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Stress fractures are fatigue fractures of bone, and result from an overuse mechanism. These injuries present most commonly in the legs and feet of long distance runners and military personnel, but can also occur in the upper extremity and the spine depending on the causative activity. Nutritional, hormonal, and biomechanical factors all contribute to the development of bony stress injuries, and no two stress fractures behave exactly alike. A detailed history, thorough physical examination, and proper imaging are required to diagnose and classify these injuries. The management of stress fractures requires nutritional and emotional support, rest from the causative activity, and at times surgical fixation. Recently developed biological treatment options may help to stabilize these injuries and stimulate more rapid healing.

Stress fractures are overuse injuries of bone that result from an imbalance of training, healing, nutrition, hormones, and biomechanics. They present most commonly in the lower extremities of runners and military personnel but can also occur in the upper extremity and spine depending on the causative activity. Stress fractures occur along a continuum of severity with no two stress fractures exhibiting the same behavior. A detailed history that includes training frequency and intensity, dietary habits, menstruation, and rest/sleep along with a thorough physical examination and proper imaging are required for diagnosing and risk stratifying these injuries. Treatment of stress fractures requires nutritional and emotional support, rest from the causative activity, and surgical stabilization in the case of high-risk sites. In recent years, orthobiologic treatment options to enhance the healing potential of bone have been developed and have shown promise for the treatment of stress fractures in the future.

Stress fractures represent a fatigue failure of bone, occurring along a spectrum of severity of structural injury with healing potential that varies by location. Many stress fracture classification systems currently exist in the literature. These systems employ various imaging modalities, but few include clinical parameters or have been validated for reliability between evaluators. Though many are generalizable, a gold standard classification system for grading stress fractures has yet to be determined.

This chapter discusses pathologies related to the first metatarsophalangeal joint and the forefoot. Brief description of the etiology and pathomechanics of hallux valgus followed by the clinical presentation and associated deformities are presented. The relevant imaging modalities, conservative and various surgical management techniques, and their indications are deliberated upon.

“Stress” or “March” fractures is an important question for the traumatologists and radiologists. An important factor in this topic is the timely and qualitative diagnosis of this type of fractures. The choice of the optimal method of diagnosis, reliable visualization of bone-destructive changes significantly affect the tactics of further treatment and the amount of possible surgical intervention. In this article, the authors presents two clinical cases of diagnosis of “marching” fractures.

Vitamin D is an essential, fat-soluble nutrient that is a key modulator of bone health. Despite the gaining popularity throughout published medical studies, no consensus has been reached regarding a serum vitamin D level that will guarantee adequate skeletal health in a patient with an increased functional demand. The purpose of the present investigation was to examine the serum concentrations of vitamin D in patients with confirmed stress fractures. A total of 124 patients were included in our retrospective cohort study. Of the 124 patients, 53 had vitamin D levels measured within 3 months of diagnosis. An association was seen in patients with a stress fracture and vitamin D level measured, as 44 (83.02%) of the 53 patients had a serum 25-hydroxyvitamin D level

Skeletal-muscle problems are considered as a major cause of disability in developed countries. The articular surface Damages and in the higher levels of disease, subchondral bone injuries, indicate degenerative joint disease progression. Military forces, as a non-communicable disease imposing an extra burden on the health system of armed forces, is paid attention more than before. This study is aimed to investigate the findings of the correlation of demographic and anthropometric images in military patients suffering from pain and to compare the results with civilain patients.76 patients referred to Imam Reza Hospital were selected after filling out the personal information and consent forms. Painful Joint pain levels were measured by the numerical scale of Osteoarthritis Index WOMAC (with scoring from 0 = no pain to 10 = maximum pain) by the patient is recorded. MRI images of knee were performed using a circular knee coil by a 1.5 Tesla imaging device, Siemens product. The results were analyzed by SPSS software.The incidence of Talus type I, II, IIA, IIIAVN is rather in military personnel than civilian. The parameters of March fracture (p =0.012) and Calcaneus stress fx (p=0/028) had a more statistical significant difference in Military personnel than civilians (p

