CLINICALLY SPEAKING
Multiple Simultaneous Metatarsal Stress Fractures in the Same Foot Murat Mert, Ethem Ayhan Unkar, Ali Volkan Ozluk, Tolga Tuzuner, Sinan Erdog˘an,
MD* MD* MD* MD* MD*
Metatarsal stress fractures are common overuse injuries in athletes, military recruits, and ballet dancers, usually occurring in the second, third, and fourth metatarsals, respectively. Such fractures may also occur in a variety of other individuals, regardless of demographic characteristics, sex, or profession, and they are highly associated with excessive activity. Moreover, these types of fractures are usually diagnosed late and have poor outcomes. To our knowledge, there has been only one case report of an individual with stress fractures of all three central metatarsals in the same foot. We describe herein a racehorse training jockey who presented with multiple simultaneous metatarsal stress fractures in the same foot. We also discuss the possible mechanisms by which this entity occurred, as well as its management and outcome. (J Am Podiatr Med Assoc 105(2): 177-180, 2015)
Metatarsal stress fractures are common in athletes, soldiers, and ballet dancers1-6 and constitute 22.5% of all stress fractures.4 This type of fracture has been estimated to affect up to 14% of all patients with fractures. Up to 75% of metatarsal stress fractures occur in the second or third metatarsal, with fewer occurring in the fourth metatarsal. Fatigue fractures of the first and fifth metatarsals are rarely observed.5 Bone stress injuries are a direct result of repetitive stresses, which may create a condition of maltraining. Precipitating factors are repetitive traumas, low-grade external forces, rapid application of muscular force to the bone, and pathologic bone weakness.2,7-9 Biomechanical factors associated with multiple stress fractures include high longitudinal arch of the foot, leg-length inequality, and forefoot varus.10,11 Runners with high weekly training mileage are at risk for initial and recurrent stress fractures of the lower extremities. Half of all female patients with stress fractures have menstrual irregularities, and the combination of nutrition, training factors, exercise-induced amenorrhea, and *Department of Orthopaedics and Traumatology, Istanbul Training and Research Hospital, Istanbul, Turkey. Corresponding author: Murat Mert, MD, Department of Orthopaedics and Traumatology, Istanbul Training and Research Hospital, Samatya - Fatih, Istanbul, 34098, Turkey. (E-mail: [email protected])
hormonal situation may cause changes in bone metabolism that lead to stress fractures.12,13 The forefoot has unique biomechanical features in that loads are distributed unequally across multiple bones. In a study evaluating the reason for the high incidence of stress fractures in the lateral metatarsals, the relationships between the cross-sectional geometric properties of the lateral metatarsals and peak plantar pressure were determined.14 ‘‘Metatarsals 2–4 were found to have the weakest cross-sectional geometric properties; and metatarsal 2, and to a lesser extent metatarsal 3, experience relatively high peak pressures. The strengths and plantar pressure values of metatarsals 2 and 3 are consistent with the high incidence of stress fractures in these bones.’’14(p253) There has been only one case report of an individual with stress fractures of all three central metatarsals in the same foot.15 We describe herein a racehorse training jockey who presented with multiple simultaneous metatarsal stress fractures in the same foot. We also discuss the possible mechanisms by which this entity occurred, as well as its management and outcome.
Case Report A 27-year-old man presented with mild and unresolved pain in his left foot of 21 days’ duration. At
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177
that time, he was seen by another emergency service. The patient was a racehorse training jockey. As part of his duties, he rode horses 7 days per week (total, 21 hours). His weight was 65 kg, and his height was 170 cm. He had no history of fractures or accidents and no history of any collagenous or inflammatory disease or diabetes mellitus. He smoked 30 cigarettes per day, and his alcohol intake was at social levels. The patient reported having difficulty with weightbearing but no swelling, erythema, or weakness. Initially he had visited another clinic, where the radiographs of his foot taken 3 weeks after the onset of his complaints revealed stress fractures in the second, third, and fourth distal metatarsals (Fig. 1). The patient’s foot was placed in a nonweightbearing below-the-knee cast for 6 weeks, followed by 4 weeks of orthopedic orthosis. No solid union was radiologically observed 13 weeks later (Fig. 2). He had been treated conservatively with partial weightbearing and no excessive physical activities but had been unable to return to his job even 7 months after the beginning of his complaints. At the end of the 7-month period, when the patient was for the first time evaluated at the Istanbul Training and Research Hospital, Department of Orthopaedics and Traumatology (Istanbul, Turkey), radiographs and computed tomography showed union in the fourth metatarsal but nonunion in the second and third metatarsals (Fig. 3). He noted moderate metatarsal-
Figure 1. Plain radiograph taken 3 weeks after the onset of symptoms showing stress fractures in all three central metatarsals.
