Subscribe to RSS
Please copy the URL and add it into your RSS Feed Reader.
https://www.thieme-connect.de/rss/thieme/en/10.1055-s-00000070.xml
Download PDF
Semin Musculoskelet Radiol 2005; 09(3): 210-226
DOI: 10.1055/s-2005-921941
DOI: 10.1055/s-2005-921941
Stress Fractures and Related Disorders in Foot and Ankle: Plain Films, Scintigraphy, CT, and MR Imaging
Further Information
Publication History
Publication Date:
25 October 2005 (online)
ABSTRACT
The accurate diagnosis of stress-induced changes in the foot and ankle requires careful and detailed clinical history and examination. This is of paramount importance in ensuring the correct imaging interpretation and for excluding other differential diagnoses. Advanced imaging (scintigraphy and MR imaging) plays a vital role in the early diagnosis of this type of injury, and CT has an important contributory role in the diagnosis of injury where imaging features by the other modalities are equivocal. An early diagnosis reached by judicious use of imaging techniques is the cornerstone of appropriate management, with a high probability of a full recovery, a low risk of complications, and a return to predisease activity.
KEYWORDS
Stress fracture - imaging - MR - ankle - foot
REFERENCES
- 1 Anderson M W, Greenspan A. Stress fractures. Radiology. 1996; 199 1-12
- 2 Pentecost R L, Murray R A, Brindley H H. Fatigue, insufficiency, and pathologic fractures. JAMA. 1964; 187 1001-1004
- 3 Resnick D, Goergen T G, Niwayama G.
Physical injury: concepts and terminology . In: Resnick D Diagnosis of Bone and Joint Disorders. 3rd ed. Philadelphia; WB Saunders 1995: 2561-2693MissingFormLabel - 4 Breithaupt MDS. Zur patholgie des menschlichen fusses. Med Ztg. 1855; 24 169-171 175-177
- 5 Hulkko A, Orava S. Stress fractures in the athletes. Int J Sports Med. 1987; 8 221-226
- 6 Milgrom C, Giladi M, Stein M et al.. Stress fractures in military recruits. A prospective study showing an unusually high incidence. J Bone Joint Surg Br. 1985; 67 732-735
- 7 Lassus J, Tulikoura I, Konttinen Y, Salo J, Santavirta S. Bone stress injuries of the lower extremity: a review. Acta Orthop Scand. 2002; 73 359-368
- 8 Prokuski L J, Saltzman C L. Challenging fractures of the foot and ankle. Radiol Clin North Am. 1997; 35 655-670
- 9 Berquist T H.
Foot and ankle . In: Kricun ME Imaging of Sports Injuries. Philadelphia; Lippincott Williams & Wilkins 1992: 167-215MissingFormLabel - 10 Matheson G O, Clement D B, McKenzie D C, Taunton J E, Lloyd-Smith D R, MacIntyre J G. Stress fractures in athletes: a study of 320 cases. Am J Sports Med. 1987; 15 46-58
- 11 Renström P, Kannus P.
Prevention of sports injuries . In: Krauss RH Sports Medicine. Philadelphia; WB Saunders 1991MissingFormLabel - 12 Clanton T O.
Athletic injuries to the soft tissues of the foot and ankle . In: Coughlin MJ, Mann RA Surgery of the Foot and Ankle. 7th ed. Vol 2. St. Louis; Mosby 1999: 1090-1209MissingFormLabel - 13 Peris P. Stress fractures. Best Pract Res Clin Rheumatol. 2003; 17 1043-1061
- 14 Peris P. Stress fractures in rheumatological practice: clinical significance and localizations. Rheumatol Int. 2002; 22 77-79
- 15 Rogers L F.
Skeletal biomechanics . In: Rogers LF Radiology of Skeletal Trauma. 2nd ed. Vol 1. New York; Churchill Livingstone 1992: 20MissingFormLabel - 16 Sterling J C, Edelstein D W, Calvo R D, Webb II R. Stress fractures in the athlete: diagnosis and management. Sports Med. 1992; 14 336-346
- 17 Sweet D E, Allman R M. RPC of the month from the AFIP. Radiology. 1971; 99 687-693
- 18 Burr D B. Remodeling and the repair of fatigue damage. Calcif Tissue Int. 1993; 53(suppl 1) S75-S81
- 19 Lane J M, Werntz J R.
The biology of pathologic fracture repair . In: Lane JM, Healey JH Diagnosis and Management of Pathologic Fractures. New York; Raven Press 1993: 1-11MissingFormLabel - 20 Taylor D, Tilmans A. Stress intensity variations in bone microcracks during the repair process. J Theor Biol. 2004; 229 169-177
- 21 Bentolila V, Boyce T M, Fyhrie D P, Drumb R, Skerry T M, Schaffler M B. Intracortical remodeling in adult rat long bones after fatigue loading. Bone. 1998; 23 275-281
- 22 Taylor D, Casolari E, Bignardi C. Predicting stress fractures using a probabilistic model of damage, repair and adaptation. J Orthop Res. 2004; 22 487-494
- 23 Pavlov H. Physical injury: sports related abnormalities. In: Resnick D Diagnosis of Bone and Joint Disorders. 3rd ed. Philadelphia; WB Saunders 1995: 3229-3263
MissingFormLabel
- 24 Daffner R H, Pavlov H. Stress fractures: current concepts. AJR Am J Roentgenol. 1992; 159 245-252
- 25 Carter D R, Caler W E. Cycle-dependent and time-dependent bone fracture with repeated loading. J Biomech Eng. 1983; 105 166-170
- 26 Radin E, Blaha J, Litsky A et al.. Practical Biomechanics for the Orthopaedic Surgeon. 2nd ed. New York; Churchill Livingstone 1992
MissingFormLabel
- 27 Sallis R E, Jones K. Stress fractures in athletes: how to spot this underdiagnosed injury. Postgrad Med. 1991; 89 185-188 191-192
- 28 Jones B H, Harris JMCA, Vinh T N, Rubin C. Exercise-induced stress fractures and stress reactions of bone: epidemiology, etiology and classification. Exerc Sport Sci Rev. 1989; 17 379-422
- 29 Markey K L. Stress fractures. Clin Sports Med. 1987; 6 405-425
- 30 Stanitski C L, McMaster J H, Scranton P E. On the nature of stress fractures. Am J Sports Med. 1978; 6 391-396
- 31 Ha K I, Hahn S H, Chung Y, Yang B K, Yi S R. A clinical study of stress fractures in sports activities. Orthopedics. 1991; 14 1089-1095
- 32 Devas M. Stress fractures in children. J Bone Joint Surg Br. 1963; 45 528-541
- 33 Taylor J A, Sartoris D J, Huang G S, Resnick D L. Painful conditions affecting the first metatarsal sesamoid bones. Radiographics. 1993; 13 817-830
- 34 Sammarco G J. Diagnosis and treatment in dancers. Clin Orthop. 1984; 187 176-187
- 35 Umans H, Pavlov H. Stress fractures of the lower extremities. Semin Roentgenol. 1994; 29 176-193
- 36 McBryde Jr A M, Anderson R B. Sesamoid foot problems in the athlete. Clin Sports Med. 1988; 7 51-60
- 37 Chillag K, Grana W A. Medial sesamoid stress fracture. Orthopedics. 1985; 8 819-821
- 38 Puddu G, Cerullo G, Selvanetti A, De Paulis F.
