AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• FURTHER READING
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• FURTHER READING
• Multimedia
• References

Background

With an increase in public interest in physical fitness, clinical practitioners are diagnosing stress fractures with greater frequency.¹ First described by Aristotle in 200 BC, stress fractures were initially recorded in the medical literature in 1855 by the Prussian military physician Breithaupt, who described what is now known as a march fracture, or stress fracture of the metatarsals.

Metatarsal stress fractures are not limited to high-level athletes or military recruits. This type of injury is seen in runners of all levels, as well as ballet dancers and gymnasts and patients with rheumatoid arthritis (RA), metabolic bone disease, and neuropathic conditions.² Metatarsal stress fractures are also seen with increasing frequency in patients who engage in aerobics activities, particularly high-impact aerobics.

Frequency

United States

The incidence of stress fractures in the general population is unknown, as virtually all literature on the subject is derived from a military population or advanced-level athletes. Stress fractures are estimated to constitute up to 16% of all injuries that are related to athletic participation; running is the cause in most of these cases. Most stress fractures (95%) involve the lower extremities, particularly the metatarsals.

Functional Anatomy

The second and third metatarsals are relatively fixed in position within the foot; the first, fourth, and fifth metatarsals are relatively mobile. More stress is placed on the second and third metatarsals during ambulation; thus, these bones are at increased risk for stress fractures.

The fifth metatarsal, which is approximately 1.5 cm from the proximal pole of the bone, bears greater stress in those who oversupinate when they walk or run. The fifth metatarsal also has a diminished blood supply and, thus, a decreased ability to heal.

Stress fractures of the proximal fifth metatarsal must be distinguished from proximal avulsion fractures ("pseudo-Jones" fractures) and Jones fractures. The proximal avulsion fracture is usually associated with a lateral ankle strain and occurs at the insertion of the peroneus brevis tendon. The true Jones fracture is an acute fracture of the proximal diametaphyseal junction.

CLINICAL

Section 3 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• FURTHER READING
• Multimedia
• References

History

• Patients usually report having increased the intensity or duration of their exercise regimen.
• Initially, dull pain only occurs with exercise, then the condition progresses to pain at rest.
• Pain starts diffusely, then localizes to the site of the fracture.
• Stress fractures can be historically distinguished from a true Jones fracture, because patients with a stress mechanism as the etiology report a long history of prodromal symptoms of pain over the proximal fifth metatarsal.
• Menstrual irregularities should be explored in female patients due to a high association between female athletics, amenorrhea, and osteoporosis—otherwise known as the female athletic triad.^{3, 4}

Physical

• Inspect the affected foot for swelling, bruising, or warmth.
• Inspect both feet for a side-by-side comparison.
• Palpate the affected foot to find the point of maximal tenderness. Specifically seek to determine if the point of maximal tenderness is related to bony or soft-tissue problems.
• Inspect the patient's athletic shoes for signs of excessive supination or excessive wear under the metatarsal heads.

Causes

• Increased intensity, duration, or frequency of exercise
• New footwear
• Insufficient rest periods
• Continuing to train despite pain
• Osteopenia/osteoporosis
• Rheumatoid arthritis
• Neuropathic foot
• Female athletic triad

DIFFERENTIALS

Section 4 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• FURTHER READING
• Multimedia
• References

Other Problems to Be Considered

Acute metatarsal fracture
Hallux rigidus
Jones fracture
Sesamoid stress fracture
Acute sesamoid fracture
Proximal fifth-metatarsal avulsion fracture (pseudo-Jones fracture)

WORKUP

Section 5 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• FURTHER READING
• Multimedia
• References

Lab Studies

• Due to a known association between RA and stress fractures, the clinician may consider a workup for RA, with an erythrocyte sedimentation rate (ESR) and rheumatoid panel. This workup is not routine in most patients, but it is a consideration when the clinical picture is unclear or indicates the possibility of RA.
• A workup for osteoporosis may be considered, especially in oligomenorrheic females and in patients who have (or have had) multiple stress fractures.

