Talus insufficiency fracture due to long-term methotrexate therapy in a patient with rheumatoid arthritis

Insufficiency fractures are a well-known complication in patients with inflammatory rheumatic diseases, but can also be caused by long-term methotrexate (MTX) therapy. We report on a 72-year-old female patient with rheumatoid arthritis and more than 10 years of MTX treatment who was diagnosed with an insufficiency fracture of the trochlea tali without previous trauma. After discontinuation of MTX therapy and initiation of osteoanabolic treatment, there was a distinct clinical improvement with prompt fracture healing. The case underlines the importance of early MRI diagnosis and treatment adjustment in cases of suspected MTX osteopathy to avoid missing or protracted fracture healing and to minimize the risk of further fractures.