eMedicine Specialties > Sports Medicine > Foot and Ankle

Metatarsal Stress Fracture: Differential Diagnoses & Workup

Author: Andrew D Perron, MD, Residency Director, Department of Emergency Medicine, Maine Medical Center
Contributor Information and Disclosures

Updated: Aug 12, 2009

Differential Diagnoses

Metatarsalgia
Morton Neuroma
Turf Toe

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

Laboratory 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 (see Images 1-2 or below).
      Radiograph of the feet. This image depicts a stre...

      Radiograph of the feet. This image depicts a stress fracture of the left second metatarsal with exuberant callus.

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      Radiograph of the feet. This image depicts a stre...

      Radiograph of the feet. This image depicts a stress fracture of the left second metatarsal with exuberant callus.


      Radiograph of the left foot. This image depicts a...

      Radiograph of the left foot. This image depicts a stress fracture of the fifth metatarsal.

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      Radiograph of the left foot. This image depicts a...

      Radiograph of the left foot. This image depicts a stress fracture of the fifth metatarsal.

  • Bone scanning6,7
    • Technetium-99 (99m Tc) 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) (see Image 3 or below).
      Bone scan of the lower extremities. This image de...

      Bone scan of the lower extremities. This image depicts a right fifth metatarsal stress fracture.

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      Bone scan of the lower extremities. This image de...

      Bone scan of the lower extremities. This image depicts a right fifth metatarsal stress fracture.

    • 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.
  • Ultrasonography
    • In a case-control study, Banal et al evaluated the sensitivity and specificity of ultrasonography to detect early stress fractures as an alternative imaging modality to MRI and bone scan scintigraphy, which are expensive or invasive, time-consuming, and poorly accessible.27  The investigators analyzed 41 feet from 37 patients with ultrasonography and dedicated MRI. MRI detected 13 fractures in 12 patients. Ultrasonography sensitivity was 83%; specificity, 76%; positive predictive value, 59%; and negative predictive value, 92%.27 These findings led Banal et al to conclude that when radiographs are normal, ultrasonography should be used in the diagnosis of metatarsal bone stress fractures due to its low cost, noninvasiveness, rapidity, and easy technique with good sensitivity and specificity.

More on Metatarsal Stress Fracture

Overview: Metatarsal Stress Fracture
Differential Diagnoses & Workup: Metatarsal Stress Fracture
Treatment & Medication: Metatarsal Stress Fracture
Follow-up: Metatarsal Stress Fracture
Multimedia: Metatarsal Stress Fracture
References
Further Reading
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References

  1. Maitra RS, Johnson DL. Stress fractures. Clinical history and physical examination. Clin Sports Med. Apr 1997;16(2):259-74. [Medline].

  2. Hockenbury RT. Forefoot problems in athletes. Med Sci Sports Exerc. Jul 1999;31(7 suppl):S448-58. [Medline].

  3. Reeder MT, Dick BH, Atkins JK, Pribis AB, Martinez JM. Stress fractures. Current concepts of diagnosis and treatment. Sports Med. Sep 1996;22(3):198-212. [Medline].

  4. Brukner P, Bennell K. Stress fractures in female athletes. Diagnosis, management and rehabilitation. Sports Med. Dec 1997;24(6):419-29. [Medline].

  5. Sallis RE, Jones K. Stress fractures in athletes. How to spot this underdiagnosed injury. Postgrad Med. May 1 1991;89(6):185-8, 191-2. [Medline].

  6. Matheson GO, Clement DB, McKenzie DC, et al. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. Jan-Feb 1987;15(1):46-58. [Medline].

  7. Monteleone GP Jr. Stress fractures in the athlete. Orthop Clin North Am. Jul 1995;26(3):423-32. [Medline].

  8. Deutsch AL, Coel MN, Mink JH. Imaging of stress injuries to bone. Radiography, scintigraphy, and MR imaging. Clin Sports Med. Apr 1997;16(2):275-90. [Medline].

  9. Kiuru MJ, Pihlajamaki HK, Hietanen HJ, Ahovuo JA. MR imaging, bone scintigraphy, and radiography in bone stress injuries of the pelvis and the lower extremity. Acta Radiol. Mar 2002;43(2):207-12. [Medline].