178
Figure 2. Plain anteroposterior radiograph at week
13 showing no solid union in the second and third metatarsals. gia on the second and third metatarsal heads and difficulty walking. He was, therefore, evaluated for additional diseases, such as gout, osteoporosis, diabetes mellitus, and hypophosphatasia. His blood glucose, uric acid, calcium, vitamin D, and alkaline phosphatase levels were within normal limits, and there was no evidence of gout or hyphophosphatasia. We decided that surgery was the best treatment at this point. A longitudinal incision was made between the second and third metatarsals, and cancellous autografting was performed using material taken from his own proximal tibia, along with Kirschner wire fixation of the second metatarsal and drilling and grafting of the third metatarsal. We prefered Kirschner wire osteosynthesis owing to our clinic’s history of successful results in osteosynthesis of distal metatarsal fractures with Kirsch-
Figure 3. At 7 months, computed tomography
showed union in the fourth metatarsal but nonunion in the second and third metatarsals.
March/April 2015 Vol 105 No 2 Journal of the American Podiatric Medical Association
ner wire, our clinical experience, and the costeffectiveness of the method. A nonweightbearing cast was placed on his foot for 6 weeks, followed by a walking cast for 4 weeks, resulting in union. Five months after surgery, he returned to his job. The patient healed well; at his most recent follow-up, 1 year after surgery, he showed radiographic evidence of healing (Fig. 4) and was asymptomatic. We removed the Kirschner wire under local anesthesia. Written informed consent was obtained from the patient for publication of this case report and the accompanying images.
Discussion Most metatarsal stress fractures are treated nonsurgically, with protected weightbearing in cast shoes for 4 to 6 weeks usually being sufficient.1,5,6,16,17 To our knowledge, there has been only one case report of a patient with stress fractures of the second, third, and fourth metatarsals in the same foot.15 In this patient, a military aviator, the fractures were sequential, suggesting that the likely etiologic factor was altered foot biomechanics. Instability of the first ray has been thought to cause the lesser metatarsals to bear greater weight due to improper pressure distribution and induce stress fractures of the lesser metatarsals.18 The present patient, however, showed no evidence of
Figure 4. Radiograph performed 12 months postop-
eratively.
foot abnormalities, such as metatarsus adductus, first-ray hypermobility, or pes cavus. Stress fractures have been found to develop in two distinct areas of the lateral metatarsals: proximal (at the base) and nonproximal (distal). The signs, symptoms, diagnosis, prognosis, treatment, and outcomes of these two types of stress fractures are different and have differing risk factors and clinical outcomes.2 Delayed union and nonunion are often observed in proximal stress fractures. Although the fractures in the present patient were nonproximal, there was nonunion of the second and third metatarsals. Internal fixation and grafting were, therefore, applied. High training volume is associated with nonproximal stress fractures, whereas low training volume is associated with proximal stress fractures.2 The present patient had high training activity daily in that he rode horses for 3 hours per day, 7 days per week. Kinematic contributors to stress may have included high muscle fatigue and overbending strains associated with riding horses, which may have caused critical loading at all three lateral metatarsals. Several factors are involved in training horses that may increase the jockey’s risk of foot injuries, including frequent mounting and dismounting of the horse, different riding speeds (eg, trotting, cantering, galloping, and walking), jockey preferences in wearing thin-soled riding boots coupled with the use of unforgiving iron stirrups, and falls that the jockey may sustain while riding. This type of injury, however, can also occur in other professions in which individuals must stand on their toes.1 Metabolic diseases, such as hypophosphatasia, should also be considered as possible causative factors in patients with multiple stress fractures of the foot. These diseases, which can cause multiple pseudofractures and pathologic fractures of the lower extremities, can be diagnosed by measuring serum concentrations of alkaline phosphatase isoenzymes.9,19 In the present patient, alkaline phosphatase values were normal. Multiple stress injuries in foot bones may occur simultaneously in physically active young adults. Magnetic resonance imaging can be used to detect bone stress injuries in cases missed by plain radiographs. The use of magnetic resonance imaging can result in early detection and grading of bone and in early and appropriate management.7 Technetium-99 bone scintigraphy can also be used to detect stress fractures and stress reactions in symptomatic and asymptomatic patients. Nussbaum et al20 detected 19 stress injuries in 23 ballet dancers by using bone scans. In the present patient,