Stress fractures . In: Harries M, Williams C, Stanish WD, Micheli LJ Oxford Textbook of Sports Medicine. Oxford, UK; Oxford University Press 1996: 546-563MissingFormLabel - 39 Yokoe K, Kameyama Y. Relationship between stress fractures of the proximal phalanx of the great toe and hallux valgus. Am J Sports Med. 2004; 32 1032-1034
- 40 Jones P. Fatigue failure osteochondral fracture of the proximal phalanx of the great toe. Am J Sports Med. 1987; 15 616-618
- 41 Pitsis G C, Best J P, Sullivan M R. Unusual stress fractures of the proximal phalanx of the great toe: a report of two cases. Br J Sports Med. 2004; 38 e31
- 42 Chowchuen P, Resnick D. Stress fractures of the metatarsal heads. Skeletal Radiol. 1998; 27 22-25
- 43 Levy J M. Stress fractures of the first metatarsal. AJR Am J Roentgenol. 1978; 130 679-681
- 44 Harrington T, Crichton K J, Anderson I F. Overuse ballet injury of the base of the second metatarsal. Am J Sports Med. 1993; 21 591-598
- 45 Daffner R H. Stress fractures: current concepts. Skeletal Radiol. 1978; 2 221-229
- 46 Drez Jr D, Young J C, Johnston R D, Parker W D. Metatarsal stress fractures. Am J Sports Med. 1980; 8 123-125
- 47 Protzman R R, Griffis C G. Stress fractures in men and women undergoing military training. J Bone Joint Surg Am. 1977; 59 825
- 48 Pecina M, Bojanic I, Dubravcic S. Stress fractures in figure skaters. Am J Sports Med. 1990; 18 277-279
- 49 Lehman R C, Torg J S, Pavlov H, DeLee J C. Fractures of the base of the fifth metatarsal distal to the tuberosity: a review. Foot Ankle. 1987; 7 245-252
- 50 Jones R. Fracture of the base of the 5th metatarsal bone by indirect violence. Ann Surg. 1902; 35 697-700
- 51 Torg J S, Balduini F C, Zelko R R, Pavlov H, Peff T C, Das M. Fractures of the base of fifth metatarsal distal to the tuberosity. Classification and guidelines for non-surgical and surgical management. J Bone Joint Surg Am. 1984; 66 209-214
- 52 Ford L T, Gilula L A. Stress fractures of the middle metatarsals following the Keller operation. J Bone Joint Surg Am. 1977; 59 117-118
- 53 Michetti M L. March fracture following a McBride bunionectomy: a case report. J Am Podiatry Assoc. 1970; 60 286-287
- 54 Kitaoka H B, Cracchiolo III A. Stress fracture of the lateral metatarsals following double-stem implant arthroplasty of the hallux metatarsophalangeal joint. Clin Orthop. 1989; 239 211-216
- 55 Smith A M, Alwan T, Davies M S. Perioperative complications of the Scarf osteotomy. Foot Ankle Int. 2003; 24 222-227
- 56 Davitt J S, Morgan J M. Stress fracture of the fifth metatarsal after Evans' calcaneal osteotomy: a report of two cases. Foot Ankle Int. 1998; 19 710-712
- 57 Sammarco G J, Idusuyi O B. Stress fracture of the base of the third metatarsal after an endoscopic plantar fasciotomy: a case report. Foot Ankle Int. 1998; 19 157-159
- 58 Friend G. Sequential metatarsal fracture after Keller arthroplasty with implant. J Foot Surg. 1981; 20 227-231
- 59 Creighton R, Sonoga A, Gordon G. Stress fracture of the tarsal middle cuneiform bone: a case report. J Am Podiatr Med Assoc. 1990; 80 489-495
- 60 Meurman K O, Elfving S. Stress fracture of the cuneiform bones. Br J Radiol. 1980; 53 157-160
- 61 Schweitzer M E, Karasick D.
The foot . In: Roger LF Radiology of Skeletal Trauma. 3rd ed. New York; Churchill Livingstone 2002: 1319-1406MissingFormLabel - 62 Pavlov H, Torg J S, Freiberger R H. Tarsal navicular stress fractures: radiographic evaluation. Radiology. 1983; 148 641-645
- 63 Torg J S, Pavlov H, Cooley L H et al.. Stress fractures of the tarsal navicular. J Bone Joint Surg Am. 1982; 64 700-712