We present the palaeopathological analysis of a right fourth metatarsal (ATD6-124) recovered from the Atapuerca–Gran Dolina site (Spain). This fossil, ca. 1 Ma, belongs to Homo antecessor, the earliest known European hominin species. The metatarsal exhibits a proliferative lesion on its medial periosteal surface. Periosteal reaction can be the bone response to a wide number of injurious processes. We describe a lesion on the basis of macroscopic and microscopic analyses, including microtomography and scanning electron microscopy. Externally, the osteoblastic lesion presents a highly porotic and disorganised morphology. Internally, we observe a series of micro-fractures on the compact bone that do not affect the medullary canal. We provide a differential diagnosis and suggest that the ATD6-124 lesion could correspond to a pedal stress fracture, also known as fatigue or march fracture. Stress fractures have been related to a load increase and muscular fatigue. This type of fracture has been widely reported in the foot of soldiers and athletes, which are usually engaged in strenuous, excessive or prolonged locomotive activities. Despite its high frequency in these groups, stress fractures have not been reported as such in fossil collections, with the exception of a metatarsal belonging to the Sima de los Huesos site (Atapuerca). Copyright © 2013 John Wiley & Sons, Ltd.

Stress fractures and soft tissue overuse injuries are common among endurance athletes. They are not a single consistent injury. They occur along a spectrum of severity which can impact treatment and prognosis. When treating overuse injuries, it should be borne in mind that no two stress fractures behave exactly alike. Treatment protocols should be individualized to the patient or athlete, the causative activity, the anatomical site, and the severity of the injury. As athletes become more competitive and focus solely on one sport, the incidence of stress fractures and other overuse injuries has continued to increase. A wholistic approach to the treatment of these injuries should be taken by orthopedists and sports medicine specialists in order to obtain optimal outcomes and minimize loss of fitness and time away from sports participation.

Proximal stress fractures of the second metatarsal are rare. They have been reported mainly in classical ballet dancers. Non-operative treatment has usually led to good results and rapid return to full activities. We present a series of nine cases with stress fractures of the proximal second metatarsal. The patients were all actively involved in sports. None of them were dancers. In all of these patients non-operative treatment lasting for an average of 13 months had failed. All of the patients were operated on using the same method. In the operation drilling was performed around and through the fracture line. The patients were followed for an average of 38 months. All except one of the patients were able to return to their prior level of activity within 4-6 months. In conclusion if non-operative treatment fails surgery seems to give good results in most patients with a stress fracture of the proximal second metatarsal.

Aim The aim of this study was to determine the incidence/frequency of march fractures in the German Armed Forces in the years from 1998 to 2000. In particular, the age, length of service, distribution of the metatarsals and the occurrence of anthropometric risk factors were considered. Methods At the Medicostatistical Institute of the German Armed Forces the records of soldiers, 191 cases with 204 fractures, with diagnosed "march fractures" were selected and analyzed. Results 82% of the affected soldiers were between 19 and 22 years old. More than 50% of the fractures occurred within the first eight weeks of service. In about 64% the 3rd metatarsal was affected, in 25% the 2nd metatarsal and in only 11% of all cases the 4th, 5th, and 1st metatarsals. Soldiers were exempted from duty for an average of 26.5 days. No specific anthropometric risk factors were found to be connected with the occurrence of march fractures. Conclusion March fractures in the German Armed Forces are non-predictable injuries of young and physically fit individuals; youth is not a protective factor. There is an increased risk for march fractures during the first weeks of military service. There appears to be no possibility for a screening.

The availability of x-ray examination to the large number of individuals in the Armed Services has brought to light many minimal injuries which tend to be ignored or overlooked in a comparable civilian population, while the rigors of training have increased the incidence of such injuries. There have been many reports on march fractures of the metatarsals observed during training periods and following marches. To the metatarsal fracture have been added march fracture of the femoral neck (1), march fracture of the femur (2), of the tibia (3), of the fibula (4), and even march fracture of the pelvis (5). These fractures have been called, also, insufficiency fractures and fatigue fractures. They are not new. The march fracture of the metatarsal has long been known. It was noted among recruits in the French army, where it was called pes marches. It was frequent, also, among the German troops, especially after practising the “goose-step” of the old Imperial Army, being known as Fussgeschwulst. Insufficiency fra...

