Stress Fractures and their Treatment

This final installment of a 3 part series excerpted from The Runners Guide to Heatlthy Feet and Ankles focuses on specific stress fractures and their treatment.


The Runner’s Guide to Healthy Feet and Ankles:
Simple Steps to Prevent Injury and Run Stronger

by Dr. Brian W. Fullem et al.
Link: http://amzn.to/2yuCBPQ


Metatarsal Stress Fractures

If you have pain on the top of the foot accompanied by swelling, suspect a metatarsal stress fracture. The pain can range from an ache when the fracture is first developing to sharp shooting pain. You’ll usually feel more pain at toe-off. Compare the injured foot to the uninjured foot. If you pull your toes up away from the ground, you’ll normally see the five extensor tendons that help to move the toes up pretty clearly. But in the case of a stress fracture the swelling in the area of the fracture will obscure the ability to see these tendons.

Two simple tests at home to help figure out if you have a stress fracture are to press over the area and find a spot that causes sharp pain and to hop on one foot for a minute. If the pain increases while you’re hopping or if the pain is so signicant that you have to stop immediately, you may have a stress fracture.

A visit to the sports podiatrist will usually start with a plain X-ray.

Figure 1

Figure 1. Note the subtle difference in swelling behind the second toe in the foot on the right. is would be difficult to detect without a comparison the unaffected foot. The patient was found to have a stress fracture of the second metatarsal.

It’s very important to understand that the fracture may not show up on an X-ray, which shouldn’t be the last test performed if it doesn’t indicate a break. Your podiatrist might have a diagnostic ultrasound machine, which is another method that can be used to detect a stress fracture. If the fracture isn’t discovered with in-office diagnostic testing, then an MRI, a bone scan, or CT scan may be the next test ordered by your doctor.

These long, thin bones are subject to significant ground reaction forces during running, which can lead to a break in one of the cortices. In a cross-section the bone is square- shaped with four distinct sides. A stress fracture will sometimes not show on radiograph until it’s healing because it’s not completely through the bone and may involve only one of the four sides.

The length pattern of the bones can predispose a bone that is longer than the first metatarsal to extra stress. Pain will be felt most at toe-off and or impact.

Use of a surgical shoe (a stiff-soled shoe also known as a fracture shoe) to offload the painful area will often suffice for metatarsal stress fractures. If you have pain when walking in a surgical shoe, then it may be necessary to move to a CAM walker, a removable, short leg cast boot. If pain is still noted then non-weight bearing may be warranted.

The location of the fracture is another important consideration. If the fracture is farther away from the toes than the halfway point of the bone, then no weight bearing might be required. A medical scooter, which allows the injured leg to rest on the scooter, can make it much easier to get around compared to crutches.

Figure 2

Figure 2. A medical scooter allows much more mobility than crutches when you’re keeping weight off an injured foot.

Figure 3

Figure 3. Surgical or fracture shoe, a stiff-soled shoe that doesn’t bend, allowing forefoot injuries to heal better.

Figure 4. Surgical shoe with 1/8″ adhesive felt cutout to help take more pressure o the painful area, in this case for pain in the ball of the foot under the big toe joint.

Navicular Stress Fractures

Navicular stress fractures have been found to occur in runners at a surprisingly high rate and require more aggressive initial treatment than most other stress fractures. A stress fracture of this bone requires complete non-weight bearing, use of a CAM walker and no exercises that involve movement of the foot, including swimming or other cross training methods that are usually acceptable for a stress fracture of a different bone.

Pain can be non-specific with this injury and may not be felt in one particular spot while running. In classic cases there’s pain in the top of the foot when pressing over the navicular, which is called the N spot. Pain may radiate away from this area, but pressing on the N spot can reveal significant pain. A good test at home to stress the area is to crouch down like a baseball catcher. And a second test is to hop up and down on the injured foot to assess for pain. The navicular is in the middle of the foot. When viewing the foot from the side the bone is the apex or highest point of the foot. The bone is subject to some unique impact forces owing to the location in the foot and the anatomy of the bones around it.

The N spot, the area where the navicular stress fracture will typically hurt.

