Author(s): Schan Lartigue, MD, Sera Yoo, MD, MPH, Eric K. Holder, MD
Originally published: June 12, 2025 Last updated: June 12, 2025
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Definition

Overuse disorders are defined as tissue damage resulting from repetitive microtrauma.1 Most often, these injuries develop without an identifiable inciting event.1 This section focuses on bony injuries, such as stress reaction and stress fractures, while other common overuse injures of the foot and ankle are tendinopathies, ligamentous injury, plantar fasciitis, and impingement syndromes (see Ankle and Foot Overuse Disorders: Tendinopathy and Other Soft Tissue Disorders).

Etiology

In general, overuse injuries occur in the setting of repetitive activity, insufficient training or recovery, and/or poor biomechanics; however, the etiology is multifactorial and can  differ depending on the specific structure that is injured.1 Training regimen and conditions, nutritional status, and footwear are modifiable risk factors which contribute to these disorders. Furthermore, they may be affected by patients’ anatomy, range of motion, strength, and comorbid health conditions.1

Epidemiology including risk factors and primary prevention

About half of sports-related injuries are caused by overuse rather than by acute injury.1 Up to 20% of all injuries evaluated in sports medicine office visits are found to be stress fractures.2 Contributing factors include decreased bone mineral density, female sex, low vitamin D levels, and history of prior stress fractures.3 Prevention relies on emphasizing sufficient training prior to demanding physical activity, allotting time for recovery, and correcting poor form during activity to avoid biomechanical stress.1

Patho-anatomy/physiology

The pathophysiology of bony injuries, such as a stress fracture in the foot or ankle, is related to either abnormal load on a normal bone or normal load on demineralized bone.3 Activities involving repetitive stress on the bone (e.g., running, jumping) or improper footwear can result in the development of stress fractures.3 Stress fractures are microfractures in the cortical bone tissue which develop when bone fails to adapt to a mechanical load.4  The excess loading results in increased osteoclast activity, which then temporarily weakens the bone. At this point, the integrity of the normal bone structure is lost and a microfracture develops, which is termed a stress reaction. Progression of repetitive stress without an increase in osteoblast activity results in further collapse of bony architecture and the development of a true cortical fracture.4

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

With bone injuries, patients initially present with an insidious onset of localized pain towards the end of physical activity. As the injury progresses, the pain can present during lower intensity exercise such as walking.4 To prevent complete fracture and nonunion, prompt diagnosis and effective treatment are key.

Specific secondary or associated conditions and complications

Complications of stress fractures differ by whether the stress fracture is low risk (e.g., stress fractures of the posteromedial tibia, calcaneus, and second and third metatarsal shafts) or high risk (in anatomic locations with maximal tensile load as well as poor vascular supply).4 High risk fractures are more often complicated by delayed recovery, the progression of stress reaction to complete fracture, delayed union, or nonunion. The medial malleolus, talus, navicular, proximal fifth metatarsal and great toe sesamoids are high risk stress fracture locations.1,4

Essentials of Assessment

History

History taking should include the mechanism and context of the injury (the type, frequency, and intensity of the exercise the patient participates in, equipment used, activity surface, weekly mileage, and use of footwear, orthotics, or braces), the onset, location and character of pain, the duration of symptoms, and any aggravating and alleviating factors.3,4 History of prior ankle or foot injury and rehabilitation completed for these injuries is also key. In athletes, the clinician should incorporate probing questions to assess for Relative Energy Deficiency in Sport (RED-S) also referred to as Female Athlete Triad (see Female Athlete Triad). It is essential to discuss the patient’s functional goals, as this can guide treatment.3 The patient’s medical and surgical history should also be reviewed.

Physical examination

Physical examination includes inspection of both lower extremities in the standing, supine, and prone positions with assessment of any leg-length discrepancy, local deformity, edema, erythema, ecchymosis, atrophy, tendon asymmetry, or previous scars.1,3 Palpation is used to detect tendon thickening, crepitus, tendon nodules or gapping, and areas of point tenderness.1 Passive and active range of motion of the joints of the foot and ankle should be tested, and a localized neurologic exam (strength in dorsiflexion, plantarflexion, inversion, eversion as well as foot/ankle sensation) is important.4

Functional assessment

To identify muscular imbalances or biomechanical abnormalities, it is helpful to evaluate the hip-knee-foot kinetic chain during single leg stance or squat.4 It is also important to identify risk factors such as over-striding, foot-strike position, excessive pronation/supination, or imbalance of forces during push-off during analysis of gait during ambulation, running, and jumping.5 Examination findings of forefoot varus and decreased dorsiflexion suggest the patient may have increased likelihood of developing metatarsal stress fracture.6

