FIBULAR
- Fibular stress fractures are relatively common in run-
ners, with the majority occurring in the distal third of
the fibular, just proximal to the tibiofibular ligament
attachment (Blair and Manley, 1980). - These athletes are often found to have a cavus-type
foot. The subcutaneous location of the fibula makes it
easy to recreate symptoms with direct palpation over
the involved bone. - Radiographs may not be diagnostic, whereas mag-
netic resonance (MR) examination shows focal bone
marrow edema and sometimes a well-defined vertical
fracture line (Blair and Manley, 1980). - Fibular stress fractures are noncritical injuries and a
return to running program can usually resume after 6
weeks (Bergman and Fredericson, 1999).
Medial Malleolus
- The repetitive stress of running and jumping can
create a vertical stress fracture starting at the junction
of the medial malleolus and the tibial plafond and
continuing proximally and slightly medially. - Shelbourne et al in 1988 proposed that athletes with
radiographic signs of a medial malleolar fracture,
especially a displaced fracture, who desire early
return to full participation should be treated by open
reduction and internal fixation (Shelbourne et al,
1988). - Stress reactions without frank cortical fracture can
be treated with temporary immobilization.
Unlimited ambulation in a brace is permitted and a
gradual return to running is allowed as symptoms
resolve.
Calcaneus
- Calcaneal stress fractures present as heel pain with
localized tenderness over the bone, usually in the
body of the calcaneus posterior to the talus.
•Pain elicited by squeezing the calcaneus from both
sides simultaneously can usually differentiate this
condition from retrocalcaneal bursitis, Achilles ten-
dinitis and plantar nerve entrapment (Fredericson,
Bergman, and Matheson, 1997). - Radiographs generally become positive within the
first month after pain presentation and show callus
formation perpendicular to the trabecular axis of the
calcaneus (Bergman and Fredericson, 1999). - Calcaneal stress fracture is a noncritical stress fracture
with rapid healing and return to activity is usually
possible by 4 to 6 weeks.
NAVICULAR BONES•A history of vague, activity-related midfoot pain with
associated tenderness over the dorsal border of the
navicular near the talonavicular joint (Khan et al,
1994).- Plain x-ray is rarely helpful in the detection of nav-
icular stress fracture, particularly with an incomplete
fracture. Investigation usually requires bone scan or
MRI. Computed tomography (CT) is often needed to
detect early separation of bone fragments or more
clearly define the degree of fracture (Bergman and
Fredericson, 1999). - The most common site of stress fracture within the
navicular is the central third, which is an area of rela-
tive avascularity. Significant disability can result with
delayed diagnosis or inadequate treatment.
•Treatment of an uncomplicated partial stress fracture
or nondisplaced complete stress fracture of this bone
should include at least 6 weeks of nonweightbearing
cast immobilization until the navicular is no longer
tender. This is followed by a further 6-week program
of rehabilitation (Fredericson, Bergman, and
Matheson, 1997). - Non-union navicular fractures are best treated with
screw fixation ± bone grafting.
TALUS, CUBOID, CENEIFORM- Stress fractures of the talus, cuboid, and cuneiform
bones are uncommon. In general, joint involvement,
displacement, and nonunion do not occur (Khan,
Brukne, and Bradshaw, 1993).
•Treatment can be the same as that for other noncriti-
cal stress fracture (Khan, Brukne, and Bradshaw,
1993). - Stress fractures of the body of the talus, however,
can extend into the subtalar joint, which places them
into the critical-at-risk category and requires 4 to
6 weeks of cast immobilization and occasionally
open reduction and internal fixation (Fredericson,
Bergman, and Matheson, 1997; Khan, Brukne, and
Bradshaw, 1993).
METATARSALS- Stress fractures of the metatarsal bones were first
described in military recruits as a march fracture. The
fracture typically occurs in the neck or distal shaft,
with the second and third metatarsal most commonly
affected (Matheson et al, 1987). - These are noncritical stress fractures and cross-train-
ing can begin as soon as painful ambulation subsides.
394 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE