Skip to main content

Stress Fractures of the Ankle and Hindfoot

  • Chapter
  • First Online:
Stress Fractures in Athletes

Abstract

Stress fractures of the ankle and hindfoot are common injuries in athletes. Most of these fractures can be treated nonoperatively, but certain factors including fracture location, vascular supply, lower leg alignment, and return to play considerations may require surgical intervention. Stress fractures of the ankle and hindfoot can also be classified as low risk and high risk in regard to propensity to heal with conservative treatment. Generally, low-risk fractures include the distal tibia, distal fibula, talus, and calcaneus. High-risk fractures include the medial malleolus and navicular. The treating health-care provider should have a low index for suspicion for stress fracture and be able to identify risk factors in regard to bone health, structural alignment, and training/competing issues in order to achieve a quick recovery and minimize the chance for recurrence of injury.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

References

  1. Hunt KJ, Hurwit D, Robel K, Gatewood C, Botser IB, Matheson G. Incidence and epidemiology of foot and ankle injuries in elite collegiate athletes. Am J Sports Med. 2016;45(2):426–33.

    Article  PubMed  Google Scholar 

  2. Changstrom BG, Brou L, Khodaee M, Braund C, Comstock D. Epidemiology of stress injuries among US high school athletes, 2005–2006 through 2012–2013. Am J Sports Med. 2014;43(1):26–33.

    Article  PubMed  Google Scholar 

  3. Wentz L, Liu P, Haymes E, Ilich J. Females have a greater incidence of stress fractures than males in both military and athletic populations: a systemic review. Mil Med. 2011;176(4):420–30.

    Article  PubMed  Google Scholar 

  4. Matherson O. Stress fractures in athletes: a study of 320 cases. Am J Sports Med. 1987;15:46–58.

    Article  Google Scholar 

  5. Ishibashi Y, Okamura Y, Otsuka H. Comparison of scintigraphy and magnetic resonance imaging for stress injuries of bone. Clin J Sports Med. 2002;12:79–84.

    Article  Google Scholar 

  6. Mandell JC, Khurana B, Smith SE. Stress fractures of the foot and ankle, part1: biomechanics of bone and principles of imaging and treatment. Skelet Radiol. 2017;46:1021–9.

    Article  Google Scholar 

  7. Bergman AG, Fredericson M, Ho C, Matheeson GO. Asymptomatic tibial stress reactions: MRI detection and clinical follow-uop in distancve runners. AJR Am J Roentgenol. 2004;183(3):635–8.

    Article  PubMed  Google Scholar 

  8. Caesar BC, McCollum GA, Elliott R, Williams A, Calder JDF. Stress fractures of the tibia and medial malleolus. Foot Ankle Clin. 2013;18(2):339–55.

    Article  PubMed  Google Scholar 

  9. Shelbourne KD, Fisher DA, Rettig AC, McCarroll JR. Stress fractures of the medial malleolus. Am J Sports Med. 1988;16(1):60–3.

    Article  CAS  PubMed  Google Scholar 

  10. Mandell JC, Khurana B, Smith SE. Stress Fractures of the foot and ankle, part 2: site-specific etiology, imaging, and treatment, and differential diagnosis. Skelet Radiol. 2017;46:1065–186.

    Google Scholar 

  11. Drakos MC, Domb B, Starkey C, Callahan L, Allen AA. Injury in the National Basketball Association: a 17-year overview. Sports Health. 2010;2(4):284–90.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Jowett AJL, Birks CL, Blackney MC. Medial malleolar stress fracture secondary to chronic ankle impingement. Foot Ankle Int. 2008;29(7):716–20.

    Article  PubMed  Google Scholar 

  13. Tol JL, van Dijk CN. Etiology of the anterior ankle impingement syndrome: a descriptive anatomical study. Foot Ankle Int. 2004;25:383–6.

    Google Scholar 

  14. Mankin HJ. The resonse of the articular cartilage to mechanical injury. J Bone Joint Surg Am. 1982;64:460–6.

    Article  CAS  PubMed  Google Scholar 

  15. van Dijk CN, Bossuyt PM, Marti RK. Medial ankle pain after lateral ligament rupture. J Bone Joint Br. 1996;78:562–7.

    Article  Google Scholar 

  16. Donley BG, IIaslan H. Stress fractures of the medial malleolus. Oper Tech Sports Med. 2006;14:252–8.

    Article  Google Scholar 

  17. Wegner AM, Wolinsky PR, Robbins MA, Garcia TC, Maitra S, Amanatullah DF. Antiglide plating of vertical medial malleolus fractures provide stiffer initial fixation than bicortical or unicortical screw fixation. Clin Biomech. 2016;31:29–32.

    Article  Google Scholar 

  18. O’Malley MJ. Medial Malleolar Stress Fractures in the National Basketball Association (NBA). Am J Sports Med, in submission.

