Stress Fractures of the Foot

A stress fracture is a small crack in a normal bone which occurs after repeated overuse. They are common in the feet of active people.


The three important ankle and foot stress fractures are:

 

 

Symptom of a stress fracture are:

 

  • pain which worsens with activity and decreases with rest
  • swelling.

 

Causes of a Stress Fracture

Stress fractures often result from a rapid increase in the intensity of exercise or sporting activity. They can also be caused by a change in the surface of play and wearing worn-out or uncomfortable footwear. 


Some people have structural foot issues that make stress fractures more likely. The most important are:

 

  • ankle and talo-navicular joint stiffness (spur impingement +/- ossicles)
  • high arched (cavo-varus) feet
  • bunions (hallux valgus).

 

Other people have weaker than normal bones (osteoporosis) which make fractures more likely. These are called insufficiency fractures instead.


Navicular Stress Fracture

 

 

  • It is seen in runners and jumping athletes.

 

 

  • Pain occurs in the top of the foot just in front of the ankle (the "N-spot").

 

 

  • A vertical split begins at the top of the bone ( see CT images ) and can spread through to its base (Saxena grades I, II and III).

 

  • Healing can take many months and surgery is recommended if healing is not occurring or the fracture is > 30% through the bone ( see plate fixation image ).

 

Nav AP CT
Nav Coronal CT
Nav Plate Fixation

Diagnosing a Stress Fracture

The correct diagnosis can take time to make unless thought of early.

Like all conditions, diagnosis requires:
  • evaluating symptoms and risk factors
  • performs a thorough examination of the foot and ankle.
Diagnostic tests including X-ray, CT, MRI or bone scan are required to confirm the fracture.

If a stress fracture is diagnosed, a vitamin D level blood test is often recommended to check for reversible causes of bone weakness.

Treatment of Stress Fractures

Non-surgical treatment

Stress fractures can be treated non-surgically. This requires prolonged rest, limited physical activity and immobilisation in a "moon-boot".
  • The duration of this treatment is unpredictable.
  • X-rays and/or scans are required every 6 weeks until healing has occurred.
  • Delayed healing and/or re-fracture can occur.
Surgical treatment
  • If a stress fracture fails to heal, gets worse (see navicular stress fracture above) or recurs, surgery is usually recommended.
  • Elite athletes and people with structural foot issues are often offered earlier surgery to make recovery more predictable. 
  • Surgery involves stabilising the fracture with a metal screw or plate +/- bone graft, then rest and immobilisation in a "moon-boot".

Prevention of Stress Fractures

The following measures may help to prevent stress fractures:
  • start any new sporting activity slowly and progress gradually
  • cross-training or altering exercises
  • maintain a healthy diet and include calcium and vitamin D rich foods in the diet
  • wear well-fitting and comfortable footwear specifically designed for the sporting activity
  • avoiding old or worn out shoes.
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