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anteroposterior/lateral radiographs of the foot revealed stress fractures in the second, third, and fourth distal metatarsals, so no further radiologic assessment was needed in the first place. Metatarsal stress fractures can be managed successfully by nonoperative treatment when diagnosed before the development of cortical breakage. When cortical breaks occur, nonoperative treatment is usually unsuccessful, with more than 50% of patients having union complications that necessitate surgery.1 In the literature, the sites at which delayed union occurs most frequently include the anterior middle tibia, the sesamoid bones in the big toe, the base of the fifth metatarsal, and the tarsal navicular.4 The present patient showed nonunion at the second and third metatarsals that required internal fixation and grafting. Nonunion may have been caused by late diagnosis and treatment. Most multiple metatarsal stress fractures are sequential and additional.15,21 In contrast, the present patient experienced fatigue fractures of all three central metatarsals simultaneously. Further investigations are needed to determine the mechanisms and predisposing factors for simultaneous multiple metatarsal stress fractures.
Conclusions All health-care providers should be aware of the possibility of metatarsal stress fractures in patients whose pain does not resolve after decreased activity and medication therapy. When radiographs are negative, magnetic resonance imaging, computed tomography, and bone scans can be performed for early diagnosis and appropriate treatment. Various methods, such as osteosynthesis with Kirschner wire, screws, or plates, can effectively be used in distal metatarsal fractures. Financial Disclosure: None reported. Conflict of Interest: None reported.
References 1. CHUCKPAIWONG B, COOK C, NUNLEY JA: Stress fractures of the second metatarsal base occur in nondancers. Clin Ortop Relat Res 461: 197, 2007. 2. CHUCKPAIWONG B, COOK C, PIETROBON R, ET AL: Second metatarsal stress fracture in sport: comparative risk factors between proximal and non-proximal locations. Br J Sports Med 41: 510, 2007. 3. GEHRMANN RM, RENARD RL: Current concepts review: stress fractures of the foot. Foot Ankle Int 27: 750, 2006.
180
4. HULKKO A, ORAVA S: Stress fractures in athletes. Int J Sports Med 8: 221, 1987. 5. QUEEN RM, CROWDER TT, JOHNSON H, ET AL: Treatment of metatarsal stress fractures: case reports. Foot Ankle Int 28: 506, 2007. 6. RAMMELT S, HEINECK J, ZWIPP H: Metatarsal fractures. Injury 35 (suppl 2): SB77, 2004. 7. NIVA MH, SORMAALA MJ, KIURU MJ, ET AL: Bone stress injuries of the ankle and foot: an 86-month magnetic resonance imaging-based study of physically active young adults. Am J Sports Med 35: 643, 2007. 8. SORMAALA M: Bone Stress Injuries of the Foot and Ankle [doctoral dissertation], University of Helsinki, Helsinki, Finland, December 2006. 9. STERLING JC, CALVO RD, HOLDEN SC: An unusual stress fracture in a multiple sport athlete. Med Sci Sports Exerc 23: 298, 1991. 10. KORPELAINEN R, ORAVA S, KARPAKKA J, ET AL: Risk factors for recurrent stress fractures in athletes. Am J Sports Med 29: 304, 2001. 11. THEODOROU DJ, THEODOROU SJ, BOUTIN RD, ET AL: Stress fractures of the lateral metatarsal bones in metatarsus adductus foot deformity: a previously unrecognized association. Skeletal Radiol 28: 679, 1999. 12. DUSEK T, PECINA M, LONCAR-DUSEK M, ET AL: Multiple stress fractures in a young female runner. Acta Chir Orthop Traumatol Cech 71: 308, 2004. 13. WARREN MP, BROOKS-GUNN J, FOX RP, ET AL: Lack of bone accretion and amenorrhea: evidence for a relative osteopenia in weight-bearing bones. J Clin Endocrinol Metab 72: 847, 1991. 14. GRIFFIN NL, RICHMOND BG: Cross-sectional geometry of the human forefoot. Bone 37: 253, 2005. 15. CARMONT MR, PATRICK JH, CASSAR-PULLICINO VN, ET AL: Sequential metatarsal fatigue fractures secondary to abnormal foot biomechanics. Mil Med 171: 292, 2006. 