eMedicine Specialties > Sports Medicine > Foot and Ankle

Metatarsal Stress Fracture

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

Updated: Sep 26, 2007

Introduction

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

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

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
[ CLOSE WINDOW ]

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].

[ CLOSE WINDOW ]

Further Reading

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

[ CLOSE WINDOW ]

Keywords

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

[ CLOSE WINDOW ]

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, Medical Director, Center for Sports Medicine, O'Connor Hospital; Private Practice
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

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.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.