01Approach to the Critical Patient/attcp42

Immediate threats

›High-risk fracture identification

›Proximal 5th metatarsal zone 2 (Jones fracture)

›Poor blood supply watershed zone

›Nonunion rate 11–50% with conservative management

›Proximal 5th metatarsal zone 3

›Microtrauma-related, prolonged non-weight-bearing required

›Early surgical planning if competitive athlete

›Base of 2nd metatarsal stress fracture in dancers

›High delayed union risk

›Orthopedic referral required

›Alarm findings requiring urgent escalation

›Complete fracture with displacement >3–4 mm

›Orthopedic consultation same day

›Non-weight-bearing strict

›Compartment syndrome signs

›Severe pain with passive toe stretch

›Tense forefoot swelling

›If compartment syndrome suspected, urgent surgical consult

›Neurovascular compromise

›Absent or asymmetric dorsalis pedis pulse

›Capillary refill >3 seconds

›If neurovascular compromise present, immediate orthopedic consult

Key decision points

›Risk stratification determines management pathway

›Low-risk locations: 2nd–4th metatarsal shaft

›Conservative management appropriate in most cases

›Weight-bearing as tolerated with boot or hard-soled shoe

02History/hx80

Presenting symptoms

›Forefoot pain pattern

›Insidious onset over days to weeks

›Initially only during activity

›Progresses to earlier in exercise, then rest pain

›Localized dorsal forefoot pain

›Over affected metatarsal shaft

›Worsened by weight-bearing, running, jumping

›Associated swelling

›Localized dorsal edema

›Usually soft and non-pitting

›Pain trajectory

›Duration and progression since onset

›Acute worsening may indicate complete fracture

›Night pain or rest pain raises concern for malignancy or complete fracture

›Functional limitation

›Difficulty with push-off phase

›Antalgic gait or limp

Training and activity history

›Training errors — the "too much, too soon" pattern

›Recent increase in volume or intensity

›Mileage jump >10% per week

›Introduction of speed or hill training

›Change in surface

›Transition to harder surfaces

›Concrete or asphalt from softer tracks

›Footwear change

›New shoes without break-in

›Worn-out cushioning

›Sport and occupation context

›Running and military training: 2nd and 3rd metatarsal predominance

›Military recruits: higher risk if low physical fitness on entry

›Competitive runners: cumulative load monitoring

›Soccer: 5th metatarsal predominance

›Ballet and dance: base of 2nd metatarsal and sesamoids

Risk factor screen

›Sex and hormonal factors

›Female sex: higher overall rate

›Female military recruits >3× more likely than males

›Menstrual irregularities: amenorrhea or oligomenorrhea

›Amenorrhea or oligomenorrhea

›Up to 3× more common in athletes

›Key indicator of REDs

›Nutritional and metabolic factors

›Low energy availability

›Caloric intake insufficient relative to exercise expenditure

›Disordered eating behaviors or restrictions

›Vitamin D deficiency history

›Low sunlight exposure

›Limited dietary intake

›Calcium intake

›Dairy avoidance

›Vegan or restrictive diet

›Medication exposure

›Chronic NSAID use

›Reports of increased nonunion risk with prolonged use

›Limit to <7 days if used acutely

›Chronic corticosteroids

›Bone density suppression

›Reduce bone remodeling capacity

›Aromatase inhibitors or medroxyprogesterone (Depo-Provera)

›Estrogen-lowering effects on bone

Past medical history

›Prior stress fractures

›Strongest predictor of recurrence

›Site-specific recurrence risk

›Underlying metabolic cause evaluation essential

›Bone health diagnoses

›Osteoporosis or osteopenia

›Insufficiency fracture pattern in older adults

›DXA scan results if available

›REDs or Female Athlete Triad

›Prior diagnosis or treatment

›Eating disorder history

›Structural foot conditions

›Prior foot surgery

›Bunionectomy or hammertoe repair altering metatarsal loading

›High arch (pes cavus)

