Laboratory Studies

See the list below:

Due to a known association between RA and stress fractures, the clinician may consider a workup for RA, with an erythrocyte sedimentation rate (ESR) and rheumatoid panel. This workup is not routine in most patients, but it is a consideration when the clinical picture is unclear or indicates the possibility of RA.
A workup for osteoporosis may be considered, especially in oligomenorrheic females and in patients who have (or have had) multiple stress fractures.

Imaging Studies

See the list below:

Plain-film radiography
- Radiographs may be negative early in the process.^{[13, 15]}
- Stress-fracture changes may not be evident on plain films until 3 months after the onset of symptom(s).
- Up to 50% of stress fractures are never observed on plain films.
- Plain-film radiographs can help the physician distinguish fifth-metatarsal stress fractures from true Jones fractures. Fractures with a stress etiology show a widened fracture line, intramedullary sclerosis, and periosteal reaction (see the images below).
  
  Radiograph of the feet. This image depicts a stress fracture of the left second metatarsal with exuberant callus.
  View Media Gallery
  
  Radiograph of the left foot. This image depicts a stress fracture of the fifth metatarsal.
  View Media Gallery
Bone scanning^{[16, 17]}
- Technetium-99 (^99m Tc) diphosphonate 3-phase bone scanning has traditionally been the imaging modality of choice.
- Bone scanning is nearly 100% sensitive for the diagnosis of stress fractures, although the specificity of this modality is considerably lower.
- Bone scans can demonstrate stress fractures within 24-72 hours from the onset of symptom(s) (see the image below).
  
  Bone scan of the lower extremities. This image depicts a right fifth metatarsal stress fracture.
  View Media Gallery
- Differentiation between stress fractures and stress reactions may be determined with a bone scan.
Magnetic resonance imaging (MRI) and single-photon emission computed tomography (SPECT)^{[18, 19, 20]}: These modalities may also be used to image stress fractures; however, MRI has become the study of choice because it has the same sensitivity as a bone scan but with a much higher specificity. Additionally, MRI does not require ionizing radiation.
Ultrasonography
- In a case-control study, Banal et al evaluated the sensitivity and specificity of ultrasonography to detect early stress fractures as an alternative imaging modality to MRI and bone scan scintigraphy, which are expensive or invasive, time-consuming, and poorly accessible.^[21]The investigators analyzed 41 feet from 37 patients with ultrasonography and dedicated MRI. MRI detected 13 fractures in 12 patients. Ultrasonography sensitivity was 83%; specificity, 76%; positive predictive value, 59%; and negative predictive value, 92%.^[21]These findings led Banal et al to conclude that when radiographs are normal, ultrasonography should be used in the diagnosis of metatarsal bone stress fractures due to its low cost, noninvasiveness, rapidity, and easy technique with good sensitivity and specificity.

Treatment & Management

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Media Gallery

Radiograph of the feet. This image depicts a stress fracture of the left second metatarsal with exuberant callus.
Radiograph of the left foot. This image depicts a stress fracture of the fifth metatarsal.
Bone scan of the lower extremities. This image depicts a right fifth metatarsal stress fracture.

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Author

Valerie E Cothran, MD Assistant Professor, Department of Family and Community Medicine, Director of Primary Care Sports Medicine Fellowship, University of Maryland School of Medicine; Assistant Team Physician, University of Maryland

Valerie E Cothran, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Anthony J Saglimbeni, MD President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School; Team Physician, Santa Clara University; Consultant, University of San Francisco, Academy of Art University, Skyline College, Foothill College, De Anza College

Anthony J Saglimbeni, MD is a member of the following medical societies: California Medical Association, Santa Clara County Medical Association, Monterey County Medical Society

Disclosure: Received ownership interest from South Bay Sports and Preventive Medicine Associates, Inc for board membership.

Acknowledgements

Andrew D Perron, MD Residency Director, Department of Emergency Medicine, Maine Medical Center

Andrew D Perron, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.