16. HATCH RL, ALSOBROOK JA, CLUGSTON JR: Diagnosis and management of metatarsal fractures. Am Fam Physician 76: 817, 2007. 17. VU D, MCDIARMID T, BROWN M, ET AL: Clinical inquiries: what is the most effective management of acute fractures of the base of the fifth metatarsal? J Fam Pract 55: 713, 2006. 18. GLASOE WM, ALLEN MK, KEPROS T, ET AL: Dorsal first ray mobility in women athletes with a history of stress fracture of the second or third metatarsal. J Orthop Sports Phys Ther 32: 560, 2002. 19. HARPER MC: Metabolic bone disease presenting as multiple recurrent metatarsal fractures: a case report. Foot Ankle 9: 207, 1989. 20. NUSSBAUM AR, TREVES ST, MICHELI L: Bone stress lesions in ballet dancers: scintigraphic assessment. AJR Am J Roentgenol 150: 851, 1988. 21. GILADI M, MILGROM C, KASHTAN M, ET AL: Recurrent stress fractures in military recruits: one-year follow-up of 66 recruits. J Bone Joint Surg Br 68: 439, 1986.
March/April 2015 Vol 105 No 2 Journal of the American Podiatric Medical Association
Multiple Simultaneous Metatarsal Stress Fractures in the Same Foot Murat Mert, Ethem Ayhan Unkar, Ali Volkan Ozluk, Tolga Tuzuner, Sinan Erdog˘an,
MD* MD* MD* MD* MD*
Metatarsal stress fractures are common overuse injuries in athletes, military recruits, and ballet dancers, usually occurring in the second, third, and fourth metatarsals, respectively. Such fractures may also occur in a variety of other individuals, regardless of demographic characteristics, sex, or profession, and they are highly associated with excessive activity. Moreover, these types of fractures are usually diagnosed late and have poor outcomes. To our knowledge, there has been only one case report of an individual with stress fractures of all three central metatarsals in the same foot. We describe herein a racehorse training jockey who presented with multiple simultaneous metatarsal stress fractures in the same foot. We also discuss the possible mechanisms by which this entity occurred, as well as its management and outcome. (J Am Podiatr Med Assoc 105(2): 177-180, 2015)
Metatarsal stress fractures are common in athletes, soldiers, and ballet dancers1-6 and constitute 22.5% of all stress fractures.4 This type of fracture has been estimated to affect up to 14% of all patients with fractures. Up to 75% of metatarsal stress fractures occur in the second or third metatarsal, with fewer occurring in the fourth metatarsal. Fatigue fractures of the first and fifth metatarsals are rarely observed.5 Bone stress injuries are a direct result of repetitive stresses, which may create a condition of maltraining. Precipitating factors are repetitive traumas, low-grade external forces, rapid application of muscular force to the bone, and pathologic bone weakness.2,7-9 Biomechanical factors associated with multiple stress fractures include high longitudinal arch of the foot, leg-length inequality, and forefoot varus.10,11 Runners with high weekly training mileage are at risk for initial and recurrent stress fractures of the lower extremities. Half of all female patients with stress fractures have menstrual irregularities, and the combination of nutrition, training factors, exercise-induced amenorrhea, and *Department of Orthopaedics and Traumatology, Istanbul Training and Research Hospital, Istanbul, Turkey. Corresponding author: Murat Mert, MD, Department of Orthopaedics and Traumatology, Istanbul Training and Research Hospital, Samatya - Fatih, Istanbul, 34098, Turkey. (E-mail: [email protected])
hormonal situation may cause changes in bone metabolism that lead to stress fractures.12,13 The forefoot has unique biomechanical features in that loads are distributed unequally across multiple bones. In a study evaluating the reason for the high incidence of stress fractures in the lateral metatarsals, the relationships between the cross-sectional geometric properties of the lateral metatarsals and peak plantar pressure were determined.14 ‘‘Metatarsals 2–4 were found to have the weakest cross-sectional geometric properties; and metatarsal 2, and to a lesser extent metatarsal 3, experience relatively high peak pressures. The strengths and plantar pressure values of metatarsals 2 and 3 are consistent with the high incidence of stress fractures in these bones.’’14(p253) There has been only one case report of an individual with stress fractures of all three central metatarsals in the same foot.15 We describe herein a racehorse training jockey who presented with multiple simultaneous metatarsal stress fractures in the same foot. We also discuss the possible mechanisms by which this entity occurred, as well as its management and outcome.
Case Report A 27-year-old man presented with mild and unresolved pain in his left foot of 21 days’ duration. At
Journal of the American Podiatric Medical Association Vol 105 No 2 March/April 2015
177
that time, he was seen by another emergency service. The patient was a racehorse training jockey. As part of his duties, he rode horses 7 days per week (total, 21 hours). His weight was 65 kg, and his height was 170 cm. He had no history of fractures or accidents and no history of any collagenous or inflammatory disease or diabetes mellitus. He smoked 30 cigarettes per day, and his alcohol intake was at social levels. The patient reported having difficulty with weightbearing but no swelling, erythema, or weakness. Initially he had visited another clinic, where the radiographs of his foot taken 3 weeks after the onset of his complaints revealed stress fractures in the second, third, and fourth distal metatarsals (Fig. 1). The patient’s foot was placed in a nonweightbearing below-the-knee cast for 6 weeks, followed by 4 weeks of orthopedic orthosis. No solid union was radiologically observed 13 weeks later (Fig. 2). He had been treated conservatively with partial weightbearing and no excessive physical activities but had been unable to return to his job even 7 months after the beginning of his complaints. At the end of the 7-month period, when the patient was for the first time evaluated at the Istanbul Training and Research Hospital, Department of Orthopaedics and Traumatology (Istanbul, Turkey), radiographs and computed tomography showed union in the fourth metatarsal but nonunion in the second and third metatarsals (Fig. 3). He noted moderate metatarsal-
Figure 1. Plain radiograph taken 3 weeks after the onset of symptoms showing stress fractures in all three central metatarsals.
178
Figure 2. Plain anteroposterior radiograph at week
13 showing no solid union in the second and third metatarsals. gia on the second and third metatarsal heads and difficulty walking. He was, therefore, evaluated for additional diseases, such as gout, osteoporosis, diabetes mellitus, and hypophosphatasia. His blood glucose, uric acid, calcium, vitamin D, and alkaline phosphatase levels were within normal limits, and there was no evidence of gout or hyphophosphatasia. We decided that surgery was the best treatment at this point. A longitudinal incision was made between the second and third metatarsals, and cancellous autografting was performed using material taken from his own proximal tibia, along with Kirschner wire fixation of the second metatarsal and drilling and grafting of the third metatarsal. We prefered Kirschner wire osteosynthesis owing to our clinic’s history of successful results in osteosynthesis of distal metatarsal fractures with Kirsch-
Figure 3. At 7 months, computed tomography
showed union in the fourth metatarsal but nonunion in the second and third metatarsals.
March/April 2015 Vol 105 No 2 Journal of the American Podiatric Medical Association
ner wire, our clinical experience, and the costeffectiveness of the method. A nonweightbearing cast was placed on his foot for 6 weeks, followed by a walking cast for 4 weeks, resulting in union. Five months after surgery, he returned to his job. The patient healed well; at his most recent follow-up, 1 year after surgery, he showed radiographic evidence of healing (Fig. 4) and was asymptomatic. We removed the Kirschner wire under local anesthesia. Written informed consent was obtained from the patient for publication of this case report and the accompanying images.