›Reduces shock absorption

›Increases lateral metatarsal loading

›Systemic conditions

›Inflammatory arthropathy: RA or seronegative arthritis

›Malabsorption: celiac disease, IBD — impair calcium and vitamin D absorption

›Chronic corticosteroid use

03Physical Exam/exam49

Foot and ankle inspection

›Inspection findings

›Localized dorsal forefoot swelling

›Over affected metatarsal shaft

›Ecchymosis is a late finding

›Alignment and deformity

›Bunion or hammertoe assessment

›Arch height: pes cavus or planus

Palpation

›Point tenderness

›Focal bony tenderness directly over metatarsal shaft: key diagnostic finding

›Pinpoint over affected bone

›Differentiates from tendinopathy (along tendon) or MTP synovitis (joint line)

›Adjacent structures

›Lisfranc ligament tenderness: midfoot stability concern

›Interdigital space tenderness: Morton neuroma consideration

Provocative tests

›Axial loading test

›Push corresponding toe toward calcaneus

›Reproduces pain at fracture site

›Positive test supports stress fracture diagnosis

›Hop test

›Single-leg hop reproduces focal metatarsal pain

›High specificity for stress fracture

›Poor sensitivity — negative test does not exclude

›Heel percussion test

›Percuss heel with palm

›Positive when pain localizes to metatarsal

04Differential Diagnosis/ddx51

Overuse and musculoskeletal conditions

›Stress reaction without complete fracture line

›ICD-10 M84.37 — stress fracture, foot

›Bone marrow edema on MRI without fracture line: grade 1–2

›Managed similarly to stress fracture but may allow earlier return

›Periostitis

›Periosteal pain without true fracture

›MRI distinguishes

›Tendinopathy

›Extensor digitorum or hallucis tendinopathy

›Tenderness along tendon course rather than over bone

›Pain with resisted extension

›Peroneal tendinopathy

›Lateral foot pain along peroneal tendons

›Relevant for lateral metatarsal pain presentations

›Morton neuroma

›ICD-10 G57.6 — plantar digital neuritis

›Interdigital burning or numbness

›Positive Mulder click on compression

Articular and joint conditions

›Metatarsophalangeal synovitis and capsulitis

›ICD-10 M77.5 — other enthesopathy of foot

›Joint-line tenderness at MTP joint

›Pain with passive toe range of motion

›Freiberg infraction (avascular necrosis of metatarsal head)

›Typically 2nd metatarsal head in adolescents

›Flattening and fragmentation on radiograph

›Lisfranc injury

05Laboratory Tests/lt42

Bone health and metabolic labs

›25-hydroxyvitamin D level

›Check in all patients with stress fractures

›Deficiency is a modifiable risk factor

›Target ≥50 nmol/l (20 ng/mL) minimum; many experts recommend 75–100 nmol/l

›Supplement if deficient

›Vitamin D3 1,000–2,000 IU daily as starting dose

›Recheck level in 8–12 weeks

›Calcium, phosphorus, alkaline phosphatase

›If metabolic bone disease suspected

›Hypocalcemia and elevated ALP suggest vitamin D deficiency or osteomalacia

›Hypercalcemia raises concern for malignancy or hyperparathyroidism

›Parathyroid hormone (PTH)

›If calcium abnormal or metabolic bone disease suspected

›Elevated PTH with low calcium: secondary hyperparathyroidism

›Elevated PTH with high calcium: primary hyperparathyroidism

Hormonal and nutritional assessment

›In female athletes with menstrual dysfunction

›LH, FSH, estradiol, prolactin

›Low estradiol in functional hypothalamic amenorrhea

›TSH to exclude thyroid dysfunction

›Insulin-like growth factor 1 (IGF-1)

›Suppressed in REDs

›Reflects anabolic hormone deficiency

›Thyroid function

›TSH

›Hyperthyroidism associated with increased bone resorption

›Hypothyroidism screening in athletes with fatigue

06Diagnostic Tests/dt84

Scoring Systems

›Bone Stress Injury (BSI) Clinical Prediction Rule

›Score ≥3 raises suspicion for bone stress injury

›Validated for lower extremity stress fractures

›Guides imaging decision-making in moderate-suspicion cases

›Component factors

›Female sex

›Prior stress fracture

›Activity change >25%

›Pain with low-load activity (walking)

