Some bone stress injuries in the foot and ankle do not heal the way an ordinary overuse injury does, because the bone involved has a thinner blood supply than the bones around it. That is why certain locations get watched far more closely than others, and why two people with what looks like the same stress fracture can end up on very different plans.
Dr. Nick Strasser, a foot and ankle surgeon at Vanderbilt and Chief of the Foot and Ankle division, talked through his own approach to these injuries in a recent conversation with Dr. Jason at Active Sports Therapy. His answer was specific enough to build a whole system around, and it is worth walking through for anyone dealing with foot or shin pain that will not settle down.
Why do some stress fractures need more caution than others?
A bone stress injury is really a spectrum. On one end is a bone stress reaction, which is swelling and irritation inside the bone before any crack has formed. On the other end is a full stress fracture, a visible line in the bone on imaging. Strasser named the spots in the lower extremity where this spectrum tends to behave badly:
- Fifth metatarsal fractures
- Navicular fractures
- Medial tibial stress fractures
- Anterior tibial stress fractures
- Second metatarsal fractures, which he said can sometimes fail to heal and end up needing a plate
These areas share a common problem: less blood supply than the bone next to them, so the body’s normal repair process is slower and less reliable.
What does a foot and ankle surgeon check first?
Strasser’s starting point is almost always an x-ray, because it is quick and inexpensive. From there, his plan follows the clinical picture:
- Locate exactly where the tenderness is, since location drives everything else
- Get an x-ray to see whether anything is already visible
- If the spot is one of the higher risk zones, use a boot for two to three weeks
- Repeat the x-ray to check the bone and confirm the symptoms have improved
- Progress activity if things look good, or change course if they do not
It really comes down to location for me.
Why might an MRI follow a clean x-ray?
An x-ray mostly shows a stress fracture once the bone has already started remodeling around it. Earlier in the process, the bone can be stressed and swollen with no visible line yet. An MRI can pick up that swelling, called bone edema, which lets a clinician grade how far along the injury is before it shows up on a plain film.
This is where our side of it looks a little different. Patients often find us before anyone has settled on a diagnosis, sometimes thinking they have a tendon problem rather than a stress injury. We refer for an x-ray right away the same way Strasser described. When that comes back clean and the location is still tender, we often refer for an MRI fairly quickly to grade the bone edema rather than waiting to see if symptoms resolve on their own.
How does timing change the plan?
| Step | Dr. Strasser’s setting | Our clinic |
|---|---|---|
| Who is usually seen first | Patients who have already been dealing with symptoms for some time | Patients earlier in the course, often before a diagnosis is settled |
| First imaging | X-ray | X-ray referral |
| If x-ray is clean | Boot trial, repeat x-ray at two to three weeks | Often an MRI referral to grade bone edema |
| If more is needed | Surgical plating for cases that fail to heal | Referral to a surgeon like Dr. Strasser |
What happens when a stress fracture does not heal?
Strasser mentioned that some second metatarsal fractures do not resolve on their own and need a plate, a small piece of hardware a surgeon secures to the bone to hold it still while it knits. That kind of surgical care sits outside what happens in our clinic. Our part of that story is the assessment that gets someone to the right person quickly, and the rehabilitative care that follows once the bone itself is cleared to load again.
How does our clinic fit around this care?
Most of the bone stress injuries we see do not end up needing surgery. Once the bone is cleared to progress, the work becomes activity modification, our shockwave therapy, and guided rehabilitative exercise to rebuild strength and range of motion around the area. We also use that window to work on the rest of the kinetic chain, so that by the time someone is cleared for their sport in Hendersonville or wherever they train, the area around the injury is stronger than it was before.
Key points
- Bone stress injuries exist on a spectrum from bone stress reaction to full fracture
- Fifth metatarsal, navicular, medial tibial, anterior tibial, and some second metatarsal fractures carry higher risk
- An x-ray is usually the first step, with a boot and repeat x-ray for higher risk zones
- A clean x-ray does not always rule out a bone stress injury, which is where MRI grading can help
- Surgical plating is reserved for fractures that do not resolve on their own
Frequently asked questions
How long does a bone stress injury take to get better?
It depends heavily on the bone involved and how early it was caught, so there is no single timeline that applies to everyone. Dr. Strasser’s own protocol rechecks progress at two to three weeks rather than guessing at a date up front.
Can I keep training on a stress fracture?
That depends on the location and what imaging shows, which is why an exam and x-ray come before any decision about activity. Pushing through pain at one of the higher risk zones is generally discouraged until it has been checked.
Is a stress reaction the same thing as a stress fracture?
Not quite. A stress reaction is the bone swelling and irritation stage before a visible crack forms, while a stress fracture means a line is already present on imaging.
Do all stress fractures need an MRI?
No. Many can be managed with an x-ray and a period of activity modification. MRI tends to get used when the location is high risk, the x-ray is unclear, or symptoms are not improving as expected.
If you have foot, shin, or ankle pain that has not settled, book a new patient visit and we will work out exactly which bone or tissue is involved before deciding on a plan.
Active Sports Therapy · 123 Stadium Drive, Hendersonville, TN 37075 · 615-537-5520
Sources
- Boden BP, Osbahr DC. High risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg. 2000. https://pubmed.ncbi.nlm.nih.gov/11104400/
- Kaeding CC, Miller T. The comprehensive description of stress fractures: a new classification system. J Bone Joint Surg Am. 2013. https://doi.org/10.2106/JBJS.L.00890
Transcript of the video
Your question on like the bone stress injury, you know assessment. I mean, yes, you’re right. We probably are going to go to an MRI pretty quickly. That being said a lot of times by the time they get they come in they’ve been dealing with for some time where they’re like mentally they that’s sometimes where the patients are at too.
So it’s it’s kind of taking all that into consideration, but it really comes down to location for me, you know where I think about the four big problems we talked about fifth metatarsal fractures navicular fractures can be really problematic media fractures stress fractures can be problematic and then anterior tibial stress fractures can be an issue and then sometimes second met actually can be a little bit of a challenge. I’ve had a couple that haven’t healed that needs to be plated in some in some sports. And so it comes down to the clinical exam where they have in pain we can get an extra, you know, we getting an x-ray is pretty low cost and you can oftentimes get an x-ray and then even just repeating the X-ray tell them like I’m gonna put you in a boot tree like a stress injury had to come back two weeks three repeat an x-ray make sure it looks okay if you’re symptoms are better great. We’ll let you progress if they’re not and there’s something concerning on x-ray that might need to do something different with it.
With Dr. Nick Strasser, foot and ankle surgeon at Vanderbilt and Chief of the Foot and Ankle division. See his practice.