The aim of the present study was the assessment of metatarsal head loading in combat boots of the German armed forces. With respect to the prevention of metatarsal stress fractures, we evaluated how cushioning insoles (made of EVA foam or neoprene) achieved a load reduction in comparison with conventional insoles.Local pressure, force and impulse values were determined with the pedar-m expert in-shoe pressure measurement system applied in 26 volunteers during walking with four different insoles made of synthetic mesh, EVA foam and neoprene. Data analysis was performed with SAS and tested for statistical differences with non-parametric tests (with p0.05 as a significance level).For the peak pressures under the metatarsal heads (MT) the following order was found: MT-IIMT-IIIMT-IMT-IVMT-V. A comparison of the insoles indicated that the neoprene insole resulted in the lowest peak pressures with significant load reductions under MT-III to MT-V (p0.00001). Furthermore, the impulse values under MT-II to MT-V were significantly lower with neoprene insoles (p0.0002). However, the subjects rated the conventional insoles as more comfortable and better fitting than the newly developed insoles.The cushioning insoles were superior to the conventional insoles with respect to the plantar pressure distribution. With respect to the load reduction we can conclude that the modified insoles might be able to reduce the incidence of march fractures. The biomechanical advantage does not appear to be related to personal preferences.

Although “march fractures” of the metatarsals have been encountered with increasing frequency (2, 6, 12, 13), similar “stress”, fractures in the other weight-bearing bones are apparently much less common. More than 200 metatarsal march fractures have been observed at the authors' station, but until recently none had been seen in other bones. Three instances of march fracture in the tibia were then encountered within two months, and a search of the files revealed a fourth case. Pfahler (10) reported a single instance of this type of fracture of the tibia at the meeting of the American Roentgen Ray Society in 1939. This “insufficiency fracture” had occurred in a high-school athlete. The fracture line was narrow, incomplete, and extended only through the thickness of the cortex. The callus resembled an osteogenic sarcoma, and Pfahler stated that up to that time he had never seen a fracture of this kind. Barth, in discussing the report, remarked that no such case had been seen in his clinic. Pfahler commented...

Several reports have been published on “march” fracture of the tibia (3, 7, 8, 12, 14, 15, 16), but dealing usually isolated cases or small series. The same type of fracture of the metatarsals has been discussed in numerous publications (1, 4, 5, 6, 9, 10, 11, 13, 17), especially during World War II, with several large series of cases being presented. Having failed initially to recognize the first case of march fracture of the tibia encountered, and having seen 14 additional cases in a relatively short period of time, the author considered it appropriate again to call attention to this lesion, which is seldom seen in civilian life but is found with considerable frequency at any Army camp where a large number of recruits are undergoing strenuous military training. The tibia is second only to the metatarsals as the most common site of occurrence of this type of fracture. Krause (12), in reporting 4 cases observed among soldiers in active training, states that the most common location of the fracture is on t...

1. 1. Metatarsal march fracture is primarily an occupational disease of soldiers. 2. 2. The author believes that metatarsal march fractures are caused by fatigue of the peroneus longus and tibialis posticus muscles. 3. 3. March fractures are more properly termed fatigue fractures. There is no basis for the belief, as some authors have indicated, that metatarsal march fractures are due to spasm and overactivity of the interossei muscles. 4. 4. The presence of an atavistic foot as an etiological factor of metatarsal march fracture is greatly over-rated. 5. 5. All of the metatarsal march fractures in this series which were investigated occurred in soldiers with normal feet, or in cases of slight degree of pes planus and in cases of pes cavus. Not a single case of severe pes planus was encountered. 6. 6. Pre-induction occupation of the soldier does not appear to be a decisive element except insofar as the tolerance of fatigue may be concerned. 7. 7. The thinness of the metatarsal bone plays no important role in the etiology of metatarsal fractures as more fractures occurred in metatarsal bones other than the thinnest. 8. 8. All age groups from eighteen to thirty-eight were involved in metatarsal march fractures but the eighteen and nineteen year old group were chiefly affected. 9. 9. March fractures of the metatarsals involved all bones of the metatarsal segment but chiefly the second and third of the right foot. 10. 10. Twenty-three cases of multiple metatarsal march fractures were encountered. 11. 11. Fractures of the metatarsal bone involved 2.35 per cent of 10,953 cases seen by the Orthopedic Surgical Section at our Station Hospital.