Figure 5. The N spot, the area where the navicular stress fracture will typically hurt.

The Matheson study mentioned earlier in this chapter found that 25 percent of the fractures were of tarsal bones, which includes the navicular. The diagnosis and treatment of navicular stress fractures can be difficult, because the symptoms don’t always occur right over the bone and initial X-rays will rarely reveal signs of a fracture. The gold standard of conservative treatment consists of eight to ten weeks of immobilization, including no weight bearing. is is one of the few injuries where it’s best to not do any cross training that involves the foot, even pool running, because the tendons that insert around the bone can stress the area and delay healing.

I co-authored a paper with Dr. Amol Saxena and Dr. Dave Hannaford that proposed a classification system for the treatment of these injuries based on CT findings that’s both prognostic and diagnostic. The classification is divided in type 1, a fracture through one cortex of the bone; type 2, a fracture that extends into the body of the bone; and type 3, a complete fracture. We found in our studies that type 1 responds best to conservative treatment and type 3 responds best to surgical treatment, consisting of a screw to stabilize and help the fracture site heal. The injury will take an average of three to four months to return to activity. ere may be an associated degenerative change in the talo-navicular joint that can cause pain years after a navicular stress fracture.

Making an early and accurate diagnosis is paramount to successful treatment and to lessen the chance of future arthritic- type changes. An initial radiograph may sometimes reveal the fracture but that generally means it could be a complete fracture. If I suspect a navicular stress fracture, my next test after a radiograph is often a bone scan. If the bone scan is negative, then you do not have a bone injury or stress fracture. A positive bone scan can be followed up with a CT scan, which will assess the severity of the fracture.

Figure 6. MRI of navicular stress fracture, read as “no fracture” by a radiologist.

Figure 6. MRI of navicular stress fracture, read as “no fracture” by a radiologist.

Figure 7. CT scan of the same navicular clearly showing the fracture. A CT scan can better identify a bone injury, especially for the navicular bone.

Figure 7. CT scan of the same navicular clearly showing the fracture. A CT scan can better identify a bone injury, especially for the navicular bone.

Many physicians will automatically order an MRI as the next diagnostic study after an X-ray. Doing so could lead to missing some fractures, as the MRI exam isn’t as good as a CT scan for evaluating an older fracture. The two prior photos are an MRI and a CT scan of the same foot a week apart; both were read as “no fracture” by the radiologist. (In fairness to radiologists, they usually don’t have the benefit of physically examining the patient.) The CT scan clearly shows the fracture while the MRI showed bone marrow edema, which is sometimes a sign of a fracture.

Calcaneal Stress Fractures

The calcaneus is the main heel bone in the body. It’s a dense, thick bone and not a very common spot for a stress fracture, although I have treated as many as three patients in a short time for one. Physicians often initially treat all heel pain as plantar fasciitis, because that’s the most common cause of heel pain. Plantar fasciitis usually hurts more with your first steps in the morning and after sitting. A calcaneal stress fracture will hurt more with increased activity and is o en lacking that sharp pain with your first steps. The pain may be noted in a similar location as plantar fasciitis, so try this test: Apply compression on each side of the heel bone in a “squeeze” test of the calcaneus. Grab the heel and interlock your fingers with the hands on either side of the heel and squeeze. If there’s pain, you might have a stress fracture.

Figure 8. Squeeze test to check for a possible calcaneal stress fracture.

Figure 8. Squeeze test to check for a possible calcaneal stress fracture.

If pain persists even after taking one to two weeks off from running, and if the pain increases with more activity and time on your feet, then consider a visit to the podiatrist. This isn’t an injury to try to train through, because if the fracture line becomes bigger there’s a greater potential for non-healing or a complete break, which would require surgery to allow proper healing.

The diagnosis is best confirmed with a bone scan and will rarely show up on an X-ray or diagnostic ultrasound unless the fracture is more advanced. If the fracture does show up on a plain radiograph, it is an indication that the fracture is more severe and the fracture will take longer to heal. In some cases, returning to running can take up to six months.

Treatment consists of immobilization in a walking boot and non- weight bearing if walking in the boot is painful.