Imaging Studies

• Plain-film radiography
• • Radiographs may be negative early in the process.^{3, 5}
  • Stress-fracture changes may not be evident on plain films until 3 months after the onset of symptom(s).
  • Up to 50% of stress fractures are never observed on plain films.
• • Plain-film radiographs can help the physician distinguish fifth-metatarsal stress fractures from true Jones fractures. Fractures with a stress etiology show a widened fracture line, intramedullary sclerosis, and periosteal reaction.
• Bone scanning^{6, 7}
• • Technetium-99 (^99mTc) diphosphonate 3-phase bone scanning has traditionally been the imaging modality of choice.
  • Bone scanning is nearly 100% sensitive for the diagnosis of stress fractures, although the specificity of this modality is considerably lower.
  • Bone scans can demonstrate stress fractures within 24-72 hours from the onset of symptom(s).
  • Differentiation between stress fractures and stress reactions may be determined with a bone scan.
• Magnetic resonance imaging (MRI) and single-photon emission computed tomography (SPECT)^{8, 9, 10}: These modalities may also be used to image stress fractures; however, MRI has become the study of choice because it has the same sensitivity as a bone scan but with a much higher specificity. Additionally, MRI does not require ionizing radiation.

TREATMENT

Section 6 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• FURTHER READING
• Multimedia
• References

Acute Phase

Rehabilitation Program

Physical Therapy

The patient should rest from the offending activity. Immobilization is recommended for comfort, with use of a postoperative (wooden-soled) shoe or short CAM Walker (Bird and Cronin, Inc, Eagan, Minn). It is important to apply ice and elevate the foot to minimize pain and swelling. If there is marked pain or minimal evidence of healing for stress fractures of the second or third metatarsals, a short-leg walking cast can be used until there is radiographic evidence of healing.

Recreational Therapy

During the respite period from the offending activity, the patient may maintain fitness by cycling, aqua-running, or resistance training by using equipment that does not involve the affected area.

Surgical Intervention

Stress fractures of the second or third metatarsals rarely require surgical intervention. Most of these fractures heal uneventfully, and nonunion is rare. However, stress fractures of the fifth-metatarsal base are more problematic. Displacement of these fractures tends to increase with continued weight bearing. The treatment options are 2-fold as follows:

• Less-active patients should be non-weight bearing in a short-leg cast for 6-8 weeks or until there is radiographic evidence of healing. If an established nonunion develops, screw fixation and/or bone grafting may be required.¹¹
• For active patients, early intramedullary screw fixation, with or without bone grafting, is often recommended.

Consultations

Consult an orthopedic surgeon for fifth-metatarsal fractures or for second- or third-metatarsal fractures that do not demonstrate radiographic healing after 6 weeks.

Recovery Phase

Rehabilitation Program

Physical Therapy

During the recovery phase, the patient may progress to weight bearing as tolerated, initially in a wooden-soled shoe, and then in a comfortable shoe.

Recreational Therapy

Aqua-running, swimming, or bicycling may be continued to maintain physical fitness.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The patient may be allowed to gradually return to his or her sport with a slow build-up in intensity and duration, with regular rest intervals. No more than a 10% increase in intensity or duration should be allowed from week to week. Any pain recurrence should prompt a rest period, followed by resuming the activity at a lower level.

Recreational Therapy

The patient may resume running with a slow increase in duration and intensity of the workouts (ie, no more than a 10% increase in intensity or duration per week).

Surgical Intervention

Patients who continue to have painful nonunion fractures are candidates for surgical intervention.¹¹ A fibrous nonunion that is not painful and does not limit the patient's functional abilities may be left alone.

Consultations

An orthopedic surgeon should be consulted in cases in which there is radiographic evidence of nonunion or prolonged pain.

MEDICATION

Section 7 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• FURTHER READING
• Multimedia
• References

Analgesics may be needed in the acute phase of the treatment for metatarsal stress fractures. The patient often encounters mild to moderate pain until a period of rest and/or immobilization has occurred.

