Metatarsal fatigue and insufficiency (stress) fractures

Case contributed by Dr Yuan Ling

Presentation

Fit and healthy runner with midfoot pain.

Patient Data

Age: 55 years
Gender: Male

Extensive marrow edema signal of the 2nd metatarsal base and diaphysis is compatible with bone stress. Cortical breach with periostitis indicates a stress fracture. Florid surrounding soft tissue inflammation. 

This is a classic location. Note that the 2nd metatarsal is the longest, therefore bears the most weight.

MRI

Treated with 4 weeks in a cam walker (moon boot). Went on holiday for 4 weeks. Returned with increasing forefoot pain.

Stress fracture at the 2nd metatarsal proximal diaphysis is healing, with more mature cortical and periosteal new bone. However, marrow hyperintensity has progressed to the neck and head region, and surrounding soft tissue inflammation is also more distal. Subchondral linear hypointensity along the plantar aspect of the metatarsal head is compatible with insufficiency fracture.

Case Discussion

The initial stress fracture is due to fatigue - repetitive mechanical overload in normal bone.

Disuse osteopenia following a period of rest in a cam walker results in demineralization and loss of bone strength.

Subsequent reloading of the foot resulted in a subchondral insufficiency fracture at the metatarsal head - normal load but in abnormal, weakened bone.

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Case information

rID: 69345
Published: 7th Jul 2019
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included
Institution: Imaging @ Olympic Park

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