Figure 9. Short leg walking boot, sometimes called a CAM walker.

Figure 9. Short leg walking boot, sometimes called a CAM walker.

A bone stimulator is a good adjunct if possible. Cross training in a pool or other non-impact exercise such as a bike or AlterG are good exercises. If there’s pain with any cross training, then that exercise should be avoided. If there’s pain when swimming with this or any foot injury, put a buoy between your feet and just use your arms.

When I have patients who haven’t responded to conservative therapy for plantar fasciitis, I often order another diagnostic test such as an MRI, bone scan, or CT scan. I have found several stress fractures and plantar fascial tears that didn’t improve after treatment that usually resolves plantar fasciitis. I suspect that stress fractures of the calcaneus have a great association with lower bone density and low levels of vitamin D as the main causes, as opposed to any biomechanical abnormality.

Figure 10. X-ray showing a calcaneal stress fracture in a thirty-year-old woman. She felt sharp pain during a race a er having pain for a few weeks.

Figure 10. X-ray showing a calcaneal stress fracture in a thirty-year-old woman. She felt sharp pain during a race a er having pain for a few weeks.

 Sesamoid Stress Fractures

The sesamoid complex consists of two bones under the first metatarsal head (big toe joint). The bones serve to help absorb shock and assist the tendons that pull the hallux (big toe) down (plantar flexion). Owing to a poor blood supply to the area and the small size of the bones, a fracture of these bones often leads to difficulty healing.

Pain will be felt under the ball of the foot. You might feel pain with any motion of the big toe. There may also be a feeling of swelling in the area, but it’s difficult to see any swelling upon examination. It may sometimes feel as if the big toe joint was jammed or damaged. Any movement of the joint can cause pain due to the fact that the bones are embedded within the tendons that help to move the hallux.

If pain begins in this area, then icing (without placing excess pressure on the area) is important. Avoid high heels, which place much of the body weight directly on the sesamoids. Try to always wear flat, well-cushioned shoes, and avoid barefoot walking if possible. In addition to icing, special pads that can help offload the area are a good first treatment. Dr. Jill’s is a company that fabricates a reusable silicone pad called a Dancer’s Pad that has a cutout for the sesamoids.

For runners with forefoot pain, I often recommend trying a shoe that has no difference between the height of the heel and the forefoot, or a zero-drop shoe. In a traditional running shoe, the heel is about 12 mm higher than the forefoot. Many companies now offer lower heel heights. Try to fnd a shoe that has a lower ramp height but is well-cushioned. If switching to a lower-heeled shoe doesn’t help to alleviate the pain, then the pain might be caused by more than just inflammation.

Figure 11. Dr. Jill’s Dancer’s Pad for sesamoid pain applied to the foot.

Figure 11. Dr. Jill’s Dancer’s Pad for sesamoid pain applied to the foot.

Figure 12

Figure 12. Foot with sesamoids highlighted. Diagram of sesamoids on bottom of the foot.

Figure 13

Figure 13. Drawing by Annemarie Fullem, PT.

If pain and swelling persist after resting and attempts to offload the area aren’t successful, an X-ray can often detect a stress fracture of the sesamoids. The best treatment is to splint the big toe in a downward (plantarflexed) position and be non- weight bearing for up to six weeks.

Spica type taping for sesamoid fracture. Photo courtesy of Dr. Amol Saxena

Figure 14. Spica type taping for sesamoid fracture. Photo courtesy of Dr. Amol Saxena

In less severe cases a surgical shoe with padding to offload the area can work well. Recently, I’ve been using ESWT on sesamoid injuries with success. The treatment is performed in the office. I typically perform up to five treatments, spaced a week apart. The advantage of the treatment is the production of new blood vessels to the area of the sesamoids, which, as we saw, have a poor blood supply and can be slow to heal.

If the bone does not heal properly and conservative treatment fails, surgery to remove the affected bone may be required.

Figure 15. X-ray of foot from behind highlighting a fractured sesamoid. Note the irregular appearance.

Figure 15. X-ray of foot from behind highlighting a fractured sesamoid. Note the irregular appearance.