Drug Category: Nonsteroidal anti-inflammatory drugs

These agents have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but these drugs may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Drug Category: Analgesics

Pain control is essential for quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.

FOLLOW-UP

Section 8 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• FURTHER READING
• Multimedia
• References

Return to Play

• After recovery from metatarsal stress fractures, patients may return to play when they can participate without pain.
• The intensity and duration of activities need to be increased slowly, and the patient must adhere to regular rest periods.

Complications

• Nonunion is the primary complication of metatarsal stress fractures.
• Nonunion rates of 35-50% in fifth-metatarsal stress fractures are reported in the literature. For other metatarsal stress fractures, the nonunion rate is low.

Prevention

• Increases in sports-training demands, whether in intensity or duration, should be performed in a slow cyclical manner, and rest periods need to be built into training regimens. Use of orthotics has not been proven to decrease the incidence of metatarsal stress fractures.
• Athletes who develop pain during exercise need to decrease their training level to one that is painless, and then they can slowly resume a training regimen.
• Physicians, coaches, trainers, and parents need to be aware of metatarsal stress fractures and the symptoms. Prompt treatment can reduce morbidity and time lost from the offending sport or activity.

Prognosis

• Stress fractures in the first 4 metatarsals routinely heal without complication.
• Stress fractures at the base of the fifth metatarsal have a nonunion rate of 35-50%.

Education

• The key to preventing stress fractures lies in the education of athletes, parents, coaches, trainers, and doctors.
• Properly selected and fitted equipment, particularly running shoes, is important in deterrence of metatarsal stress fractures.
• Training needs to be performed in a slow cyclical progression that allows the body to adapt. Adequate rest and recovery time needs to be incorporated into the participant's training regimen.
• The quality of physical activity, rather than quantity, should be stressed in any exercise program.
• The athlete, coach, trainer, and physician must recognize that exercise regimens are not "one size fits all." Tailor the training to the participant's baseline ability, previous experience, and current level of physical activity.

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center and Sports Injury Center. Also, see eMedicine's patient education article Broken Foot.

MISCELLANEOUS

Section 9 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• FURTHER READING
• Multimedia
• References

Medical/Legal Pitfalls

• Failure to consider the diagnosis of metatarsal stress fracture
• Failure to pursue the diagnosis if plain films are negative
• Failure to refer patients with fifth-metatarsal stress fractures to an orthopedic specialist

FURTHER READING

Section 10 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• FURTHER READING
• Multimedia
• References

Gehrmann RM, Renard RL. Current concepts review: stress fractures of the foot. Foot Ankle Int. Sep 2006;27(9):750-7. [Medline].

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• FURTHER READING
• Multimedia
• References

Media file 1:  Radiograph of the feet. This image depicts a stress fracture of the left second metatarsal with exuberant callus.
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Media type:  X-RAY

Media file 2:  Radiograph of the left foot. This image depicts a stress fracture of the fifth metatarsal.
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Media type:  X-RAY

Media file 3:  Bone scan of the lower extremities. This image depicts a right fifth metatarsal stress fracture.
	View Full Size Image
Media type:  Nuclear Image

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• FURTHER READING
• Multimedia
• References

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17. Coady CM, Micheli LJ. Stress fractures in the pediatric athlete. Clin Sports Med. Apr 1997;16(2):225-38. [Medline].
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19. Guettler JH, Ruskan GJ, Bytomski JR, et al. Fifth metatarsal stress fractures in elite basketball players: evaluation of forces acting on the fifth metatarsal. Am J Orthop. Nov 2006;35(11):532-6. [Medline].
20. Heaslet MW, Kanda-Mehtani SL. Return-to-activity levels in 96 athletes with stress fractures of the foot, ankle, and leg: a retrospective analysis. J Am Podiatr Med Assoc. Jan-Feb 2007;97(1):81-4. [Medline].
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Article Last Updated: Sep 26, 2007