›Age <20 years

›Ottawa Foot Rules

›Validated for acute traumatic injuries to exclude acute fracture

›Bone tenderness at base of 5th metatarsal or navicular

›Inability to weight-bear at time of injury and in ED

›Less applicable to overuse stress fractures

›Use to screen for acute fracture component

›Does not rule out stress fracture

›REDs Clinical Assessment Tool version 2 (CAT2)

›IOC-endorsed tool for athletes with suspected low energy availability

›Categorizes severity: low, moderate, high, very high risk

›Guides return-to-sport clearance and multidisciplinary referral

›LEAF-Q (Low Energy Availability in Females Questionnaire)

›Validated screening tool for LEA in female athletes

›Positive screen triggers nutritional and hormonal evaluation

MRI

›MRI foot without contrast

›Gold standard imaging modality

›Sensitivity up to 99%; specificity up to 97%

›Detects stress reaction before fracture line develops

›MRI grading of bone stress injuries

›Grade 1: periosteal edema on T2 only

›Grade 2: bone marrow edema on T2 without fracture line

›Grade 3: bone marrow edema on T1 and T2 without fracture line

›Grade 4: fracture line visible on T1 and T2

›Indications for MRI in metatarsal stress fracture

›Radiographs negative but clinical suspicion remains high

›High-risk fracture location (proximal 5th metatarsal zone 2–3, base of 2nd metatarsal)

›Elite or competitive athlete requiring definitive early diagnosis

›Failure to improve with appropriate conservative management

›ACR Appropriateness Criteria 2024 — MRI usually appropriate for stress fracture evaluation when radiographs are negative

›Preferred over CT for marrow and periosteal detail

CT

›CT foot role in metatarsal stress fracture

›Indications

›Equivocal MRI or MRI contraindicated

›Surgical planning for high-risk fractures

›Characterize osteoid osteoma nidus or malignancy

›CT characteristics

›Cortical thickening and periosteal new bone

›Fracture line visualization

›Less sensitive than MRI for early stress reactions

›ACR Appropriateness Criteria 2024

›CT usually appropriate as alternative when MRI unavailable or contraindicated

›Complementary to MRI for cortical detail

›CT limitations

›Lower sensitivity for bone marrow edema versus MRI

›May miss early grade 1–2 stress reactions

›Radiation exposure consideration

›Relevant in young athletes with potential for repeated imaging

Ultrasound

›POCUS and diagnostic ultrasound

›Emerging role as bedside adjunct

›Periosteal thickening and irregularity visible

›Cortical disruption at fracture site

›Hyperemia on power Doppler suggests active bone stress response

›Limitations

›Operator-dependent

›Cannot assess marrow edema or grade injury

›Not a replacement for MRI in high-risk or unclear cases

›Practical utility in ED or urgent care

›Rapid assessment when MRI not immediately available

›Can differentiate bony tenderness from soft tissue source

Plain radiography

›Foot radiographs (AP, lateral, oblique views)

›First-line imaging for metatarsal pain

›High specificity 88–96% when positive

›Low sensitivity — often normal in first 2–3 weeks

›Positive findings

›Periosteal reaction (earliest radiographic sign)