Discussion Most metatarsal stress fractures are treated nonsurgically, with protected weightbearing in cast shoes for 4 to 6 weeks usually being sufficient.1,5,6,16,17 To our knowledge, there has been only one case report of a patient with stress fractures of the second, third, and fourth metatarsals in the same foot.15 In this patient, a military aviator, the fractures were sequential, suggesting that the likely etiologic factor was altered foot biomechanics. Instability of the first ray has been thought to cause the lesser metatarsals to bear greater weight due to improper pressure distribution and induce stress fractures of the lesser metatarsals.18 The present patient, however, showed no evidence of
Figure 4. Radiograph performed 12 months postop-
eratively.
foot abnormalities, such as metatarsus adductus, first-ray hypermobility, or pes cavus. Stress fractures have been found to develop in two distinct areas of the lateral metatarsals: proximal (at the base) and nonproximal (distal). The signs, symptoms, diagnosis, prognosis, treatment, and outcomes of these two types of stress fractures are different and have differing risk factors and clinical outcomes.2 Delayed union and nonunion are often observed in proximal stress fractures. Although the fractures in the present patient were nonproximal, there was nonunion of the second and third metatarsals. Internal fixation and grafting were, therefore, applied. High training volume is associated with nonproximal stress fractures, whereas low training volume is associated with proximal stress fractures.2 The present patient had high training activity daily in that he rode horses for 3 hours per day, 7 days per week. Kinematic contributors to stress may have included high muscle fatigue and overbending strains associated with riding horses, which may have caused critical loading at all three lateral metatarsals. Several factors are involved in training horses that may increase the jockey’s risk of foot injuries, including frequent mounting and dismounting of the horse, different riding speeds (eg, trotting, cantering, galloping, and walking), jockey preferences in wearing thin-soled riding boots coupled with the use of unforgiving iron stirrups, and falls that the jockey may sustain while riding. This type of injury, however, can also occur in other professions in which individuals must stand on their toes.1 Metabolic diseases, such as hypophosphatasia, should also be considered as possible causative factors in patients with multiple stress fractures of the foot. These diseases, which can cause multiple pseudofractures and pathologic fractures of the lower extremities, can be diagnosed by measuring serum concentrations of alkaline phosphatase isoenzymes.9,19 In the present patient, alkaline phosphatase values were normal. Multiple stress injuries in foot bones may occur simultaneously in physically active young adults. Magnetic resonance imaging can be used to detect bone stress injuries in cases missed by plain radiographs. The use of magnetic resonance imaging can result in early detection and grading of bone and in early and appropriate management.7 Technetium-99 bone scintigraphy can also be used to detect stress fractures and stress reactions in symptomatic and asymptomatic patients. Nussbaum et al20 detected 19 stress injuries in 23 ballet dancers by using bone scans. In the present patient,
Journal of the American Podiatric Medical Association Vol 105 No 2 March/April 2015
179
anteroposterior/lateral radiographs of the foot revealed stress fractures in the second, third, and fourth distal metatarsals, so no further radiologic assessment was needed in the first place. Metatarsal stress fractures can be managed successfully by nonoperative treatment when diagnosed before the development of cortical breakage. When cortical breaks occur, nonoperative treatment is usually unsuccessful, with more than 50% of patients having union complications that necessitate surgery.1 In the literature, the sites at which delayed union occurs most frequently include the anterior middle tibia, the sesamoid bones in the big toe, the base of the fifth metatarsal, and the tarsal navicular.4 The present patient showed nonunion at the second and third metatarsals that required internal fixation and grafting. Nonunion may have been caused by late diagnosis and treatment. Most multiple metatarsal stress fractures are sequential and additional.15,21 In contrast, the present patient experienced fatigue fractures of all three central metatarsals simultaneously. Further investigations are needed to determine the mechanisms and predisposing factors for simultaneous multiple metatarsal stress fractures.
Conclusions All health-care providers should be aware of the possibility of metatarsal stress fractures in patients whose pain does not resolve after decreased activity and medication therapy. When radiographs are negative, magnetic resonance imaging, computed tomography, and bone scans can be performed for early diagnosis and appropriate treatment. Various methods, such as osteosynthesis with Kirschner wire, screws, or plates, can effectively be used in distal metatarsal fractures. Financial Disclosure: None reported. Conflict of Interest: None reported.