    Google Scholar 

  19. Nguyen A, Beasley I, Calder J. Stress fractures of the medial malleolus in the professional soccer player demonstrate excellent outcomes when treated with open reduction internal fixation and arthroscopic spur debridement. Knee Surg Sports Traumatol Arthrosc. 2019;27:2884–9.

    Article  PubMed  Google Scholar 

  20. Johanson MA. Contributing factors in microtrauma injuries of the lower extremity. J Back Musculoskelet Rehabil. 1992;2:12–25.

    Article  CAS  PubMed  Google Scholar 

  21. Migrom C, Finestone A, Segev S, Olin C, Arndt T, Ekenman I. Are overground or treadmill runners more likely to sustain tibial stress fractures? Br J Sports Med. 2003;37(2):160–3.

    Article  Google Scholar 

  22. Ekenman I, Tsai-Fellander L, Johansson C, O’Brien M. The plantar flexor muscle attachments on the tibia. Scand J Med Sci Sports. 2007;5(3):160–4.

    Article  Google Scholar 

  23. Crowell HP, Davis IS. Gait retraining to reduce lower extremity loading in runners. Clin Biomech. 2011;26(1):78–83.

    Article  Google Scholar 

  24. Kijowski R, Choi J, Shinki K, Del Rio AM, De Smet A. Validation of MRI classification system for tibial stress injuries. Am J Roentgenol. 2012;198(4):878–84.

    Article  Google Scholar 

  25. Bernholt DL, Garzon-Muvdi J, Chhabra A, McFarland EG. Stress fracture of the distal tibial physis in an adolescent recreational dancer. Am J Sports Med. 2013;41(7):1649–52.

    Article  PubMed  Google Scholar 

  26. Woods M, Kijowski R, Sanford M, Choi J, De Smet A. Magnetic resonance imaging findings in patients with fibula stress injuries. Skelet Radiol. 2008;37(9):835–41.

    Article  Google Scholar 

  27. Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987;15(1):46–58.

    Article  PubMed  Google Scholar 

  28. Devas MB, Sweetnam R. Stress fractures of the fibula. J Bone Joint Surg Br. 1956;38B:818–29.

    Article  Google Scholar 

  29. Cheng YC, Yang H, Ni L, Song D, Zhang H. Stress fracture of the distal fibula in flatfoot patients: case report. Int J Clin Med. 2015;8(4):6303–7.

    Google Scholar 

  30. Wang Q, Whittle M, Cunningham J, Kenwright J. Fibula and its ligaments in load transmission and ankle stability. Clin Orthop Relat Res. 1996;330:261–70.

    Article  Google Scholar 

  31. Freidman MA, Draganich LF, Toolan B, Brage ME. The effects of adult acquired flatfoot deformity on tibiotalar joint contact characteristics. Foot Ankle Int. 2001;22:241–6.

    Article  Google Scholar 

  32. McClone JJ. Stress fractures of the talus. J Am Podiatry Assoc. 1965;55:814–7.

    Article  Google Scholar 

  33. Long NM, Zoga AC, Kier R, Kavanaugh EC. Insuffiencey and nondisplaced fractures of the talar head: MRI appearances. AJR Am J Roentgenol. 2012;199:613–7.

    Article  Google Scholar 

  34. Sormaala MJ, Niva MH, Kiuru M, Mattila VM, Pihlajamaki HK. Bone stress injuries of the talus in military recruits. Bone. 2006;39:199–204.

    Article  PubMed  Google Scholar 

  35. Elias I, Zoga AC, Raiken SM, Peterson JR, Besser MP, Morrison WB, Schweitzer ME. Bone stress injury of the ankle in professional ballet dancers seen on MRI. BMC Musculoskelet Disord. 2008;9:39.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Sormaal MJ, Niva MH, Kiuru MJ, Mattila VM, Pihlajamaki HK. Outcomes of stress fractures of the talus. Am J Sports Med. 2006;34(11):1809–14.

    Article  Google Scholar 

  37. Black KP, Ehlert KJ. A stress fracture of the lateral process of the talus in a runner. J Bone Joint Am. 1994;76A:441–3.

    Google Scholar 

  38. Motto SG. Stress fracture of the lateral process of the talus-a case report. Br J Sports Med. 1993;27(4):375–6.

    Article  Google Scholar 

  39. Stocker B, Bennett JT. Stress fracture of the talus following resection of a talocalcaneal coalition: a case report. Foot Ankle Int. 2001;22(1):56–8.

    Article  CAS  PubMed  Google Scholar 

  40. Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg. 2000;8:344–53.

    Article  CAS  PubMed  Google Scholar 

  41. Salzer MJ, Bluman EM, Noonan S, Chiodo CP, de Asla RJ. Injuries observed in minimalist runners. Foot Ankle Int. 2012;33(4):262–6.

