Metatarsal Stress Fracture Workup

Updated: Jan 16, 2019
  • Author: Valerie E Cothran, MD; Chief Editor: Craig C Young, MD  more...
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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 stres 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 Radiograph of the left foot. This image depicts a stress fracture of the fifth metatarsal.
  • 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 dep Bone scan of the lower extremities. This image depicts a right fifth metatarsal stress fracture.
    • 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.