- 64 Goergen T G, Venn-Watson E A, Rossman D J, Resnick D, Gerber K H. Tarsal navicular stress fractures in runners. AJR Am J Roentgenol. 1981; 136 201-203
- 65 Towne L C, Blazina M E, Cozen L N. Fatigue fracture of the tarsal navicular. J Bone Joint Surg Am. 1970; 52 376-378
- 66 Hulkko A, Orava S, Peltokallio P, Tulikoura I, Walden M. Stress fracture of the navicular bone: nine cases in athletes. Acta Orthop Scand. 1985; 56 303-305
- 67 Kiss Z, Khan K, Fuller P. Stress fractures of the tarsal navicular bone: CT findings in 55 cases. AJR Am J Roentgenol. 1993; 160 111-115
- 68 Khan K M, Fuller P J, Brukner P D, Kearney C, Burry H C. Outcome of conservative and surgical management of navicular stress fracture in athletes. Am J Sports Med. 1992; 20 657-666
- 69 Battaglia H, Simmen H P, Meier W. Stress fractures of the cuboid bone: an easy to treat rarity. Swiss Surg. 2002; 8 3-6
- 70 Yu J S, Solmen J. Stress fractures associated with plantar fascia disruption: two case reports involving the cuboid. J Comput Assist Tomogr. 2001; 25 971-974
- 71 Okazaki K, Nakashima S, Nomura S. Stress fracture of an os peroneum. J Orthop Trauma. 2003; 17 654-656
- 72 Robinson P, White L M. Soft-tissue and osseous ankle impingement syndromes of the ankle: role of imaging in diagnosis and management. Radiographics. 2002; 22 1457-1471
- 73 Peace K A, Hillier J C, Hulme A, Healy J C. MRI features of posterior ankle impingement syndrome in ballet dancers: a review of 25 cases. Clin Radiol. 2004; 59 1025-1033
- 74 Hontas M J, Haddad R J, Schlesinger L C. Conditions of the talus in the runner. Am J Sports Med. 1986; 14 486-490
- 75 Stocker B, Bennett J T. Stress fracture of the talus following resection of a talocalcaneal coalition: a case report. Foot Ankle Int. 2001; 22 56-58
- 76 Wilson Jr E S, Katz F N. Stress fractures: an analysis of 250 consecutive cases. Radiology. 1969; 92 481-486
- 77 Hopson C N, Perry D R. Stress fractures of the calcaneus in women marine recruits. Clin Orthop. 1977; 128 159-162
- 78 Kroening P M, Shelton M L. Stress fractures. Am J Roentgenol Radium Ther Nucl Med. 1963; 89 1281-1286
- 79 Stein R E, Stelling F H. Stress fracture of the calcaneus in a child with cerebral palsy. J Bone Joint Surg Am. 1977; 59 131
- 80 Darby R E. Stress fractures of the os calcis. JAMA. 1967; 200 1183-1184
- 81 Devas M B, Sweetnam R. Stress fractures of the fibula: a review of fifty cases in athletes. J Bone Joint Surg Br. 1956; 38 818-829
- 82 Ingersoll C F. Ice skater's fracture. Radiology. 1943; 50 469-479
- 83 Castillo M, Tehranzadeh J, Morillo G. Atypical healed stress fracture of the fibula masquerading as chronic osteomyelitis. A case report of magnetic resonance distinction. Am J Sports Med. 1988; 16 185-188
- 84 Murr S. Dislocation of the peroneal tendons with marginal fracture of the lateral malleolus. J Bone Joint Surg Br. 1961; 43 563-565
- 85 Wilson A J.
The ankle . In: Roger LF Radiology of Skeletal Trauma. 3rd ed. New York; Churchill Livingstone 2002: 1222-1317MissingFormLabel - 86 Rettig A C, Shelbourne K D, Beltz H F, Robertson D W, Arfken P. Radiographic evaluation of foot and ankle injuries in the athlete. Clin Sports Med. 1987; 6 905-919
- 87 Shelbourne K D, Fisher D A, Rettig A C, McCarroll J R. Stress fractures of the medial malleolus. Am J Sports Med. 1988; 16 60-63
- 88 Horst F, Nunley J A. Tibiofibular synostosis stress fracture: a case report. Foot Ankle Int. 2004; 25 507-509
- 89 Mäenpää H M, Soini I, Lehto M U, Belt E A. Insufficiency fractures in patients with chronic inflammatory joint diseases. Clin Exp Rheumatol. 2002; 20 77-79
- 90 Gill G, Benbow S, Tesfaye S, Kaczmarczyk E, Kaye L. Painless stress fractures in diabetic neuropathic feet. Postgrad Med J. 1997; 73 241-242
- 91 McBryde A. Stress fractures in runners. Clin Sports Med. 1985; 4 737-752
- 92 Hogan K A, Gross R H. Overuse injuries in pediatric athletes. Orthop Clin North Am. 2003; 34 405-415
- 93 Chambers H G. Ankle and foot disorders in skeletally immature athletes. Orthop Clin North Am. 2003; 34 445-459
- 94 O'Neill D B, Micheli L J. Tarsal coalition: a follow-up of adolescent athletes. Am J Sports Med. 1989; 17 544-549
- 95 Canale S T, Williams K D. Iselin's disease. J Pediatr Orthop. 1992; 12 90-93
- 96 De Smet A A, Fisher D R, Burnstein M I, Graf B K, Lange R H. Value of MR imaging in staging osteochondral lesions of the talus (osteochondritis dissecans): results in 14 patients. AJR Am J Roentgenol. 1990; 154 555-558
- 97 Sijbrandij E S, van Gils A P, de Lange E E. Overuse and sports-related injuries of the ankle and hind foot: MR imaging findings. A pictorial review. Eur J Radiol. 2002; 43 45-56
- 98 Rosenberg Z S, Beltran J, Bencardino J T. MR imaging of the ankle and foot. Radiographics. 2000; 20 S153-S179
- 99 Ashman C J, Klecker R J, Yu J S. Forefoot pain involving the metatarsal region: differential diagnosis with MR imaging. Radiographics. 2001; 21 1425-1440
- 100 Saini A, Saifuddin A. MRI of osteonecrosis: pictorial review. Clin Radiol. 2004; 59 1079-1093
- 101 Schweitzer M E, Mandel S, Schwartzman R J, Knobler R L, Tahmoush A J. Reflex sympathetic dystrophy revisited: MR imaging findings before and after infusion of contrast material. Radiology. 1995; 195 211-214
- 102 Koch E, Hofer H O, Sialer G, Marincek B, von Schulthess G K. Failure of MR imaging to detect reflex sympathetic dystrophy of the extremities. AJR Am J Roentgenol. 1991; 156 113-115
- 103 Zwas S T, Elkanovitch R, Frank G. Interpretation and classification of bone scintigraphic findings in stress fractures. J Nucl Med. 1987; 28 452-457
- 104 Fredericson M, Bergman A G, Hoffman K L, Dillingham M S. Tibial stress reaction in runners: correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995; 23 472-481
- 105 Miller J H. The radiological aspects of stress fractures and chronic stress injuries. Curr Orthop. 2003; 17 150-155
- 106 Sullivan D, Warren R F, Pavlov H, Kelman G. Stress fractures in 51 runners. Clin Orthop. 1984; 187 188-192
- 107 Greaney R B, Gerber F H, Laughlin R L et al.. Distribution and natural history of stress fractures in U.S. Marine recruits. Radiology. 1983; 146 339-346
- 108 Mulligan M E. The “gray cortex”: an early sign of stress fracture. Skeletal Radiol. 1995; 24 201-203
- 109 Spitz D J, Newberg A H. Imaging of stress fractures in the athlete. Radiol Clin North Am. 2002; 40 313-331
- 110 Roub L W, Gumerman L W, Hanley Jr E N, Clark M N, Goodman M, Herbert D L. Bone stress: a radionuclide imaging perspective. Radiology. 1979; 132 431-438
- 111 Prather J L, Nusynowtiz M L, Snowdy H A, Hughes A D, McCartney W H, Bagg R J. Scintigraphic findings in stress fractures. J Bone Joint Surg Am. 1977; 59 869-874
- 112 Sterling J C, Webb Jr R F, Meyers M C, Calvo R D. False negative bone scan in a female runner. Med Sci Sports Exerc. 1993; 25 179-185
- 113 Kanstrup I L. Bone scintigraphy in sports medicine: a review. Scand J Med Sci Sports. 1997; 7 322-330
- 114 Matheson G O, Clement D B, McKenzie D C, Taunton J E, Lloyd-Smith D R, MacIntyre J G. Scintigraphic uptake of 99mTc at non-painful sites in athletes with stress fractures: the concept of bone strain. Sports Med. 1987; 4 65-75
- 115 Milgrom C, Chisin R, Giladi M et al.. Multiple stress fractures. Clin Orthop. 1985; 192 174-179
- 116 Deutsch A L, Coel M N, Mink J H. Imaging of stress injuries to bone: radiography, scintigraphy and MR imaging. Clin Sports Med. 1997; 16 275-290