›Faint cortical lucency

›Cortical thickening or sclerosis

›Callus formation at healing stage

›Weight-bearing AP radiograph

›Essential to evaluate Lisfranc alignment

›1st–2nd metatarsal base gap >2 mm suggests Lisfranc injury

›Repeat radiographs at 2–3 weeks

›Acceptable alternative for low-risk locations with mild symptoms

›Periosteal reaction may become visible by 2–3 weeks

07Disposition/dispo39

Discharge criteria

›Safe for discharge — low-risk fractures

›2nd–4th metatarsal shaft stress fractures with intact alignment

›Weight-bearing as tolerated in protective footwear

›Outpatient sports medicine or orthopedic follow-up within 1–2 weeks

›Pain controlled with acetaminophen and ice

›No rest pain or severe night pain

›Able to ambulate safely with CAM boot or hard-soled shoe

›Patient education on activity restrictions completed

›Discharge with walking boot and follow-up instructions

›Written return precautions provided

›Sudden worsening of pain

›New inability to weight-bear

Orthopedic referral indications

›Urgent same-day or next-day orthopedic consult

›Proximal 5th metatarsal zone 2 (Jones fracture) or zone 3

›Regardless of displacement

›Athlete requiring surgical fixation discussion

›Displacement >3–4 mm or angulation >10°

›Surgical fixation likely required

›Multiple metatarsal fractures

›Lisfranc injury must be excluded

›Compartment syndrome or neurovascular compromise

›Emergent surgical consultation

›Elective orthopedic referral

›Nonunion at 3–6 months

›First metatarsal fractures that are displaced, comminuted, or intra-articular

›Base of 2nd metatarsal stress fracture in dancers

08Treatment/t90

Immediate management — all patients

›Pain management

›Acetaminophen first-line

›500–1,000 mg orally every 4–6 hours

›Maximum 4,000 mg per 24 hours; 3,000 mg in older adults or hepatic disease

›Ice application

›15–20 minutes every 2–4 hours for first 48–72 hours

›Cloth barrier to protect skin

›NSAIDs — use with caution

›Reports of increased nonunion risk with prolonged use

›If used, limit to <7 days and only for resting or night pain

›Avoid in high-risk fracture locations (Jones fracture)

Conservative management — low-risk fractures (2nd–4th metatarsal shaft)

›Activity modification

›Avoid pain-provoking activities

›No activity beyond 3/10 pain threshold

›Eliminate running, jumping, plyometrics

›Cross-training to maintain cardiovascular fitness

›Cycling: lower extremity unloaded

›Swimming or pool running: non-impact aerobic maintenance

›Protective footwear and immobilization

›CAM (controlled ankle motion) walking boot

›3–6 weeks weight-bearing as tolerated

›Reduces metatarsal bending forces

›Hard-soled shoe as alternative for mild cases

›Reduces forefoot flex during toe-off

›Less effective than CAM boot for significant pain

›Crutches

›If pain prevents comfortable ambulation in boot

›Avoid strict non-weight-bearing unless fracture severity warrants

›Return-to-activity protocol

›Prerequisite: pain-free for 5 consecutive days during daily activities

›Provocative testing negative: axial load, hop test

›No tenderness on palpation

›Graduated walk-to-run program

›Begin with walking intervals alternating with jogging

›Progress by 10% per week maximum

›Return to sport by 6–12 weeks in most low-risk cases

High-risk fracture management

›Jones fracture — proximal 5th metatarsal zone 2

›Non-weight-bearing cast minimum 6 weeks if non-operative

›Short-leg non-weight-bearing cast

›Re-imaging at 6 weeks to confirm healing

›Surgical fixation (intramedullary screw) strongly preferred

›Elite and competitive athletes: early surgical fixation recommended

›Reduces nonunion risk and accelerates return to sport

›Discuss risks and expected timeline: typically 6–8 weeks post-fixation

›Proximal 5th metatarsal zone 3

›Non-weight-bearing cast 6–20 weeks depending on healing response

›Extended duration due to poor vascularity

›Serial imaging at 6-week intervals

›Surgical fixation if non-union or athlete

›Intramedullary screw fixation technique

›Base of 2nd metatarsal (dancer's fracture site)

