What is the treatment for a foot stress fracture?

Treatment of Foot Stress Fractures

The primary treatment for foot stress fractures is conservative management with protective immobilization using a walking boot or cast, activity modification to reduce weight-bearing, and appropriate pain management until clinical and radiographic evidence of healing is observed. 1

Diagnosis and Assessment

• Initial evaluation should include radiographs to confirm diagnosis, though stress fractures may not be visible for 2-3 weeks after symptom onset 2
• If radiographs are negative but clinical suspicion is high, MRI is the gold standard for definitive diagnosis with excellent sensitivity 3, 4
• CT scanning provides better visualization of fracture patterns that may be difficult to detect on plain radiographs 5

Treatment Algorithm Based on Risk Classification

Low-Risk Stress Fractures

Low-risk fractures include posteromedial tibia, calcaneus, and second/third metatarsals 6

• Initial Management:

  • Protective immobilization with walking boot or cast 1, 2
  • Activity modification with reduced weight-bearing 1
  • NSAIDs for pain management 1, 2
  • Immobilization should be maintained until clinical and radiographic evidence of healing 1

• Rehabilitation Phase:

  • Gradual return to weight-bearing activities with supportive footwear 1
  • Physical therapy to restore range of motion and strength 1
  • Progressive return to activity only after pain resolution and clinical improvement 2

High-Risk Stress Fractures

High-risk fractures include anterior tibial cortex, medial malleolus, navicular, base of second metatarsal, proximal fifth metatarsal, hallux sesamoids, and talus 7, 6

• Management Approach:
  • More aggressive treatment required due to risk of delayed union, nonunion, or displacement 7
  • Strict non-weight bearing with crutches may be necessary 2
  • Pneumatic bracing can be used to facilitate healing 2
  • Surgical consultation should be considered, especially for fractures in weight-bearing surfaces 1, 7

Special Considerations

• Patients with osteoporosis or on bisphosphonate therapy are at higher risk for fracture completion and may require more aggressive management 3
• Postmenopausal women are particularly at risk for stress fractures and may need longer periods of activity modification 4
• Metatarsal stress fractures (commonly called "march fractures") typically occur in the distal second and third metatarsals due to excessive repetitive stress 8

Monitoring and Follow-up

• Follow-up imaging is necessary to ensure proper healing, particularly for high-risk fractures 5
• For persistent pain after adequate conservative management, further evaluation with advanced imaging may be warranted 1
• Early return to high-impact activities before adequate healing should be avoided to prevent complications 1

Complications to Monitor

• Delayed union or nonunion is more common in high-risk fractures, particularly those with watershed blood supply (anterior tibial cortex, navicular, proximal tibial cortex) 6
• Fracture displacement can occur with inadequate immobilization or premature return to activity 8
• Persistent pain may indicate inadequate healing or development of complications 1