    Article  Google Scholar 

  42. Sormaala MJ, Niva MH, Kiuru MJ, Mattaila VM, Pihlajamaki HK. Stress injuries of the calcaneus detected with imaging in military recruits. J Bone Joint Am. 2006;88(10):2237–42.

    Google Scholar 

  43. Pearce CJ, Zaw H, Calder JD. Stress fracture of the anterior process of the calcaneus associated with a calcaneonavicular coalition: a case report. Foot Ankle Int. 2011;32(1):85–8.

    Article  PubMed  Google Scholar 

  44. Taketomi S, Uchiyama E, Iwaso H. Stress fracture of the anterior process of the calcaneus. Foot Ankle Spec. 2013;6(5):389–92.

    Article  PubMed  Google Scholar 

  45. Van Meensel AS, Peers K. Navicular stress fractures in high performing twin brothers: a case report. Acta Orthop Belg. 2010;76(3):407–12.

    PubMed  Google Scholar 

  46. Maquirriain J, Ghisis JP. The incidence and distribution of stress fractures in elite tennis players. Br J Sports Med. 2006;40(5):454–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Towne LC, Blazina ME, Cozen LN. Fatigue fracture of the tarsal navicular. J Bone Joint Am. 1970;52(2):376–8.

    CAS  Google Scholar 

  48. Khan KM, Bruckner PD, Kearney C, Fuller PJ, Bradshaw CJ, Kiss ZS. Tarsal navicular stress fractures in athletes. Sports Med. 1994;17:65–76.

    Article  CAS  PubMed  Google Scholar 

  49. Vopat B, Beaulieu-Jones BR, Waryasz G, McHale KJ, Sanchez G, Logan CA, Whalen JM, DiGovanni CW, Provencher MT. Epidemiology of navicular injury at the NFL combine and their impact on an athlete’s prospective NFL career. Orthop J Sports Med. 2017;5(8):1–7.

    Article  Google Scholar 

  50. McKeon KE, McCormick JJ, Johnson JE, Klein SE. Intraosseous and extraosseous arterial anatomy of the adult navicular. Foot Ankle Int. 2012;33(10):857–61.

    Article  PubMed  Google Scholar 

  51. Kitaoka HB, Luo ZP, An KN. Contact features of the talonavicular joint of the foot. Clin Orthop Relat Res. 1996;325:290–5.

    Article  Google Scholar 

  52. Becker J, James S, Osternig L, Chou L. Foot kinematics differ between runners with and without a history of navicular stress fractures. Orthop J Sports Med. 2018;6(4):1–9.

    Article  Google Scholar 

  53. Ingalls J, Wissman R. The os supravaviculare and navicular stress fractures. Skelet Radiol. 2011;40:937–41.

    Article  Google Scholar 

  54. Nunang P, Quah C, Pillai A. A rare case of an osteochondral lesion of the tarsal navicular with a subacute stress fracture in a high level athlete. Foot. 2014;24:213–4.

    Article  Google Scholar 

  55. Saxena A, Behan SA, Valerio DL. Navicular stress fracture outcomes in athletes: analysis of 62 injuries. J Foot Ankle Surg. 2017;56:943–8.

    Article  PubMed  Google Scholar 

  56. Torg JS, Pavlov H, Cooley LH, Bryant MH, Arnoczky SP, Bergfeld J, Hunter LY. Stress fractures of the tarsal navicular: a retrospective review of 21 cases. J Bone Joint Am. 1982;64(5):700–12.

    CAS  Google Scholar 

  57. Khan KM, Fuller PJ, Brukner PD, Kearney C. Outcome of conservative and surgical management of navicular stress fracture in athletes. Am J Sports Med. 1992;20(6):657–66.

    Article  CAS  PubMed  Google Scholar 

  58. Saxena A, Fullem B, Hannaford D. Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system. J Foot Ankle Surg. 2000;39(2):96–103.

    Article  CAS  PubMed  Google Scholar 

  59. Torg JS, Moyer J, Gaughan JP, Boden BP. Management of tarsal navicular stress fractures: conservative versus surgical treatment: a meta-analysis. Am J Sports Med. 2010;38(5):1048–53.

    Article  PubMed  Google Scholar 

  60. Mallee WH, Weel H, van Dijk CN. Surgical versus conservative treatment for high-risk stress fractures of the lower leg: a systemic review. Br J Sports Med. 2015;49:370–6.

    Article  PubMed  Google Scholar 

  61. Fishman FG, Adams SB, Easley ME, Nunley JA. Vascularized pedicle bone grafting for nonunions of the tarsal navicular. Foot Ankle Int. 2012;33(9):734–9.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Hubbard, C.E., O’Malley, M.J. (2020). Stress Fractures of the Ankle and Hindfoot. In: Miller, T.L., Kaeding, C.C. (eds) Stress Fractures in Athletes. Springer, Cham. https://doi.org/10.1007/978-3-030-46919-1_18

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-46919-1_18

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-46918-4

  • Online ISBN: 978-3-030-46919-1

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics