In a post I wrote a few weeks ago, I answered some common questions athletes and active people often have about stress fractures. I discussed some risk factors, the typical presentation and diagnosis of a stress fracture. I also briefly mentioned that certain stress fractures are considered high risk.

In this post, I discuss some of these lower extremity stress fractures. While femoral neck stress fractures and certain tibial stress fractures can be serious injuries, I’ll share information on high-risk stress fractures of the foot and ankle that often afflict runners and athletes in jumping sports.

Navicular stress fracture

A navicular stress fracture presents the athlete and orthopaedic surgeon a challenge due to a high risk of nonunion. A stress fracture in the central third of the bone can be slow to heal due to its location between blood vessels entering the bone on either side.

Also read:
Ask Dr. Geier – Navicular Stress Fractures
Ask Dr. Geier – Stress Fractures

Sprinting athletes and athletes in jumping sports like basketball can develop pain and point tenderness along the medial side of the midfoot (on the side of the great toe on top of the arch of the foot). X-rays might show a stress fracture if pain has been present more than two weeks. MRI or CT can demonstrate a navicular stress fracture.

Debate exists as to the proper first-line treatment. Due to the risk of nonunion, weightbearing is thought to be detrimental. Either making the patient nonweightbearing in a cast or performing surgery to place one or two screws across the fracture are felt to be more appropriate treatments to help these difficult stress fractures heal.

Location of pain with a navicular fracture or stress fracture

Base of the fifth metatarsal stress fracture

This stress fracture often occurs in basketball and soccer players. Athletes with certain types of feet are thought to have a higher risk for this type of stress fracture. Athletes notice pain on the outside the foot with training that takes longer and longer to go away. The surgeon usually finds tenderness at the base of the fifth metatarsal and pain with inversion of the foot.

Sometimes a fifth metatarsal stress fracture can be treated by making the patient nonweightbearing in a cast. In high-level athletes, most orthopaedic surgeons treat the stress fracture surgically with a screw placed down the center of the bone. Return to sports can take 6 to 10 weeks after surgery, but refracture can occur.

Sesamoid stress fracture

The sesamoids are the small bones that lie underneath the first metatarsal head (the ball of the foot). Stress fractures of the medial sesamoid can occur with repetitive stress, especially dorsiflexion of the toes. The orthopaedic surgeon finds tenderness to palpation directly along the involved sesamoid bone and pain with dorsiflexion of the first metatarsophalangeal joint. Nonoperative treatments are usually attempted first. These include orthotics, rigid immobilization, periods of limited weightbearing and cortisone injections. Surgery can occasionally be necessary. Removing part or all of the involve sesamoid or screw fixation can be performed.

Medial malleolus stress fracture

This is the bony prominence on the medial (inside) side of the ankle. Medial malleolus stress fractures are rare injuries that affect runners and athletes of jumping and kicking sports. Usually orthopaedic surgeons treat patients with these stress fractures by making them nonweightbearing in a cast. Some surgeons perform internal fixation with screws to try to get the athlete back to sports sooner.

Stress fracture of the talus

This is another rare stress fracture of the foot and ankle, affecting the lower bone in the ankle joint. Military recruits often suffer stress fractures of the talus. Excessive pronation might be a factor for some patients, so orthotics might be an option for a patient with a talar stress fracture. Due to the risk of nonunion, some orthopaedic surgeons treat patients with talar stress fractures by making them strictly nonweightbearing.

Also read:
Ask Dr. Geier – Femoral Neck Stress Fractures
Watch out for disordered eating

If an athlete or active individual in a running or jumping sport or exercise has localized pain along a bone in the foot or ankle that is increasing or not improving, it can be worthwhile to have an orthopaedic surgeon examine it to determine if a stress fracture is present.

Jogger with foot pain and possible stress fracture

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Mayer SW, Joyner PW, Almekinders LC, Parekh SG. Stress Fractures of the Foot and Ankle in Athletes. Sports Health: A Multidisciplinary Approach. May 14, 2013