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1 · SNAPSHOT

Stress Fracture (Metatarsal / Navicular / Calcaneal) body chart — Illustrative, not diagnostic. Canva body chart for Stress Fracture (Metatarsal / Navicular / Calcaneal).

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Who: Runners, dancers and military personnel. Anyone after a change in training volume, intensity, surface, footwear, nutrition or recovery.
What: Repetitive loading exceeding bone remodelling capacity.
How it behaves: Gradual, focal, load-related pain with no specific trauma. Pain early in activity, and — in advanced stages — persisting afterwards. Eased by rest and unloading.

The one thing to take from this page:

The diagnosis is a load-capacity mismatch. The management is decided by WHERE.

Site decides everything

Site	Risk	What it needs
Navicular	High	Image early. Often subtle and delayed. Strict offload, specialist consideration
Proximal 5th metatarsal (Jones)	High	Image early. Fixation is a real conversation
Metatarsal shafts (2nd, 3rd)	Lower	Offload, correct the load, graded return
Calcaneus	Lower — and it mimics plantar heel pain	Focal calcaneal tenderness + load pain → image

Delayed diagnosis at a high-risk site buys nonunion, prolonged recovery and surgical referral [1][2].

⚠️ No Australian guideline exists. Anchored to site-specific reviews and, for the fifth metatarsal, an elite-athlete consensus.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

Five stages, in your course's order. The history is the diagnosis here — this is a load story before it is a bone story.

MAIN PROBLEM

"There's a sore spot in my foot that's getting worse the more I run."
"It used to hurt at the end of the run, now it hurts from the start."
"It's fine if I don't run."

That progression — end of activity, then during, then after — is the staging in the patient's own words.

BODY CHART

Mark it focally. "Can you point to it with one finger?" A pain they can cover with a fingertip is a bone pain until proven otherwise.
Name the site. Navicular, metatarsal shaft, base of the fifth, calcaneus — because the site decides the plan.
Mark swelling if present.

BEHAVIOUR

	Fits bone stress	Points elsewhere
Aggs	Weight-bearing, impact, and it's getting earlier in the session	Position and footwear → mechanical forefoot pain
Eases	Rest and unloading	Nothing changes it → screen wider
Progression	Worsening over weeks	Fluctuating with exposure → tendon or joint
Localisation	Focal, pointable	Diffuse, under the heads → metatarsalgia

HISTORY — the load audit

Ask all of it, because the answer is usually in here:

Training volume, intensity, surface and footwear — and what changed, and when.
A return after a break. Deconditioned bone meeting old training loads.
Recovery — sleep, rest days, back-to-back sessions.
Nutrition and energy availability. Ask it properly.
Previous bone stress injury. Recurrence changes the workup.

SPECIAL / SCREENING QUESTIONS

The bone-health screen — and this is not optional in a runner, an adolescent, or anyone with a recurrent or slow-healing injury:

Energy availability, dietary restriction, weight change.
Menstrual status where relevant. Nutrition, menstrual and bone-health variables help distinguish higher-risk injuries in female runners [3].
Vitamin D and calcium intake. Vitamin D insufficiency is a modifiable risk factor (Knechtle et al. 2021).
Endocrine factors, medications, prior fractures, family history.
In adolescents: growth, nutrition, menstrual status and sport volume all matter (Beck & Drysdale 2021).

Assessing this region? Download the Ankle & Foot assessment template →

3 · HYPOTHESIS RANKING

Competing pattern	The one discriminating feature
Lisfranc / midfoot sprain	A twist or axial load event with plantar arch bruising and pain on forefoot torsion. Bone stress is gradual with no trauma.
Metatarsalgia	Diffuse pain under the metatarsal heads with callus, no focal bony tenderness or percussion pain.
Morton's neuroma	Webspace burning radiating into the toes, with sensory change and a positive Mulder's click.

The one that catches people out

Calcaneal stress fracture mimics plantar heel pain. Focal calcaneal tenderness plus load pain should prompt imaging rather than another six weeks of plantar fascia loading [4]. A plantar heel pain that isn't responding is a re-examination, not a re-prescription.

And know which sites you're worried about

Separate low-risk from high-risk. Navicular and proximal fifth metatarsal need earlier imaging and specialist consideration than many metatarsal shaft injuries (Paavana et al. 2024; Mandell et al. 2017).

4 · RED FLAGS — DON'T MISS THIS

This section is free, on every pattern, forever. Safety is never gated.

Finding	What it suggests	What you do
Focal navicular tenderness (the "N spot") + exertional midfoot pain	High-risk navicular BSI	Image early — MRI or CT. Offload now
Focal tenderness at the base of the 5th metatarsal	High-risk Jones-zone injury	Image early. Offload. Specialist consideration
Focal bony tenderness + positive percussion or hop, with a load history	Bone stress injury	Offload and image
Pain now present at rest or at night	Advanced injury	Image, and stop loading
A normal early X-ray with a convincing story	Plain films are frequently normal early	Do not clear it. MRI
Recurrent bone stress injuries	Metabolic or energy-availability contribution	Metabolic workup and medical referral
Adolescent with midfoot pain and a nonspecific presentation	Navicular BSI presents vaguely in this group	Advanced imaging

The three rules that survive everything else

1. Navicular and base of the fifth are high-risk. Image early. The literature is unanimous.

2. A normal early radiograph clears nothing. MRI is the preferred confirmation and grading tool. The navicular is the exception to "MRI settles it": in one athlete cohort, initial CT correlated with a correct diagnosis and initial MRI didn't always (Saxena et al. 2017) [12] — a negative MRI with a convincing N-spot story still goes back to the specialist.