Laboratory studies

Laboratory findings are not essential to the evaluation of foot and ankle overuse injuries, though they may help rule out other conditions such as infection, malignancy, or rheumatologic conditions.7 If an alternative diagnosis is suspected, C-reactive protein, erythrocyte sedimentation rate, complete blood count, metabolic panel, vitamin D and calcium levels should be ordered. A bone metabolic panel (vitamin D, calcium, parathyroid hormone, and thyroid hormone levels) may be used to evaluate bone health in patients with repeated stress injury.7

Imaging

Standing foot and ankle x-rays can supplement the clinical history and physical examination. It is important to note, however, that plain radiographs may initially be negative with estimates of sensitivity ranging from 12-56%.8 In light of this, magnetic resonance imaging (MRI) is the gold standard for evaluation of stress fractures, with sensitivity of 68-99%.8 A four-stage grading system is used to classify stress fractures based on MRI findings: grade 1 injuries show periosteal edema on fat-suppressed images, grade 2 injuries demonstrate abnormal increased signal intensity on fat-suppressed T-2 weighted images, grade 3 injuries show decreased signal intensity on T-1 weighted images, and grade 4 injuries demonstrate a fracture line on both T-1 and T-2 weighted images.9 Higher MRI grade has been associated with delayed recovery of bone stress injuries in track and field athletes.9

Supplemental assessment tools

Quantitative gait analysis and evaluation of running and jumping technique can help identify biomechanical deficiencies.2,3

Early predictions of outcomes

Progression of the pain from occurrence only with activity to occurrence at rest or with low-intensity activity can be a predictor of slower recovery and poor outcomes.4

Environmental

Environmental factors such as footwear, running surfaces, and lap direction can impact the amount of stress on the body.5 Running with worn-out shoes or on hard surfaces may produce greater stresses on the body, while excess cushioning increases torque and also increases stress.10

Social role and social support system

The involvement of the patient, parents (in young athletes), athletic trainers, and coaches can impact outcomes. Providing education about the injury and expectations for recovery is key to promoting treatment adherence. Sport psychologists should be involved in cases of disordered eating resulting in poor nutrition and predisposing to bony injuries.11

Professional issues

Return to prior activity, whether it is return to play in athletes or return to professional work, presents challenges. A multidisciplinary approach is essential, especially in cases of professional athletes, for whom wrong decisions can be season-ending or career-ending.12

Rehabilitation Management and Treatments

In many conditions, there are no specific treatment guidelines for ankle and foot overuse injuries.11 Treatment is based on clinical reports, expert opinion, and literature reviews.1 Effective treatment of stress fractures is specific to the location and may be achieved with rest or immobilization for a number of weeks, exercise modification, non-weight bearing status, and/or surgical treatment depending on the risk of complications and the response to treatment.1

At different disease stages

Stress fracture treatment involves relative rest, addressing training errors and muscular imbalances, and mechanical alignment optimization. This may involve bracing, a walking boot or casting. Treatment of low-risk fractures is first relative rest, followed by exercise modification on a pain free level within 3-8 weeks. Treatment of high-risk stress fractures, depending on the location and severity, may require absolute rest (4-12 weeks) or surgery.1,17 Non-weight bearing status may be necessary.3,9 Referral to physical therapy for muscle strengthening and generalized conditioning is important.1,13 Analgesics may be used for pain control, but anti-inflammatory medications may interfere with bone healing and should be used sparingly.13 Orthotics may be helpful in athletes with hyperpronation.1

Coordination of care

A multidisciplinary healthcare team composed of physiatrists, orthopedic surgeons, family physicians, and physical therapists (as well as nutrition and sports psychologists in the case of stress fractures) is essential.11

Patient & family education

Patients and their support systems, such as family, coaches, and trainers, should be involved in care and provided with education about the diagnosis, treatment options, and expectations for recovery. The decision to return to play should be made alongside patients and their families.14

Measurement of treatment outcomes

Re-evaluation during the treatment period can be done every 2-3 weeks.15 With treatment, pain is expected to progressively subside within several weeks. If symptoms persist, compliance to treatment should be evaluated, and modifications to activity and a more gradual rehabilitation program should be considered.15 After imaging confirms the diagnosis, there is rarely a need for repeat imaging, as radiographic healing lags behind clinical healing: MRI may remain positive for up to a year following the injury.16 Clinical response to treatment should be used to measure outcomes instead, unless treatment fails to progress and there is concern that the fracture has extended or nonunion has developed.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