›Close monitoring with early orthopedic involvement

›Possible prolonged immobilization

›Modification of ballet-specific training

Bone health optimization

›Vitamin D supplementation

›Supplement if 25-hydroxyvitamin D <50 nmol/l

›Vitamin D3 1,000–2,000 IU daily

›Higher doses (2,000–4,000 IU) for significant deficiency — guided by level

›Recheck in 8–12 weeks

›Target ≥50 nmol/l minimum; 75–100 nmol/l for athletes

›Calcium

›Ensure adequate daily intake 1,000–1,200 mg/day

›Dietary sources preferred: dairy, fortified foods, leafy greens

›Supplemental calcium carbonate or citrate if dietary intake insufficient

›Divide supplemental doses ≤500 mg per dose for absorption

Nutritional and energy availability management

›Low energy availability (LEA) correction

›Caloric intake increase sufficient to cover training expenditure

›Target energy availability ≥45 kcal/kg lean body mass/day

›Reduce training load if caloric increase is not immediately feasible

›Dietitian referral for structured nutrition plan

›Especially important in athletes with disordered eating

›Adequate protein intake supports bone healing

›Medication adjustment

›Discontinue or taper chronic corticosteroids if possible

›Coordinate with prescribing physician

›Review aromatase inhibitors and medroxyprogesterone

›Consider bone-protective agents if discontinuation not feasible

Rehabilitation and biomechanics

›Physical therapy referral

›Strength and biomechanics assessment

›Hip abductor and intrinsic foot muscle strengthening

›Gait retraining to reduce metatarsal loading

›Footwear assessment and orthotics

›Custom orthotics for high arch or pronation abnormality

›Metatarsal pad placement to offload affected metatarsal

›Gradual reloading — optimal loading principles

›Introduce load progressively once pain-free

›Bone remodeling requires controlled mechanical stimulation

›Warden et al. (2021) evidence base: optimal loading accelerates healing

›Avoid complete disuse for low-risk fractures

›Protected weight-bearing preserves bone density during recovery

09Special Populations/sp75

Pregnancy

›Physiologic considerations

›Calcium demands increased in pregnancy and lactation

›Fetal skeletal development draws maternal calcium

›Dietary calcium 1,000–1,200 mg/day maintained

›Vitamin D status

›Supplement as for non-pregnant; 1,000–2,000 IU vitamin D3 daily is safe

›Target ≥50 nmol/l

›Imaging in pregnancy

›Plain radiographs with gonadal and fetal shielding when clinically necessary

›Foot radiograph radiation dose very low; acceptable risk

›MRI preferred if high-risk location requires further characterization

›No ionizing radiation; gadolinium contrast avoided unless essential

›CT foot: low radiation dose, acceptable when MRI not available and clinical decision required

›Management modifications

›Conservative management preferred; weight-bearing as tolerated

›CAM boot or hard-soled shoe

›NSAIDs avoid, especially after 20 weeks gestation

›Risk of premature closure of ductus arteriosus

›Acetaminophen first-line for pain

›Surgical fixation deferred to postpartum when possible

›Coordinate with obstetric team if urgent fixation required

Geriatric

›Insufficiency fracture pattern

›Normal loading on weakened bone from osteoporosis

›May occur without significant training change

›Lower-energy mechanism than fatigue fracture in athletes

›Multifactorial bone loss

›Age-related decline in bone density

›Vitamin D and calcium deficiency highly prevalent

›Sarcopenia reduces protective muscle forces

›Falls and footwear assessment

›Footwear evaluation

›Poorly fitting or unsupportive shoes common contributor

›Falls risk assessment

›Orthostatic blood pressure

›Gait and balance evaluation

›Polypharmacy review

›Medication considerations

›NSAIDs: increased GI and renal risk in older adults

›Short course with gastroprotection if used

›Acetaminophen preferred

›Bisphosphonate therapy

›Indicated if osteoporosis confirmed on DXA

›Coordinate with primary care or endocrinology

›Atypical femoral fractures associated with prolonged bisphosphonate use (relevant counseling)

›DXA scan

›Strongly indicated in older adults with any stress or insufficiency fracture

›T-score ≤−2.5: osteoporosis — treat

›T-score −1.0 to −2.5: osteopenia — optimize calcium and vitamin D

Pediatrics

›Growth plate (physeal) considerations

›Stress fractures in pediatric athletes can involve growth plates

›Growth plate injury at 5th metatarsal base: Iselin disease apophysitis differential

›Do not confuse normal apophysis with fracture on radiograph

›MRI useful to distinguish physeal injury from stress fracture

›Edema pattern on MRI guides management

›Nutritional considerations

›Energy availability is critical during growth phase

›Restriction during growth associated with irreversible bone density deficits

›Adequate calcium intake: adolescents 1,300 mg/day

›Eating disorder identification

›AAP recommends routine screening in adolescent athletes

›Multidisciplinary team involvement when eating disorder identified

›REDs in adolescent athletes

›Highest-risk group for long-term bone health consequences

›Peak bone mass occurs in adolescence; deficits may be permanent

›Menstrual irregularities in female adolescent athletes: urgent evaluation

›Return-to-sport criteria conservative in adolescents

›Full symptom resolution before resuming high-impact activity

›Bone health optimization before return

›Management specifics

›Acetaminophen for pain

›15 mg/kg per dose every 4–6 hours

›Maximum 75 mg/kg/day (not exceeding 4,000 mg/day)

