Republication of "Stress Fractures of the Foot and Ankle in Athletes"

Abstract

Stress fractures of the foot and ankle are common injuries in athletes. Management differs considerably based on fracture location and predisposing factors. Repetitive loading of the foot and ankle in athletes should result in physiologic bone remodeling in accordance with Wolff's law. However, when there is not sufficient time for complete healing to occur before additional loads are incurred, this process can instead lead to stress fracture. Assessment of the athlete's training regimen and overall bone health is paramount to both the discovery and treatment of these injuries, although diagnosis is often delayed in the setting of normal-appearing initial radiographs. While most stress fractures of the foot or ankle can usually be treated nonoperatively with a period of activity modification, fractures in certain locations are considered "high risk" due to poor intrinsic healing and may warrant more proactive operative management.

Keywords: ankle; athlete; foot; stress fracture.

Figure 1.

Female recreational runner and swimmer who originally presented with 1 month of left lateral ankle pain worse when weightbearing with lateral distal fibular stress fracture. She was treated with activity modification and a tall pneumatic boot. (A) Initial mortise x-ray of the left ankle demonstrates a transverse lucency at the distal fibula immediately above the incisura. (B) Left ankle mortise x-ray 1 month later demonstrates interval healing and callous formation.

Figure 2.

Young male recreational athlete who recently joined a running group with a quick increase in his running mileage presented with right heel pain that began abruptly on a 5-mile run 2 months prior to presentation with imaging demonstrating a posterior calcaneal stress fracture that was treated with activity modification and eventual gradual resumption to impact and running activities. Figure 2 shows a single-view lateral plain film of the right calcaneus with an area of boney sclerosis in the posterior tuberosity oriented perpendicular to the trabecula from dorsoproximal to plantar-distal. Therefore, at times these fractures require more proactive management, including restricted weightbearing, casting or immobilization, and even early operative intervention at initial presentation to optimize outcome.

Figure 3.

A recreational female jogger and avid dancer presented with 5 weeks worsening forefoot pain that had not improved with change in shoewear or decreased running mileage. (A) Initial AP of the right foot demonstrates a transverse cortical lucency with surrounding callous formation at the distal 2nd metatarsal shaft. (B) Clinical photograph of plantar skin callous formation and (C) pressure mapping demonstrate increased 2nd and 3rd metatarsal head loading.

Figure 4.

Young male recreational athlete who presented with 1 month of medial left ankle pain. (A) Initial anteroposterior x-ray of left ankle demonstrate a subtle vertical lucency arising from shoulder of the plafond. (B) Initial lateral x-ray. After loss to follow-up and persistent weightbearing, he again presented 1 month later with worsening symptoms. (C) Left ankle mortise x-ray demonstrated interval worsening of the fracture line with slight displacement.

Figure 5.

Young female cross-country runner who presented with 1 month of left foot pain associated with running and weightbearing activity. Initial radiographs and magnetic resonance imaging demonstrate a fracture of the dorsal navicular with extension to the midbody, alongside a dorsal avulsion fragment. Initial left foot x-rays. (A) Anteroposterior (AP) view. (B) Oblique view. (C) Lateral view. (D) Left foot magnetic resonance imaging, axial slice at dorsal navicular. (E) Sagittal image at midbody of navicular. (F) She underwent surgical fixation of the fracture in situ with 2 cannulated headless screws and excision of the avulsion fragment. Postoperative x-rays 2 months after the procedure: AP view. (G) Lateral view.

Figure 6.

A young male and recreational runner with a subtle cavus foot who presented with 6 weeks worsening lateral foot pain and inability to run his usual distances. (A) Initial AP of the left foot demonstrates a transverse cortical lucency at the base of the 4th metatarsal with local cortical thickening. (B) Left foot oblique x-ray re-demonstrates stress fracture and cortical thickening at the lateral aspect of the 4th metatarsal base.

Figure 7.

Young male lacrosse player who presented with worsening left lateral foot pain after 3 years of prodromal symptoms. Radiographs demonstrate a proximal fifth metatarsal stress fracture in the setting of metatarsus adductus. (A) Anteroposterior (AP) view. (B) Oblique view. (C) Lateral view. (D) He underwent screw fixation and went on to successful union and pain-free return to sport. Postoperative radiographs 6 months after the procedure: AP view. (E) Oblique view. (F) Lateral view.

Figure 8.

A middle-age male and recreational runner with a forefoot driven cavus foot and resultant “tripod” overload who presented with 8 weeks worsening pain under his 1st metatarsophalangeal joint with running and weight-bearing. (A) Initial sesamoid view of the left foot demonstrates a transverse cortical lucency through the tibial sesamoid. (B) Left foot lateral x-ray demonstrates the relative plantarflexed positioning of the first ray, often seen in a forefoot driven cavus.