Am J Sports Med 2001;29:100; Med Sci Sports Exerc 1999;37:S48; Phys Sportsmed 1999;27:57

Cause:Overuse, rapid increase in training load or intensity

Pathophys:Repetitive stress leads to bony microfracture; may progress to overt fracture with overload event

May be athletic or sedentary

Sx:Pain with weight bearing, relieved with unloading. Night pain typical

Si:Tenderness, swelling, ecchymosis. May be able to palpate area of focal tenderness and periosteal swelling. Tuning fork vibration transmits along bone and felt as pain at fracture site.

Generally recovers if load modified so that pain-free.

Nonunion. Progression to complete fracture, open fracture (rare). Anterior tibial “dreaded black line” heals only after surgery because of distraction bowing with loading of tibia

Xray:Plain films may be normal or show localized periosteal reaction. Bone scintography nonspecific, virtually 100% sensitive. MRI may show bony edema and fracture line, sensitivity same as bone scan but more specific (Phys Sportsmed 1998;26:31); CT best for visualizing actual fracture line in foot bones.

Rx:

Activity modification and splinting for 2-6 weeks, or until comfortable weight bearing. Gradual return to activity with pain as guide:

• Foot: 1st, 2nd metatarsal most common, cast (hard sole) shoe for 6 weeks. 5th metatarsal at distal 1/3 needs NWB short leg cast boot vs pin to heal.
• Tarsal: Common in runners. Non-weight bearing cast 6-8 weeks. Danger of nonunion—discuss with surgeon. Refer for prolonged pain after cast removed or for displaced fx.
• Tibia: Use high leg aircast or walking boot for pain-free ambulation for 6 weeks. Anterior, middle 1/3 fx through cortex needs referral for possible pin.
• Femoral neck: Common in runners. Superior (compression) surface heals with rest, toe touch crutch ambulation 6-12 wks, inferior (distraction) surface fx needs referral because may need operation (Clin Sports Med 1997;16:307).