1. Some minor injuries of bones and joints are described. 2. The importance of differentiating between the lesions which represent end results, e.g., calcification of ligaments and those which are part of an active process, e.g., osteochondritis desiccans, are emphasised. 3. A case of Panner's Disease and a march fracture of the neck of the femur are described. 4. The frequency of these lesions in young adults is emphasised.

1. 1. Six hundred and ninety two cases are reported with 724 march fractures. 2. 2. These patients were all treated by use of the steel bar countersunk in the slip sole of the shoe. 3. 3. Fifty-eight cases did not respond to the usual treatment; of this number thirteen were hospitalized and forty-five excused from certain portions of their training cycle. These fifty-eight trainees eventually finished training and were qualified for overseas. One man received a medical discharge. This was for an injured right knee and not for his march fracture. 4. 4. Two hundred thirteen thousand and twenty-four training hours were saved during fourteen months using the march bar treatment. 5. 5. Our series shows that most of the fractures occurred when the training cycle was stepped up in the fifth and sixth weeks of training. 6. 6. March fracture occurred more often in the right foot than the left. Any one of the metatarsal bones may be involved and one soldier can have two or three march fractures at the same time. 7. 7. The relative lengths of the first, third, and fourth metatarsal bones were measured in 692 cases of march fracture; the second metatarsal being used as a base and given the value of zero. The metatarsals of 100 normal feet were measured, and these measurements compared with the march fractured feet. There was no conclusive evidence of a relatively shortened first metatarsal playing a part in the etiological factor of march fractures.

1. 1. March or “fatigue” fracture is primarily an occupational disease associated with military training. 2. 2. Because of the insidious nature of the disease, many cases of march fracture are overlooked by the uninitiated. 3. 3. Etiology is obscure, but the author believes, as in cases of march fracture of the metatarsals, that it is due to muscle fatigue or muscle imbalance. 4. 4. March fractures occur in specific areas of predilection. 5. 5. X-ray appearance is that of an “ice crack” fracture. 6. 6. Displacement of fragments is unusual except in the case of fracture of the neck of the femur, where, if the fracture is not protected from weight bearing, coxa vara commonly occurs. 7. 7. March fractures, even if incomplete and not of striking x-ray appearance, must be treated with great respect, and too early weight bearing should be prohibited. 8. 8. Ideal treatment of march fractures of lower extremity and pelvis is bed rest and prohibition of early weight bearing. In fractures of the neck of the femur, immobilization is indicated. 9. 9. No case of delayed or non-union was encountered. 10. 10. In 10,953 orthopedic cases seen in a period of nine months at an Army Station Hospital, twelve cases of march fracture of lower extremity and pelvis, excluding metatarsal march fractures, were encountered. 11. 11. Case histories of six march fractures of the tibia, one of the fibula, two of the femur, and three of the pelvis were reported.

With the advent of the Second World War there has been a decided increase in the incidence of march fracture. One may expect to encounter this lesion wherever armed forces are on the march or are undergoing extensive physical training. This is particularly true if the troops are recent recruits and if there is a weight-bearing overload due to heavy packs. As pointed out by Camp and McCullough (7), march fracture is an example of pseudofracture and may occur in a diseased bone or in a bone subjected to excessive strain. In addition to the metatarsal, the bones involved are likely to be the tibia, femur, pelvis, ribs, radius, and ulna; less frequently these fractures may occur in other parts of the skeletal system. In so far as the foot is concerned, march fracture may be defined as a painful edematous swelling of the forefoot, insidious in onset and associated with an often unsuspected fracture of a metatarsal. Breithaupt (4), a Prussian military surgeon, first called attention to this entity in 1855. He n...

