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Stress fractures of the foot

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Patients with stress fractures will usually report localized aching pain in the affected area.  They will give a history of some increase in their normal activity level (ex. went for a long hike this weekend, increased training in preparation for a marathon).  This pain typically increases with activity and decreases with rest. They may have a history of a condition that predisposes them to weaker bones such as osteoporosis (weak thin bone), amenorrhea (loss of normal menstrual cycle), or a history of smoking.

Metatarsal Stress fractures

Stress fractures involving the lesser metatarsal bones (typically 2nd or 3rd) will often present with pain and swelling in the midfoot to forefoot. On examination, there will be some degree of swelling and tenderness directly over the affected metatarsal. There may also be some associated forefoot swelling. The foot type in general may be flat, often with a long second and possibly third toe. There may also be an associated callus under the ball of the foot, at the base of the second or third toe. It is the repetitive absorption of the loading force beyond the capacity of the bone to withstand this force that causes the stress fracture. Patients usually can walk on the foot, though there will be a limp.

Jones (5th metatarsal stress fracture)

Individuals who suffer a Jones’ fracture will report pain on the outside of the midfoot (Figure 2). They have difficulty bearing weight and may walk with a limp. In most instances the patient will describe exactly when the fracture occurred, often after landing heavily or performing some other demanding but routine activity. However, sometimes the main symptom will be a chronic (long-term) ache in the outside part of the foot – representing a developing stress fracture of the base of the fifth metatarsal.  Many patients will report a history of some pain in the foot prior to the actual break. It is possible to have the problem in both feet, although usually one side hurts more. Patients with a Jones’ fracture will have pain at the fracture site (Figure 3). Often they will have high arched feet and/or an alignment of the lower extremity that tends to load the outside part of their feet (Figure 4). Sometimes, when looking at these patients’ shoes, one will see excessive wear of the outside of the sole because of the pressure put on that part of the foot and shoe.

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Figure 4, High-arched foot pattern in patient with a Jones’ fracture

Navicular Stress Fractures

Patients who develop navicular stress fractures will present with a chronic mid-foot ache.  Although anyone can get a navicular stress fracture, the most common presentation is in the athlete.  The injury may begin after a series of repetitive loading episodes.  However, unlike a typical stress fracture of the metatarsals (which are much more common), these loading episodes tend to be more dynamic.   Some examples include the lead foot of an active golfer, a middle distance runner, or any college or professional athlete performing dynamic repetitive activities.

The symptoms of a navicular stress fracture are often generalized to the mid-foot.  The relatively nonspecific location of the symptoms makes this condition difficult to diagnose.  Pain may be with athletic activities only, but some patients might even have a limp with walking. Physical examination will demonstrate a generalized tenderness around the top of the mid-foot. An astute physician may be able to localize the tenderness to the top of the navicular bone (the "N-Spot").  Certainly, attempts to hop or rise up on the toes of the affected foot will be painful.  There is some suggestion that patients with slightly higher arch feet and also patients with relatively long second toe and second metatarsal may have an increased risk of developing navicular stress fractures. These two situations may increase the concentration of force into the navicular, particularly in patients doing activities that involve them getting up on their toes such as sprinting and jumping.  But most commonly, the person with a navicular stress fracture has a normally-aligned foot.

Sesamoid Stress Fractures

Perhaps the first thing to realize about great toe sesamoid stress fractures is that in many instances they are not actually stress fractures of one of the two sesamoid bones, but rather, a “bipartite sesamoid” with an associated “sesamoiditis”. A bipartite sesamoid is a variant of a normal sesamoid where the bone remains separated into two fragments during development. “Sesamoiditis” is a general term that refers to pain under the great toe that occurs from repetitive loading to this area in a manner that is similar to metatarsalgia. Patients with deformities to the great toe, in which the sesamoid bones track abnormally, such as a bunion, can also develop a version of sesamoiditis.

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Plain x-rays will identify a Jones’ fracture (Figure 5). The fracture itself occurs at the metadiaphyseal area where the more flexible bone at the base of the 5th metatarsal meets the more rigid bone of the shaft of the metatarsal. The fracture is different from a Dancer’s fracture (Figure 6) which occurs when one of the ligaments pulls off (avulses) the tip of the 5th metatarsal base.

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Certain stress fractures may require surgery in order to aid in healing or prevent non-healing (i.e., non-union) or re-fracture. These “high risk” stress fractures include the Jones' fracture, a displaced navicular stress fracture, and other stress fractures that may not heal adequately with non-surgical treatment.

Jones Fracture:  Treatment

Like most fractures, a Jones’ fracture will usually heal if the foot is protected from the forces of weight bearing for a long enough period of time. However, the area of the bone that is fractured has a relatively poor blood supply so bone healing may be slowed. Furthermore, because the fracture is related to repetitive stress to the fracture site there is always a concern that the fracture may recur. In athletes with a Jones’ fracture, surgery is usually recommended.

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A patient that has a non-union of the Jones’ fracture or a recurrent fracture after it had appeared to have healed may need more involved reconstructive foot surgery. This reconstructive surgery would repair the fracture (often with bone grafting) and involves changing the shape of the foot by cutting and repositioning one or more bones in the foot or lower leg. Common bone cutting procedures (osteotomies) may include lateralizing calcaneal osteotomy (cutting the heel bone and shifting it more to the outside) and dorsiflexing 1st metatarsal osteotomy (cutting a wedge out of the top of the 1st metatarsal so that it may be realigned).

Navicular Stress Fracture: Treatment

Navicular stress fractures can also be difficult to treat due to the relative lack of blood supply to the navicular (a good blood supply is needed for healing of any bone injury) and the fairly extensive force that this bone absorbs in normal walking and in sporting type activities.

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If a navicular fracture heals in poor alignment, arthritis of the associated joint (the talonavicular joint) will set in, with pain and stiffness.  Surgery to fuse the talonavicular joint can alleviate much of the midfoot pain associated with talonavicular arthritis. However, it is associated with a fairly prolonged recovery time of six or more weeks of non-weightbearing. In addition, it increases the stiffness of the midfoot.

Sesamoid Stress Fracture: Treatment

Like with other stress fractures, non-operative treatment of a non-displaced acute sesamoid stress fracture requires a period of immobilization and protected weight bearing. The goal is to manage weight bearing through the heel for a period of six to eight weeks in order to give the sesamoid bones the best chance to heal properly. Specifically, the area under the base of the great toe is protected, similarly to managing sesamoiditis. An orthotic that helps to offload this area is used. This is typically an orthotic with a recessed area under the base of the first metatarsal head. This is combined with the cushioned insole and a very stiff sole of the shoe with a slight contour. A stiff sole with a rocker bottom contour will allow for a smoother dispersion of the force away from the base of the great toe. In addition, activity modification to help prevent excessive loading to this area should be performed. Time will often help to settle this condition when combined with activity modification.

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Risk factors for stress fractures include intrinsic mechanical factors (e.g. decreased bone density, foot structure), nutritional factors, hormonal factors, physical training, and extrinsic mechanical factors (e.g. footwear, running surface) (PMID: 10492029).  Patient's with osteogenesis osteoporosis, osteomalacia, osteogenesis imperfecta, Paget's disease, osteoporosis, osteomalacia, and fibrous dysplasia are at a higher risk for stress fractures (insufficiency fractures).

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