›Immobilization duration similar to adults

›CAM boot 3–6 weeks for low-risk locations

›Orthopedic referral for high-risk locations or growth plate involvement

10Background/b77

Epidemiology

›Prevalence and distribution

›Metatarsal stress fractures account for up to 38% of stress fractures in athletes

›2nd and 3rd metatarsals most commonly involved

›5th metatarsal: sport-specific predominance (soccer)

›Sex differences

›Female athletes have higher overall rates

›Female military recruits >3× more likely than males

›Age distribution

›More common in those <20 years and >40 years

›Bimodal distribution reflects athletic population and age-related bone loss

›Population-specific rates

›Military recruits

›High-incidence population due to rapid-onset training loads

›Poorer fitness on entry correlates with higher BSI rates

›Competitive runners

›Cumulative mileage primary driver

›Up to 20% of runners sustain a stress fracture during athletic career

›Racial differences

›More common in White individuals

›Least common in Black individuals — likely related to bone geometry and density differences

Pathophysiology

›Bone stress injury continuum

›Stress reaction precedes stress fracture

›Bone remodeling overwhelmed by repetitive sub-failure loading

›Normal bone turnover: osteoclast resorption followed by osteoblast repair

›When resorption outpaces repair, microdamage accumulates

›Fatigue fracture (healthy bone, excessive load)

›Primarily in athletes and military recruits

›Metatarsals most vulnerable due to bending forces during push-off

›Insufficiency fracture (weakened bone, normal load)

›Primarily in older adults, osteoporosis, or metabolic bone disease

›May occur with activities of daily living

›Metatarsal-specific biomechanics

›2nd and 3rd metatarsals

›Central location, most rigid during push-off phase

›Bear highest bending loads in running gait

›5th metatarsal proximal zone 2 (Jones fracture)

›Watershed vascular zone between nutrient artery territories

›Poor healing capacity; chronic stress from peroneus brevis pull

›High arch (pes cavus)

›Reduced shock absorption during heel strike

›Increased lateral column loading: risk for 5th metatarsal fractures

›Hyperpronation

›Increased medial column loading: risk for 2nd and 3rd metatarsal fractures

›Systemic contributors to stress fracture risk

›Relative Energy Deficiency in Sport (REDs)

›Chronically low energy availability suppresses IGF-1, estrogen, and testosterone

›Impairs osteoblast function and bone formation

›Results in lower bone mineral density and impaired stress response

›Vitamin D and calcium deficiency

›Vitamin D deficiency impairs calcium absorption and bone mineralization

›Low dietary calcium accelerates bone resorption to maintain serum calcium

Therapeutic Considerations

›Conservative management evidence base

›Low-risk metatarsal stress fractures heal well with conservative care

›6–8 weeks expected healing time for 2nd–4th metatarsal shaft

›Return to sport typically 6–12 weeks

›No advantage demonstrated for strict non-weight-bearing over protected weight-bearing in low-risk fractures

›Optimal loading principle

›Warden et al. (2021) evidence: controlled mechanical loading promotes bone remodeling

›Complete rest inferior to protected weight-bearing for bone healing

›Surgical fixation evidence for Jones fracture

›Intramedullary screw fixation superior to casting in athletes

›Faster return to sport

›Lower nonunion and refracture rates

›Class I recommendation in competitive athletes based on expert consensus

›Bone anabolic therapy — investigational in stress fractures

›Teriparatide (PTH 1-34) has been studied in stress fractures

›Not standard of care; limited evidence base

›May be considered by endocrinology in severe REDs with recurrent fractures

›Bisphosphonates: role in underlying osteoporosis, not acute stress fracture management

›Prevention strategy evidence

›Address training errors first

›Graduated load increase with adequate recovery

›Footwear and orthotics

›Properly cushioned running shoes reduce tibial and metatarsal loading

›Vitamin D and calcium supplementation

›McCabe et al. (2012): vitamin D sufficiency associated with reduced stress fracture risk