Tim Broe suffered from a fractured sesamoid that failed to heal, and after having the bone removed he won the 2004 U.S. Olympic Trials at 5,000 meters and made the final in the event that year at the Athens Olympic Games. His main event before 2004 was the steeplechase, which may be one of the main reasons he developed a sesamoid fracture. The event features twenty-eight hurdles in less than two miles of running. When hurdling, steeplechasers try to land on the ball of the foot, putting significant stress on the sesamoids.

Tibial Stress Frahactures

The tibia (shin) bone can develop stress fractures in several areas. Shin pain along the inside of the leg may initially seem to be “shin splints,” which is associated with overuse and stress of the muscles that originate along this bone. (More on this injury in Chapter 4.) The medical term for shin splints is medial tibial stress syndrome (MTSS). Pain from MTSS is usually over a larger area of up to six to eight inches along the front inner shin. Left untreated, the muscles and tendons can create a small crack in the cortex of the bone. The pain from MTSS is worse in the beginning of a run. If pain worsens and becomes more noticeable over a more discrete area—sometimes the size of a half-dollar coin—then a stress fracture should be suspected.

Figure 16. Bone scan revealing a stress fracture of the tibia.

Figure 16. Bone scan revealing a stress fracture of the tibia.

Self treatment for shin pain should involve increased calf stretching. Hold the stretch for 30 seconds, repeating five times, up to three times per day. The best way to ice this area is with water frozen in a small paper cup; ice along the medial tibial border where the pain is located. Getting on a softer surface and making sure your shoes aren’t overly worn are two things I usually recommend to runners with shin pain. Focus on improving your hip abductor strength (see Chapter 6 for core exercises). If you have a flatter foot, an orthotic device can reduce the stress on the muscles attaching the tibia that cause this pain.

Expect the initial X-rays to not reveal the fracture, as these fractures are di cult to detect with radiographs. A bone scan is often the best next diagnostic test to perform.

Treatment typically utilizes a walking boot and possibly being non–weight bearing. With most stress fractures, if there isn’t pain while walking in a cast boot or cast shoe, then being non-weight bearing isn’t necessary unless the fracture is in an area that has a higher risk of not healing properly such as the navicular, sesamoids, or other area with a poor blood supply.

The most common area in the tibia to develop a stress fracture is in the middle of the bone and along the posterior medial border. This area will usually heal well. But when the fracture is in the front of the tibia (known as the anterior cortex), then the bone may not heal as well since the blood supply to that area of the bone is poor. When an anterior tibial cortex stress fracture is visualized on X-rays this is called the “dreaded black line,” which usually indicates that healing has stopped and more drastic measures such as surgery may need to be considered. When the fracture is located on the inside ankle bone that may possibly be easier to detect on X-rays but can be confused with tendonitis, as the posterior tibial tendon courses closely around and under the medial malleolus.

Figure 17. X-ray of stress fracture of a medial malleolus.

Figure 17. X-ray of stress fracture of a medial malleolus.

Runners will sustain stress fractures of the other shin bone, the Fibula, less often. A higher arch and a supinated foot type can lead to more stress on the lateral aspect of the leg and make the Fibula more susceptible to fractures. The good news about the Fibula bone is that it doesn’t bear as much weight as the tibia, so return to activity can be sooner. Terrell Owens famously played in a Super Bowl with a Fibular fracture, but it’s certainly not recommended to run if you have pain.

Figure 18. X-ray of Fibular Stress Fracture

Figure 18. X-ray of Fibular Stress Fracture.

Treatment varies depending on the severity of the fracture and the symptoms, but sometimes just eliminating any impact exercise and cutting back on walking and weight-bearing activity may be enough. A walking cast boot may be needed for a short time until there’s no pain with walking.


Dr. Brian Fullem practices at Elite Sports Podiatry in Clearwater, FL. He ran 14:25 for 5K while at Bucknell University. This is the continuation in a series of articles by Dr. Fullem, educating us about injury care, injury prevention & other health topics for athletes at all levels of performance. The following article is the first in a 3-part series of exerpts from Dr. Fullem’s recently published book, The Runner’s Guide to Healthy Feet and Ankles.

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