- 117 Dunfee W R, Dalinka M K, Kneeland J B. Imaging of athletic injuries to the ankle and foot. Radiol Clin North Am. 2002; 40 289-312
- 118 Rupani H D, Holder L E, Espinola D A, Engin S I. Three-phase radionuclide bone imaging in sports medicine. Radiology. 1985; 156 187-196
- 119 Davies A M, Carter S R, Grimer R J, Sneath R S. Fatigue fractures of the femoral diaphysis in the skeletally immature simulating malignancy. Br J Radiol. 1989; 62 893-896
- 120 Engh C A, Robinson R A, Milgram J. Stress fractures in children. J Trauma. 1970; 10 532-541
- 121 Moore S G, Bisset III G S, Siegel M J, Donaldson J S. Pediatric musculoskeletal MR imaging. Radiology. 1991; 179 345-360
- 122 Horev G, Korenreich L, Ziv N, Grunebaum M. The enigma of stress fractures in the pediatric age: clarification or confusion through the new imaging modalities. Pediatr Radiol. 1990; 20 469-471
- 123 Stafford S A, Rosenthal D I, Gebhardt M C, Brady T J, Scott J A. MRI in stress fracture. AJR Am J Roentgenol. 1986; 147 553-556
- 124 Lee J K, Yao L. Stress fractures: MR imaging. Radiology. 1988; 169 217-220
- 125 Rubin D A, Dalinka M K, Kneeland J B. Magnetic resonance imaging of lower extremity injuries. Semin Roentgenol. 1994; 29 194-222
- 126 Schmid M R, Hodler J, Vienne P, Binkert C A, Zanetti M. Bone marrow abnormalities of foot and ankle: STIR versus T1-weighted contrast-enhanced fat-suppressed spin-echo MR imaging. Radiology. 2002; 224 463-469
- 127 Yao L, Johnson C, Gentili A, Lee J K, Seeger L L. Stress injuries of bone: analysis of MR staging criteria. Acad Radiol. 1998; 5 34-40
- 128 Arendt E A, Griffiths H J. The use of MRI in the assessment and clinical management of stress reactions of bone in high-performance athletes. Clin Sports Med. 1997; 16 291-306
- 129 Zanetti M, Steiner C L, Seifert B, Hodler J. Clinical outcome of edema-like bone marrow abnormalities of the foot. Radiology. 2002; 222 184-188
- 130 MacDougall L, Conway W F. Controversies in magnetic resonance imaging of the hip. Top Magn Reson Imaging. 1996; 8 44-50
- 131 Yamamoto T, Bullough P G. Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. J Bone Joint Surg Am. 2000; 82 858-866
- 132 Lazzarini K M, Troiano R N, Smith R C. Can running cause the appearance of marrow oedema on MR images of the foot and ankle?. Radiology. 1997; 202 540-542
- 133 Schweitzer M E, White L M. Does altered biomechanics cause bone marrow oedema?. Radiology. 1996; 198 851-853
- 134 Pal C R, Tasker A D, Ostlere S J, Watson M S. Heterogeneous signal in bone marrow on MRI of children's feet: a normal finding?. Skeletal Radiol. 1999; 28 274-278
- 135 Orava S, Hulkko A. Delayed unions and nonunions of stress fractures in athletes. Am J Sports Med. 1988; 16 378-382
- 136 Guille J T, Lipton G E, Bowen J R, Uthaman U. Delayed union following stress fracture of the distal fibula secondary to rotational malunion of lateral malleolar fracture. Am J Orthop. 1997; 26 442-445
- 137 Schils J P, Andrish J T, Piraino D W, Belhobek G H, Richmond B J, Bengfeld J A. Medial malleolar stress fractures in seven patients: review of the clinical and imaging features. Radiology. 1992; 185 219-221
- 138 Travlos J, Learmonth I D. Bilateral avascular necrosis of the talus following strenuous physical activity. J Bone Joint Surg Br. 1991; 73 863-864
- 139 Bergman A G, Fredericson M, Ho C, Matheson G O. Asymptomatic tibial stress reaction: MRI detection and clinical follow-up in distance runners. AJR Am J Roentgenol. 2004; 183 635-638
Dr.
V. N Cassar-Pullicino
Consultant Radiologist, Department of Radiology, The Robert Jones and Agnes Hunt Orthopaedic
Hospital
Oswestry, Shropshire, SY10 7AG, United Kingdom