›Armstrong et al. (2019): low 25-hydroxyvitamin D strongly associated with stress fracture in military personnel

11Patient Discharge Instructions/pdi32

copy discharge instructions

›Metatarsal stress fracture home care

›Wear the walking boot or hard-soled shoe at all times when weight-bearing

›Do not remove the boot for walking, even inside the house

›Ice the top of your foot 15–20 minutes up to 4 times per day

›Always wrap ice in a cloth to protect skin

›Take acetaminophen as directed for pain (follow package directions)

›Avoid anti-inflammatory medications (ibuprofen, naproxen) unless specifically told otherwise

›Activity restrictions

›No running, jumping, or high-impact activity until cleared by your clinician

›Swimming and cycling are acceptable for maintaining fitness

›Keep activity pain-free or at most 3 out of 10 pain

›Stop immediately if pain worsens

›Use crutches if walking is too painful even in the boot

›Nutrition and bone health

›Take vitamin D supplement as prescribed

›Good dietary sources: fortified milk, eggs, fatty fish

›Ensure 1,000–1,200 mg of calcium daily from food or supplements

›Good sources: dairy products, fortified plant milks, leafy greens

›Eat enough food to support healing — do not restrict calories

›Warning signs — return to emergency department immediately for

›Sudden severe increase in pain or new inability to walk at all

›May indicate the bone has completely broken through

›New numbness or tingling in any toe

›Toes that are pale, blue, or cold compared to the other foot

›Severe swelling that develops rapidly

›Pain that is not improving after 2–3 weeks of following instructions

›Follow-up instructions

12References/r18

Guidelines and key sources

›Primary evidence sources used in this document

›Schroeder JD, Trigg SD, Capo Dosal GE. Bone Stress Injuries: Diagnosis and Management. American Family Physician. 2024. PMID 39700362

›Mandell JC, Khurana B, Smith SE. Stress Fractures of the Foot and Ankle, Part 2: Site-Specific Etiology, Imaging, and Treatment, and Differential Diagnosis. Skeletal Radiology. 2017. PMID 28343329

›Warden SJ, Edwards WB, Willy RW. Optimal Load for Managing Low-Risk Tibial and Metatarsal Bone Stress Injuries in Runners. Journal of Orthopaedic and Sports Physical Therapy. 2021. PMID 33962529

›Morrison WB et al. ACR Appropriateness Criteria: Stress Fracture Including Sacrum Excluding Other Vertebrae. 2024 Update. Journal of the American College of Radiology. 2024

›Wright AA, Hegedus EJ, Lenchik L, et al. Diagnostic Accuracy of Various Imaging Modalities for Suspected Lower Extremity Stress Fractures. American Journal of Sports Medicine. 2016. PMID 25805712

›McCabe MP, Smyth MP, Richardson DR. Vitamin D and Stress Fractures. Foot and Ankle International. 2012. PMID 22735329

›Armstrong RA et al. Low Serum 25-Hydroxyvitamin D Status in the Pathogenesis of Stress Fractures in Military Personnel. PLoS One. 2019. PMID 32208427

›Moreira CA, Bilezikian JP. Stress Fractures: Concepts and Therapeutics. Journal of Clinical Endocrinology and Metabolism. 2017. PMID 27732325

›Sun J, Feng C, Liu Y, et al. Risk Factors of Metatarsal Stress Fracture Associated With Repetitive Sports Activities. Frontiers in Bioengineering and Biotechnology. 2024. PMID 39175621

›Presutti F, Paoletti S, Conte F, et al. Stress Fracture in Athletes: A Practical Approach. Journal of Clinical Medicine. 2026. PMID 42074879

›Mountjoy M et al. IOC Consensus Statement: Beyond the Female Athlete Triad — Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine. 2014. PMID 24620037

›Hornberger LL, Lane MA. Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics. 2021

Coding standards

›Diagnostic coding

›ICD-10 M84.37 — stress fracture, foot

›M84.371: right foot; M84.372: left foot; M84.379: unspecified foot

›ICD-10 S92.30 — fracture of unspecified metatarsal bone

›SNOMED CT 263102004 — stress fracture of metatarsal bone

Evidence & Review

Evidence & Review