The etiology of ankle and foot overuse injuries is multifaceted. Many intrinsic and extrinsic risk factors are involved, and identifying and addressing them is needed to avoid chronic damage. A comprehensive history of presenting illness including the context in which symptoms developed, as well as an understanding of the patient’s goals for treatment, should be obtained in order to make the correct diagnosis and develop an effective treatment plan. Physical examination should include a functional assessment to formulate an appropriate physical therapy regimen. While standing ankle and foot radiographs are used to evaluate for stress fracture, they may initially be negative; thus, MRI has become the gold standard in evaluation. Adequate pain control to support rehabilitation helps prevent further injury and allows for healing of damaged structures.

Cutting Edge/Emerging and Unique Concepts and Practice

Emerging treatment options for stress fractures are under investigation, but the results are largely inconclusive. Ultrasound therapy (using 1 Watt/cm2 of ultrasound energy) has been shown in a small number of randomized trials to reduce time until return to duty in soldiers; however, several other randomized trials showed no benefit.17,18 In another randomized trial, extracorporeal shock wave therapy was found to be as effective as operative therapy at reducing pain, achieving bone healing, and time to return to play in soccer players with proximal fifth metatarsal stress fractures.19 Interestingly, a study has shown prostacyclin analog iloprost demonstrated faster healing (as assessed by MRI at 3 and 12 months) as compared to analgesics alone in a small retrospective case series of knee stress fractures.20

Gaps in the Evidence-Based Knowledge

Despite the classification of overuse bony injuries into low-risk and high-risk categories, there lacks rigorous scientific evidence of the clinical importance of this classification.12 In addition, it is poorly understood how to adapt clinical decision making regarding return to work or play for certain patient populations, such as professional athletes or military personnel, as opposed to the general patient population.12 Furthermore, prophylaxis against stress fractures using calcium or vitamin D supplementation or bisphosphate therapy has been theorized; however there is no conclusive evidence to support this.13