3. Bone pain is a load mismatch — so check the load AND the capacity. Vitamin D and relative energy deficiency must be ruled out. Recurrent, high-risk or delayed-healing injuries should trigger a workup for vitamin D, calcium intake, endocrine factors, low energy availability and bone density risk [5].

Cross-links: Midfoot sprain (Lisfranc) · Metatarsalgia · Plantar fasciopathy

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Twelve slides on this pattern: what you'll hear, what to examine, what to do. Free with an account.

Guideline anchor

No Australian guideline covers foot bone stress injury.

Anchored to the foot-specific management review (Paavana et al. 2024, PMID 38435398) for the site-by-site risk stratification, the prospective MRI grading and return-to-play study (Nattiv et al. 2013, PMID 23825184) for prognosis, and the scoping review of return to running (George et al. 2024, PMID 39141251) for criteria-based progression. The elite-athlete Jones fracture consensus (Balboni et al. 2026, PMID 41451757) anchors the high-risk fifth metatarsal.

PubMed Source

None of these is an Australian document and none is a guideline in the formal sense — the Jones fracture paper is the closest, and it is a consensus plus systematic review in elite athletes specifically. The site-by-site risk logic on this page is drawn from the primary literature and labelled as such.

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The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 20

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Every source on this page resolves and title-verifies against PubMed. Newest first.

2024Paavana et al. (2024). Stress fractures of the foot - current evidence on management. Journal of clinical orthopaedics and trauma, 50, 102381. https://doi.org/10.1016/j.jcot.2024.102381
2026Modica et al. (2026). Review of Current Management of Navicular Stress Fractures in Athletes. Sports health, 18(5), 950-959. https://doi.org/10.1177/19417381251411342
2024Tenforde et al. (2024). Factors Associated With High-Risk and Low-Risk Bone Stress Injury in Female Runners: Implications for Risk Factor Stratification and Management. Orthopaedic journal of sports medicine, 12(5), 23259671241246227. https://doi.org/10.1177/23259671241246227
2018Bianchi & Luong (2018). Stress Fractures of the Calcaneus Diagnosed by Sonography: Report of 8 Cases. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine, 37(2), 521-529. https://doi.org/10.1002/jum.14276
2026Nye et al. (2026). Metabolic Workup for Bone Stress Injury: A Practical Approach for Evaluating Bone Health in Athletes. Sports health, 18(3), 521-533. https://doi.org/10.1177/19417381251398501
2024George et al. (2024). Criteria and Guidelines for Returning to Running Following a Tibial Bone Stress Injury: A Scoping Review. Sports medicine (Auckland, N.Z.), 54(9), 2247-2265. https://doi.org/10.1007/s40279-024-02051-y
2013Nattiv et al. (2013). 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. The American journal of sports medicine, 41(8), 1930-41. https://doi.org/10.1177/0363546513490645
2014Mayer et al. (2014). Stress fractures of the foot and ankle in athletes. Sports health, 6(6), 481-91. https://doi.org/10.1177/1941738113486588
2015Kahanov et al. (2015). Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open access journal of sports medicine, 6, 87-95. https://doi.org/10.2147/OAJSM.S39512
2017Shakked et al. (2017). Tarsal navicular stress fractures. Current reviews in musculoskeletal medicine, 10(1), 122-130. https://doi.org/10.1007/s12178-017-9392-9
2017Mandell et al. (2017). Stress fractures of the foot and ankle, part 2: site-specific etiology, imaging, and treatment, and differential diagnosis. Skeletal radiology, 46(9), 1165-1186. https://doi.org/10.1007/s00256-017-2632-7
2017Saxena et al. (2017). Navicular Stress Fracture Outcomes in Athletes: Analysis of 62 Injuries. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, 56(5), 943-948. https://doi.org/10.1053/j.jfas.2017.06.009
2021Troy et al. (2021). A Narrative Review of Metatarsal Bone Stress Injury in Athletic Populations: Etiology, Biomechanics, and Management. PM & R : the journal of injury, function, and rehabilitation, 13(11), 1281-1290. https://doi.org/10.1002/pmrj.12518
2021Hollander et al. (2021). High union rates following surgical treatment of proximal fifth metatarsal stress fractures. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 29(8), 2495-2503. https://doi.org/10.1007/s00167-021-06490-2
2021Knechtle et al. (2021). Vitamin D and Stress Fractures in Sport: Preventive and Therapeutic Measures-A Narrative Review. Medicina (Kaunas, Lithuania), 57(3). https://doi.org/10.3390/medicina57030223
2021Beck & Drysdale (2021). Risk Factors, Diagnosis and Management of Bone Stress Injuries in Adolescent Athletes: A Narrative Review. Sports (Basel, Switzerland), 9(4). https://doi.org/10.3390/sports9040052
2021Attia et al. (2021). Return to sport following navicular stress fracture: a systematic review and meta-analysis of three hundred and fifteen fractures. International orthopaedics, 45(10), 2699-2710. https://doi.org/10.1007/s00264-021-05147-6
2023Mehta et al. (2023). Tarsal Navicular Bone Stress Injuries: A Multicenter Case Series Investigating Clinical Presentation, Diagnostic Approach, Treatment, and Return to Sport in Adolescent Athletes. The American journal of sports medicine, 51(8), 2161-2168. https://doi.org/10.1177/03635465231170399
2024Sun et al. (2024). Risk factors of metatarsal stress fracture associated with repetitive sports activities: a systematic review. Frontiers in bioengineering and biotechnology, 12, 1435807. https://doi.org/10.3389/fbioe.2024.1435807
2026Balboni et al. (2026). Jones fractures in elite athletes-2025 International Foot and Ankle Sports Consensus and systematic review. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 34(9), 3120-3134. https://doi.org/10.1002/ksa.70241

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