Tarsal Bones

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Up to 20% of stress fractures in runners may occur in the tarsal bones [8]. Stress fracture of the tarsal bones are too often a diagnostic challenge, because many providers do not consider tarsal stress fractures in the assessment of foot and ankle pain. A high clinical suspicion of stress fractures is required for an accurate and timely diagnosis. The majority of tarsal bone stress fractures occur in the navicular (Fig. 5A, B) [28].

Old Metatarsal Stress Fracture

Fig. 2. Second metatarsal stress fracture. Fifty-one-year-old female with right foot pain for 2 weeks after recent increase in mileage using a treadmill. Coronal STIR image shows diffuse bone marrow edema (curved arroW), periosteal edema, and soft-tissue edema (straight arrow) involving and surrounding the second metatarsal shaft. No underlying fracture line is seen.

Fig. 2. Second metatarsal stress fracture. Fifty-one-year-old female with right foot pain for 2 weeks after recent increase in mileage using a treadmill. Coronal STIR image shows diffuse bone marrow edema (curved arroW), periosteal edema, and soft-tissue edema (straight arrow) involving and surrounding the second metatarsal shaft. No underlying fracture line is seen.

This diagnosis is becoming recognized with increasing frequency as physicians become more familiar with the condition. The running athlete who develops dorsal midfoot pain radiating to the medial arch should suggest the possibility of this injury. Recent studies have shown that track athletes accounted for 59% of all tarsal navicular stress fractures [28].

Rarely, stress fractures may occur in the cuboid bone. Diagnosis may again be delayed secondary to this diagnosis not being considered. It may mimic peroneal tendon pathology [41,42]. Stress fractures of the talus and calcaneus also occur in runners (Fig. 6) [43-47]. Plain film will most often be normal, and MRI is the imaging modality of choice for detection, localization, and

Fig. 3. Third metatarsal stress fracture. Sixty-year-old female runner with subacute onset of midfoot pain and tenderness. Coronal STIR image showing bone marrow edema (curved arroW) and a transverse stress fracture through the distal third metatarsal neck (straight arrow).

Stress Fracture Fifth Metatarsal Bone
Fig. 4. Healing fifth metatarsal stress fracture. Seventeen-year-old male high school football player. Coronal T1 SE image shows transverse low signal intensity through the base of the fifth metatarsal (straight arrow).

characterization of tarsal bone stress fractures. MRI most often demonstrates marrow edema or a cortical fracture line [17].

Nondisplaced and noncomminuted tarsal bone fractures may be treated with conservative management with casting and non-weight bearing for 6 weeks. Displaced or comminuted fractures are indications for surgical intervention, which may include screw fixation or autologous bone grafting, depending on the nature and age of the fracture [17,48]. Evaluation of footwear is important to prevent recurrence.

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