When Do You Need Surgery for a Stress Fracture? [Video]

Most bone stress injuries can be treated conservatively without the need to go under the knife…except in three specific locations.

Mallee and colleagues examined conservative versus surgical management of three high-risk BSIs ⛔ to discern the best management strategy.

Let’s break down the locations.

The Anterior Tibial Cortex
Of all tibial BSIs, the anterior cortex is injured in 5-15% and poses a significant threat to a patient’s military or athletic career. The anterior portion of the tibia must manage large amounts of tensile forces, and bone is not great at healing. The evidence is limited in comparing surgical versus conservative management.

Johansson et al. reported a conservative return to sport rate of 55%.
In two separate studies, Orava found that 13/14 (93%) and 9/17 (53%) anterior tibial stress fractures did not unite after initial conservative treatment.

The Navicular
Your navicular is a boat-shaped bone wedged between your talus and cuneiforms. It must handle stress from its surrounding bony tissue and muscular attachments and contains an avascular portion through its central third.

Nunley et al. proposed different surgical interventions depending on the extent and progression of the injury.
*Displaced stress fractures
*Non-displaced complete fractures with sclerotic changes
*Comminuted fractures (the bone is broken in at least two places)
*Failed conservative management

Potter and Torg found no difference in surgical versus conservative long-term outcomes.

The Base of the 5th metatarsal

Your fifth metatarsal’s biomechanics and blood supply put it at risk for poor healing. The proximal portion is stiff and rigid, while the middle mobile and adaptable, creating a significant variance in the forces the bone must withstand. Combine that with an avascular area similar to the navicular, and you can face problems😢.

5th MT BSIs are divided into three regions with different outcomes depending on the specific location.

Zone 1 has a nonunion rate of .5-1%
Zone 2 and 3 has a 67% chance of delayed healing and a 61.1% chance of refracture.

All these locations have small, limited studies that aren’t conclusive!

Whether or not you need surgery in these high-risk locations is debatable. It’s essential to understand the risks and implications of all treatment options so runners can make the best decision for them.