References

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  2. Fredericson M, Jennings F, Beaulieu C, Matheson GO. Stress fractures in athletes. Top Magn Reson Imaging. 2006;17(5):309-25. doi: 10.1097/RMR.0b013e3180421c8c. PubMed PMID: 17414993.
  3. Mayer SW, Joyner PW, Almekinders LC, Parekh SG. Stress fractures of the foot and ankle in athletes. Sports Health. 2014;6(6):481-91. doi: 10.1177/1941738113486588. PubMed PMID: 25364480; PMCID: PMC4212349.
  4. Harrast MA, Colonno D. Stress fractures in runners. Clin Sports Med. 2010;29(3):399-416. doi: 10.1016/j.csm.2010.03.001. PubMed PMID: 20610029.
  5. Strakowski JA, Jamil T. Management of common running injuries. Phys Med Rehabil Clin N Am. 2006;17(3):537-52. doi: 10.1016/j.pmr.2006.05.006. PubMed PMID: 16952751.
  6. Hughes LY. Biomechanical analysis of the foot and ankle for predisposition to developing stress fractures. J Orthop Sports Phys Ther. 1985;7(3):96-101. doi: 10.2519/jospt.1985.7.3.96. PubMed PMID: 18802276.
  7. Brukner P BK. Stress fractures. In: O’Connor F WR, editor. The Textbook of Running Medicine. New York,NY: McGraw-Hill; 2001. p. 227-56.
  8. Wright AA, Hegedus EJ, Lenchik L, Kuhn KJ, Santiago L, Smoliga JM. Diagnostic Accuracy of Various Imaging Modalities for Suspected Lower Extremity Stress Fractures: A Systematic Review With Evidence-Based Recommendations for Clinical Practice. Am J Sports Med. 2016;44(1):255-63. Epub 20150324. doi: 10.1177/0363546515574066. PubMed PMID: 25805712.
  9. Nattiv A, Kennedy G, Barrack MT, Abdelkerim A, Goolsby MA, Arends JC, Seeger LL. Correlation of MRI grading of bone stress injuries with clinical risk factors and return to play: a 5-year prospective study in collegiate track and field athletes. Am J Sports Med. 2013;41(8):1930-41. Epub 20130703. doi: 10.1177/0363546513490645. PubMed PMID: 23825184; PMCID: PMC4367232.
  10. Cavanagh PR, Lafortune MA. Ground reaction forces in distance running. J Biomech. 1980;13(5):397-406. doi: 10.1016/0021-9290(80)90033-0. PubMed PMID: 7400169.
  11. Hoenig T, Ackerman KE, Beck BR, Bouxsein ML, Burr DB, Hollander K, Popp KL, Rolvien T, Tenforde AS, Warden SJ. Bone stress injuries. Nat Rev Dis Primers. 2022;8(1):26. Epub 20220428. doi: 10.1038/s41572-022-00352-y. PubMed PMID: 35484131.
  12. Hoenig T, Eissele J, Strahl A, Popp KL, Sturznickel J, Ackerman KE, Hollander K, Warden SJ, Frosch KH, Tenforde AS, Rolvien T. Return to sport following low-risk and high-risk bone stress injuries: a systematic review and meta-analysis. Br J Sports Med. 2023;57(7):427-32. Epub 20230131. doi: 10.1136/bjsports-2022-106328. PubMed PMID: 36720584.
  13. Astur DC, Zanatta F, Arliani GG, Moraes ER, Pochini Ade C, Ejnisman B. Stress fractures: definition, diagnosis and treatment. Rev Bras Ortop. 2016;51(1):3-10. Epub 20151230. doi: 10.1016/j.rboe.2015.12.008. PubMed PMID: 26962487; PMCID: PMC4767832.
  14. George ERM, Sheerin KR, Reid D. Criteria and Guidelines for Returning to Running Following a Tibial Bone Stress Injury: A Scoping Review. Sports Med. 2024;54(9):2247-65. Epub 20240814. doi: 10.1007/s40279-024-02051-y. PubMed PMID: 39141251; PMCID: PMC11393297.
  15. Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Am Fam Physician. 2011;83(1):39-46. PubMed PMID: 21888126.
  16. Slocum KA, Gorman JD, Puckett ML, Jones SB. Resolution of abnormal MR signal intensity in patients with stress fractures of the femoral neck. AJR Am J Roentgenol. 1997;168(5):1295-9. doi: 10.2214/ajr.168.5.9129429. PubMed PMID: 9129429.
  17. Yadav YK, Salgotra KR, Banerjee A. Role of Ultrasound Therapy in the Healing of Tibial Stress Fractures. Med J Armed Forces India. 2008;64(3):234-6. Epub 20110721. doi: 10.1016/S0377-1237(08)80101-3. PubMed PMID: 27408154; PMCID: PMC4921570.
  18. Griffin XL, Parsons N, Costa ML, Metcalfe D. Ultrasound and shockwave therapy for acute fractures in adults. Cochrane Database Syst Rev. 2014;2014(6):CD008579. Epub 20140623. doi: 10.1002/14651858.CD008579.pub3. PubMed PMID: 24956457; PMCID: PMC7173732.
  19. Ramon S, Lucenteforte G, Alentorn-Geli E, Steinbacher G, Unzurrunzaga R, Alvarez-Diaz P, Barastegui D, Grossi S, Sala E, Martinez-De la Torre A, Mangano GRA, Cusco X, Rius M, Ferre-Aniorte A, Cugat R. Shockwave Treatment vs Surgery for Proximal Fifth Metatarsal Stress Fractures in Soccer Players: A Pilot Study. Foot Ankle Int. 2023;44(12):1256-65. Epub 20231031. doi: 10.1177/10711007231199094. PubMed PMID: 37905784.
  20. Mayerhoefer ME, Kramer J, Breitenseher MJ, Norden C, Vakil-Adli A, Hofmann S, Meizer R, Siedentop H, Landsiedl F, Aigner N. MRI-demonstrated outcome of subchondral stress fractures of the knee after treatment with iloprost or tramadol: observations in 14 patients. Clin J Sport Med. 2008;18(4):358-62. doi: 10.1097/JSM.0b013e31817f3e1c. PubMed PMID: 18614889.

Original Version of the Topic

Alexandra Rivera-Vega, MD, Stephanie P. Joseph, MD, William F. Micheo, MD. Ankle and foot overuse disorders. 9/20/2014

Previous Revision(s) of the Topic

William Micheo, MD, Brenda Castillo, MD, Alexandra Rivera, MD, Odrick Rosas, MD. Ankle and foot overuse disorders. 2/13/2018

Lindsay Burke, MD, Kristina Barber, MD, Malia Cali, MD, Adele Meron, MD. Ankle and Foot Overuse Disorders. 6/22/2022

Author Disclosure

Schan Lartigue, MD
Nothing to Disclose

Sera Yoo, MD, MPH
Nothing to Disclose

Eric K. Holder, MD
Nothing to Disclose