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Stress Fractures of the Foot and Ankle

General Information


  • stress fractures are fractures that develop due to repetitive strain on healthy or unhealthy bones, usually occurring in the lower extremities1,2
    • fatigue fractures are stress fractures caused by repetitive or excessive stress on otherwise healthy bones
    • pathologic or insufficiency fractures are stress fractures caused by the normal stress of daily activities on unhealthy bones weakened by conditions including metabolic bone disease and osteoporosis
  • stress fractures can occur in any of the bones in the foot and ankle, including3,4,5
    • metatarsal bones
    • navicular bone
    • cuneiform bones
    • cuboid bone
    • talus bone
    • calcaneus bone
    • sesamoids
    • lateral malleolus
    • medial malleolus

Also called

  • march fracture


  • typical grading system for severity of stress fractures2
    • grade 1
      • normal x-ray
      • mild unicortical uptake on bone scan
      • positive short T1 inversion recovery (STIR) images on magnetic resonance imaging (MRI)
    • grade 2
      • normal x-ray
      • moderate unicortical uptake on bone scan
      • positive STIR and T2 images on MRI
    • grade 3
      • discrete line on x-ray
      • activity in 50% of bone width on bone scan
      • positive T1- and T2-weighted images on MRI
    • grade 4
      • fracture or periosteal reaction on x-ray
      • bicortical uptake on bone scan
      • fracture line on MRI
  • Study Summary
    no standardized classification system available for stress fractures
    • based on systematic review of studies and/or review articles Systematic Review
    • systematic review of 43 studies and review articles evaluating stress or fatigue fractures and their classification
    • 27 different classification systems were identified
    • no classification system had statistical analysis of interobserver or intraobserver reliability
    • PubMed21378491The Physician and sportsmedicine20110201Phys Sportsmed3919393 Reference - 21378491Phys Sportsmed 2011 Feb;39(1):93


General references used

  1. Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Am Fam Physician. 2011 Jan 1;83(1):39-46full-text
  2. Pegrum J, Crisp T, Padhiar N. Diagnosis and management of bone stress injuries of the lower limb in athletes. BMJ. 2012 Apr 24;344:e2511full-text
  3. Hossain M, Clutton J, Ridgewell M, Lyons K, Perera A. Stress Fractures of the Foot. Clin Sports Med. 2015 Oct;34(4):769-90
  4. Mayer SW, Joyner PW, Almekinders LC, Parekh SG. Stress fractures of the foot and ankle in athletes. Sports Health. 2014 Nov;6(6):481-91full-text, correction can be found in Sports Health 2015 Nov;7(6):557
  5. Welck MJ, Hayes T, Pastides P, Khan W, Rudge B. Stress fractures of the foot and ankle. Injury 2017 Aug;48(8):1722

Recommendation grading systems used

  • British Medical Journal (BMJ) Rapid Recommendations uses Grades of Recommendation, Assessment, Development, and Evaluation (GRADE)
    • strength of recommendation
      • Strong recommendation - desirable effects of an intervention clearly outweigh the undesirable effects
      • Weak recommendation - uncertainty about trade-offs between desirable and undesirable effects of an intervention
    • quality of evidence
      • High-quality evidence - further research unlikely to change confidence in estimate of effect
      • Moderate-quality evidence - further research likely to have impact on confidence in estimate of effect and may change estimate
      • Low-quality evidence - further research likely to have important impact on confidence in estimate of effect and likely to change estimate
      • Very low-quality evidence - any estimate of effect is very uncertain
    • Reference - BMJ Rapid Recommendations clinical practice guideline on low intensity pulsed ultrasound (LIPUS) for bone healing (BMJ 2017 Feb 21;356:j576full-text)

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How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T116052, Stress Fractures of the Foot and Ankle; [updated 2018 Nov 30, cited place cited date here]. Available from Registration and login required.

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