References 1. CHUCKPAIWONG B, COOK C, NUNLEY JA: Stress fractures of the second metatarsal base occur in nondancers. Clin Ortop Relat Res 461: 197, 2007. 2. CHUCKPAIWONG B, COOK C, PIETROBON R, ET AL: Second metatarsal stress fracture in sport: comparative risk factors between proximal and non-proximal locations. Br J Sports Med 41: 510, 2007. 3. GEHRMANN RM, RENARD RL: Current concepts review: stress fractures of the foot. Foot Ankle Int 27: 750, 2006.
180
4. HULKKO A, ORAVA S: Stress fractures in athletes. Int J Sports Med 8: 221, 1987. 5. QUEEN RM, CROWDER TT, JOHNSON H, ET AL: Treatment of metatarsal stress fractures: case reports. Foot Ankle Int 28: 506, 2007. 6. RAMMELT S, HEINECK J, ZWIPP H: Metatarsal fractures. Injury 35 (suppl 2): SB77, 2004. 7. NIVA MH, SORMAALA MJ, KIURU MJ, ET AL: Bone stress injuries of the ankle and foot: an 86-month magnetic resonance imaging-based study of physically active young adults. Am J Sports Med 35: 643, 2007. 8. SORMAALA M: Bone Stress Injuries of the Foot and Ankle [doctoral dissertation], University of Helsinki, Helsinki, Finland, December 2006. 9. STERLING JC, CALVO RD, HOLDEN SC: An unusual stress fracture in a multiple sport athlete. Med Sci Sports Exerc 23: 298, 1991. 10. KORPELAINEN R, ORAVA S, KARPAKKA J, ET AL: Risk factors for recurrent stress fractures in athletes. Am J Sports Med 29: 304, 2001. 11. THEODOROU DJ, THEODOROU SJ, BOUTIN RD, ET AL: Stress fractures of the lateral metatarsal bones in metatarsus adductus foot deformity: a previously unrecognized association. Skeletal Radiol 28: 679, 1999. 12. DUSEK T, PECINA M, LONCAR-DUSEK M, ET AL: Multiple stress fractures in a young female runner. Acta Chir Orthop Traumatol Cech 71: 308, 2004. 13. WARREN MP, BROOKS-GUNN J, FOX RP, ET AL: Lack of bone accretion and amenorrhea: evidence for a relative osteopenia in weight-bearing bones. J Clin Endocrinol Metab 72: 847, 1991. 14. GRIFFIN NL, RICHMOND BG: Cross-sectional geometry of the human forefoot. Bone 37: 253, 2005. 15. CARMONT MR, PATRICK JH, CASSAR-PULLICINO VN, ET AL: Sequential metatarsal fatigue fractures secondary to abnormal foot biomechanics. Mil Med 171: 292, 2006. 16. HATCH RL, ALSOBROOK JA, CLUGSTON JR: Diagnosis and management of metatarsal fractures. Am Fam Physician 76: 817, 2007. 17. VU D, MCDIARMID T, BROWN M, ET AL: Clinical inquiries: what is the most effective management of acute fractures of the base of the fifth metatarsal? J Fam Pract 55: 713, 2006. 18. GLASOE WM, ALLEN MK, KEPROS T, ET AL: Dorsal first ray mobility in women athletes with a history of stress fracture of the second or third metatarsal. J Orthop Sports Phys Ther 32: 560, 2002. 19. HARPER MC: Metabolic bone disease presenting as multiple recurrent metatarsal fractures: a case report. Foot Ankle 9: 207, 1989. 20. NUSSBAUM AR, TREVES ST, MICHELI L: Bone stress lesions in ballet dancers: scintigraphic assessment. AJR Am J Roentgenol 150: 851, 1988. 21. GILADI M, MILGROM C, KASHTAN M, ET AL: Recurrent stress fractures in military recruits: one-year follow-up of 66 recruits. J Bone Joint Surg Br 68: 439, 1986.
March/April 2015 Vol 105 No 2 Journal of the American Podiatric Medical Association