  10. Spitz DJ, Newberg AH. Imaging of stress fractures in the athlete. Radiol Clin North Am. Mar 2002;40(2):313-31. [Medline].

  11. Weinfeld SB, Haddad SL, Myerson MS. Metatarsal stress fractures. Clin Sports Med. Apr 1997;16(2):319-38. [Medline].

  12. Bennell KL, Brukner PD. Epidemiology and site specificity of stress fractures. Clin Sports Med. Apr 1997;16(2):179-96. [Medline].

  13. Brukner P, Bradshaw C, Bennell K. Managing common stress fractures: let risk level guide management. Phys Sports Med. 1998;26(8):39-47.

  14. Burr DB. Bone, exercise, and stress fractures. Exerc Sport Sci Rev. 1997;25:171-94. [Medline].

  15. Chen RC, Shia DS, Kamath GV, Thomas AB, Wright RW. Troublesome stress fractures of the foot and ankle. Sports Med Arthrosc. Dec 2006;14(4):246-51. [Medline].

  16. Chuckpaiwong B, Cook C, Pietrobon R, Nunley JA. Second metatarsal stress fracture in sport: comparative risk factors between proximal and non-proximal locations. Br J Sports Med. Aug 2007;41(8):510-4. [Medline].

  17. Coady CM, Micheli LJ. Stress fractures in the pediatric athlete. Clin Sports Med. Apr 1997;16(2):225-38. [Medline].

  18. Fredericson M, Jennings F, Beaulieu C, Matheson GO. Stress fractures in athletes. Top Magn Reson Imaging. Oct 2006;17(5):309-25. [Medline].

  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].

  21. Knapp TP, Garrett WE Jr. Stress fractures: general concepts. Clin Sports Med. Apr 1997;16(2):339-56. [Medline].

  22. Nagel A, Fernholz F, Kibele C, Rosenbaum D. Long distance running increases plantar pressures beneath the metatarsal heads: a barefoot walking investigation of 200 marathon runners. Gait Posture. Feb 2 2007;epub ahead of print. [Medline].

  23. Queen RM, Crowder TT, Johnson H, Ozumba D, Toth AP. Treatment of metatarsal stress fractures: case reports. Foot Ankle Int. Apr 2007;28(4):506-10. [Medline].

  24. Quill GE Jr. Fractures of the proximal fifth metatarsal. Orthop Clin North Am. Apr 1995;26(2):353-61. [Medline].

  25. Sammarco GJ. The Jones fracture. Instr Course Lect. 1993;42:201-5. [Medline].

  26. Torg JS, Balduini FC, Zelko RR, et al. Fractures of the base of the fifth metatarsal distal to the tuberosity. Classification and guidelines for non-surgical and surgical management. J Bone Joint Surg Am. Feb 1984;66(2):209-14. [Medline]. [Full Text].

  27. Banal F, Gandjbakhch F, Foltz V, et al. Sensitivity and specificity of ultrasonography in early diagnosis of metatarsal bone stress fractures: a pilot study of 37 patients. J Rheumatol. Jun 30 2009;epub ahead of print. [Medline].

  28. Queen RM, Mall NA, Nunley JA, Chuckpaiwong B. Differences in plantar loading between flat and normal feet during different athletic tasks. Gait Posture. Jun 2009;29(4):582-6. [Medline].

  29. Albisetti W, Perugia D, De Bartolomeo O, et al. Stress fractures of the base of the metatarsal bones in young trainee ballet dancers. Int Orthop. May 5 2009;epub ahead of print. [Medline].

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Further Reading

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

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Keywords

metatarsal stress fracture, march fracture, stress fracture of the metatarsals, foot fracture, foot stress fracture, broken foot, fractured foot, female athlete triad Breithaupt fracture

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Contributor Information and Disclosures

Author

Andrew D Perron, MD, Residency Director, Department of Emergency Medicine, Maine Medical Center
Andrew D Perron, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Anthony J Saglimbeni, MD, Staff Physician, Family Practice Residency, President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
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