can be found at ACR 2016 PDF
American College of Radiology (ACR) Appropriateness Criteria for chronic foot pain can be
found at ACR 2013 PDF
American College of Radiology (ACR) Appropriateness Criteria for acute trauma to foot can be
found at ACR 2014 PDF
Society of Nuclear Medicine (SNM) procedure guideline for bone scintigraphy can be found at
SNM 2003 Jun 20 PDF
Brazilian guidelines:
Brazilian Medical Association guidelines on stress fracture of the foot and ankle in athletes can
be found in Rev Assoc Med Bras 2014 Nov-Dec;60(6):512
Review articles:
general reviews of lower extremity stress fractures can be found in
Phys Med Rehabil Clin N Am 2016 Feb;27(1):139
Open Access J Sports Med 2015;6:87 full-text
Phys Sportsmed 2014 Nov;42(4):87
Clin Sports Med 2014 Oct;33(4):591
Clin Sports Med 2012 Apr;31(2):291
Joint Bone Spine 2012 Oct;79 Suppl 2:S86
Br J Radiol 2012 Aug;85(1016):1148 full-text
J Am Acad Orthop Surg 2012 Mar;20(3):167
Pediatr Clin North Am 2010 Jun;57(3):819
Sports Med Arthrosc 2009 Sep;17(3):149
Curr Opin Pediatr 2008 Feb;20(1):58
review of fifth metatarsal fractures in the athlete can be found in Foot Ankle Clin 2013
Jun;18(2):237
review of calcaneal stress fractures can be found in JBR-BTR 2012 Mar-Apr;95(2):114
review of evaluation and management of navicular stress fractures can be found in Foot
Ankle Clin 2009 Jun;14(2):187
review of stress fractures of the navicular bone can be found in Acta Orthop Belg 2008
Dec;74(6):725
review of rehabilitation and return to running after lower limb stress fractures can be found in
Curr Sports Med Rep 2013 May-Jun;12(3):200
review of diagnosis and management of metatarsal fractures can be found in Am Fam
Physician 2007 Sep 15;76(6):817 full-text
review of overuse lower extremity injuries in sports can be found in Clin Podiatr Med Surg
2015 Apr;32(2):239
review of common problems in endurance athletes can be found in Am Fam Physician 2007
Jul 15;76(2):237 full-text
review of principles of casting and splinting can be found in Am Fam Physician 2009 Jan
1;79(1):16 full-text
MEDLINE search:
to search MEDLINE for (Lower extremity stress fractures) with targeted search (Clinical
Queries), click therapy, diagnosis, or prognosis
Patient Information
handout on stress fractures of the foot and ankle from American Academy of Orthopaedic
Surgeons
21/05/2019 DynaMed
information on stress fractures from American Orthopaedic Foot & Ankle Society
handout on stress fractures from Mayo Clinic
ICD-9/ICD-10 Codes
ICD-9 codes:
733.94 stress fracture of the metatarsals
825.20 closed fracture of unspecified bone(s) of foot (except toes)
825.25 closed fracture of metatarsal bone(s)
825.30 open fracture of unspecified bone(s) of foot (except toes)
825.35 open fracture of metatarsal bone(s)
ICD-10 codes:
M84.3 stress fracture, not elsewhere classified
use subclassification code 7: ankle and foot, to indicate site of involvement
S92.3 fracture of metatarsal bone
S92.9 fracture of foot, unspecified
References
General references used:

1. Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Am Fam
Physician. 2011 Jan 1;83(1):39-46 full-text
2. Pegrum J, Crisp T, Padhiar N. Diagnosis and management of bone stress injuries of the
lower limb in athletes. BMJ. 2012 Apr 24;344:e2511 full-text
3. Hossain M, Clutton J, Ridgewell M, Lyons K, Perera A. Stress Fractures of the Foot. Clin
Sports Med. 2015 Oct;34(4):769-90
4. Mayer SW, Joyner PW, Almekinders LC, Parekh SG. Stress fractures of the foot and ankle
in athletes. Sports Health. 2014 Nov;6(6):481-91 full-text
5. Welck MJ, Hayes T, Pastides P, Khan W, Rudge B. Stress fractures of the foot and ankle.
Injury 2017 Aug;48(8):1722
Recommendation grading systems used:
British Medical Journal (BMJ) Rapid Recommendations uses Grades of Recommendation,
Assessment, Development, and Evaluation (GRADE)
strength of recommendation
Strong recommendation - desirable effects of an intervention clearly outweigh the
undesirable effects
Conditional (weak) recommendation - uncertainty about trade-offs between desirable
and undesirable effects of an intervention
quality of evidence
High-quality evidence - further research unlikely to change confidence in estimate of
effect
Moderate-quality evidence - further research likely to have impact on confidence in
estimate of effect
Low-quality evidence - further research expected to have important impact on
confidence in estimate of effect and is likely to change estimate
Reference - BMJ Rapid Recommendations on arthroscopic surgery for degenerative knee
arthritis and meniscal tears (BMJ 2017 May 10;357:j1982 full-text full details at MAGICapp
2017 May 17 )
DynaMed editorial process:
DynaMed topics are created and maintained by the DynaMed Editorial Team and Process.
21/05/2019 DynaMed
All editorial team members and reviewers have declared that they have no financial or other
competing interests related to this topic, unless otherwise indicated.
DynaMed provides Practice-Changing DynaMed Updates, with support from our partners,
McMaster University and F1000.
Special acknowledgements:
Michelle Lin, MD (Professor of Emergency Medicine, University of California - San Francisco
School of Medicine; California, United States)
Dr. Lin declares no relevant financial conflicts of interest.
Eddy Lang, MDCM, CCFP(EM), CSPQ (Zone Clinical and Academic Department Head for
Emergency Medicine and Professor of Emergency Medicine, University of Calgary; Senior
Researcher, Alberta Health Services; Alberta, Canada)
Dr. Lang declares his position as Chair of the Canadian Association of Emergency Physicians
Stroke Practice Committee.
Dr. Lang declares no relevant financial conflicts of interest.
Alan Ehrlich, MD (Executive Editor; Associate Professor of Family Medicine, University of
Massachusetts Medical School; Massachusetts, United States)
Dr. Ehrlich declares no relevant financial conflicts of interest.
Editorial Team role definitions
Topic Editors define the scope and focus of each topic by formulating a set of clinical
questions and suggesting important guidelines, clinical trials, and other data to be addressed
within each topic. Topic Editors also serve as consultants for the internal DynaMed Plus
Editorial Team during the writing and editing process, and review the final topic drafts prior
to publication.
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includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance
of the medical literature.
Recommendations Editors provide explicit review of DynaMed Plus Overview and

Recommendations sections to ensure that all recommendations are sound, supported, and
evidence-based. This process is described in "Synthesized Recommendation Grading."
Deputy Editors are employees of DynaMed and oversee DynaMed Plus internal publishing
groups. Each is responsible for all content published within that group, including supervising
topic development at all stages of the writing and editing process, final review of all topics
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Stress fractures of the foot and ankle

Eddy Lang, MDCM, CCFP(EM), CSPQ

typical grading system for severity of stress fractures (2)

Who is most affected:

Reference - J Bone Joint Surg Am 2006 Oct;88(10):2237

Reference - Arch Pediatr Adolesc Med 2011 Aug;165(8):723 full-text

may present with mild and nonspecific symptoms

Making the diagnosis:

Reference - ACR 2016 PDF

in 2 studies evaluating thermography

many patients treated for navicular stress fracture without non-weight-bearing

Surgery and procedures:

Reference - Br J Sports Med 2015 Mar;49(6):370

athlete is pain free and site of stress fracture is not tender

Reference - PM R 2010 Aug;2(8):740

United States guidelines:

General references used:

Recommendations Editors provide explicit review of DynaMed Plus Overview and

Forneça seus comentários enviando um e-mail DynaMed em: DynaMedEditor@ebscohost.com

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