1. 1. One hundred forty-five cases of march fracture involving 142 patients were treated by hospitalization and immobilization of the injured extremity in a short-leg walking cast at the U. S. Army Hospital, Indiantown Gap Military Reservation. The injuries were incurred over a fifteen-month period, from May, 1951 until August, 1952, and include all patients treated at the hospital. 2. 2. There were 137 Caucasian and 5 Negro patients, with ages ranging from seventeen to thirty-one (average age, twenty-one). 3. 3. There were three readmissions for additional march fracture incurred from four to eight months later. 4. 4. The right foot was involved eighty-one times, the left sixty-seven. The third metatarsal was the most frequently injured, there being eighty fractures of this bone; there were fifty-five of the second metatarsal, with only ten of the fourth, and three of the fifth. There were no march fractures of the first metatarsal. Three patients had two fractures simultaneously. 5. 5. The incidence of march fractures reaches a peak around the tenth week of basic training, which corresponds to the periods of lengthy speed marches and vigorous mountain climbing.

At all Army posts there have developed considerable interest in, and speculation about, the nature of march fractures. Three cases involving the inferior pubic ramus are being recorded here which have been characterized by absence of any history of trauma, absence of any other break in the pubic ring, and roentgenographic findings believed to be indicative of march fracture. These same cases are included in a comprehensive study of “March Fractures” to be published by the Chief of the Orthopedic Section of this hospital, in another journal. Case Reports Case 1: An infantryman, aged 34 years, had been in service approximately three and a half months. He had been engaged in simulated combat maneuvers and during this rather strenuous activity began to experience some pain along the adductor aspect of the left thigh. There was no history of trauma; rather one of slow insidious development. About six weeks after onset the pain radiated as far as the perineal region, and the patient came to the Clinic for exami...

FATIGUE fracture, synonymously called march fracture, is a condition most commonly seen in recruits who are suddenly subjected to unaccustomed physical training. This entity was initially recorded by Briethaupt in 1855, and was overlooked in this country until 1939, when Roberts and Vogt1 described 12 so-called pseudofractures of the tibia. Since then, description of this condition has been generally limited to the European literature, and great interest was quickened in the early 1940's.2 3 4 From December, 1955, to May, 1958, inclusive, a total of 97 fatigue fractures of the pelvis and the lower extremity in 83 patients were observed at the . . .

The diagnosis of march fracture of the inferior pubic arch should be considered whenever there is a history of unusual physical stress associated with complaints of pain in the perineum; roentgenographic evidence of a break in the continuity of the inferior pubic ramus and calcification about the site confirm the diagnosis.

"March foot" or "march fracture" is a term applied to a painful condition of the foot first noted in army men following prolonged marches. It was thought to be caused originally by an inflammation of the tendon sheaths, but since the turn of the century opinion has favored the existence of a fracture. Some reports hold that a fracture visible or invisible by x-rays is present from the start. Others speak of a periostitis first, followed by a fracture line developing later. For the most part this condition has been noted in the second, third and fourth metatarsal bones, but the more recent literature has been reporting a few cases of a similar condition occurring in other bones, especially the fibula. Our purpose in this paper is to add 6 such cases and 1 of the foot appearing in athletes at Princeton University. The University Health Service has maintained medical

Dew and Wooten122present a series of 58 march fractures of the metatarsal bones involving 55 trainees. The majority of patients failed to disclose any preexisting pathologic condition of the feet. March fractures are attributable to the carrying of heavy full field equipment and marching of distances longer than 6 miles (9.6 km.) on a hard surfaced road. Local treatment of mild fractures consists in the use of an ice bag for seventy-two hours, a whirlpool bag, a daily massage and crutches; moderate weight bearing within pain limit is allowed. Splinting of any form is not advised because of the ensuing stiffness of the foot and the increasing morbidity. The prophylactic measures advanced by the authors have materially lowered the high incidences of march fracture. They recommend gradual lengthening of the march, progressive increase of field equipment and, what is most important, marching on the soft shoulders of the