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Metatarsal Stress Fracture

  • Author: Valerie E Cothran, MD; Chief Editor: Craig C Young, MD  more...
 
Updated: Dec 30, 2015
 

Background

With an increase in public interest in physical fitness, clinical practitioners are diagnosing stress fractures with greater frequency.[1, 2, 3] 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. See the images below.

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

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.[4, 5, 6] Metatarsal stress fractures are also seen with increasing frequency in patients who engage in aerobics activities, particularly high-impact aerobics.

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Epidemiology

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.

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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.[7, 8]

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.

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Sport-Specific Biomechanics

Queen et al investigated whether foot type (flat or normal) resulted in loading differences during four sport-specific tasks (cross-cut, side-cut, shuttle run, and landing from a simulated lay-up).[9] Of 22 healthy individuals, 12 had normal feet and 10 had flat feet, and each completed 5 trials per condition. In-shoe pressure data were collected at 50 Hz, and analyses of the entire foot and 8 regions of the foot were carried out on contact area, maximum force, and the force time integral. The investigators' findings included the following statistically significant (P < 0.05) findings[9] :

Flat feet

See the list below:

  • During the cross-cut task, there was an increase in medial midfoot contact area.
  • During the side-cut task, an increase in contact area, force time integral, and maximum force in both the medial and lateral midfoot were demonstrated.
  • During the shuttle run task, an increase in force time integral in the lateral midfoot and increases in maximum force in both the medial and lateral midfoot were present
  • During the landing task, an increase in maximum force in the medial midfoot was present. However, flat feet showed a decrease in middle forefoot maximum force.

Queen et al concluded that individuals with a normal foot may have a lower risk for medial and lateral midfoot injuries such as metatarsal stress fractures. Thus, foot type should be assessed when determining an individual's risk for metatarsal stress fractures.[9]

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Pathophysiology

Fujitaka et al studied a cohort of 273 collegiate male soccer players which included 16 who developed a fifth metatarsal stress fracture. Analysis of various history, physical, and equipment variables  suggested that stress fracture may be a result of a weak toe-grip that leads to an increase in the load applied onto the lateral side of the foot.[10]

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Contributor Information and Disclosures
Author

Valerie E Cothran, MD Assistant Professor, Department of Family and Community Medicine, Director of Primary Care Sports Medicine Fellowship, University of Maryland School of Medicine; Assistant Team Physician, University of Maryland

Valerie E Cothran, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Anthony J Saglimbeni, MD 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; Team Physician, Santa Clara University; Consultant, University of San Francisco, Academy of Art University, Skyline College, Foothill College, De Anza College

Anthony J Saglimbeni, MD is a member of the following medical societies: California Medical Association, Santa Clara County Medical Association, Monterey County Medical Society

Disclosure: Received ownership interest from South Bay Sports and Preventive Medicine Associates, Inc for board membership.

Acknowledgements

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.

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

  2. Ekstrand J, van Dijk CN. Fifth metatarsal fractures among male professional footballers: a potential career-ending disease. Br J Sports Med. 2013 Apr 9. [Medline].

  3. Rongstad KM, Tueting J, Rongstad M, Garrels K, Meis R. Fourth Metatarsal Base Stress Fractures in Athletes: A Case Series. Foot Ankle Int. 2013 Feb 5. [Medline].

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

  5. Finestone A, Milgrom C, Wolf O, Petrov K, Evans R, Moran D. Epidemiology of metatarsal stress fractures versus tibial and femoral stress fractures during elite training. Foot Ankle Int. 2011 Jan. 32(1):16-20. [Medline].

  6. Balius R, Pedret C, Estruch A, Hernández G, Ruiz-Cotorro A, Mota J. Stress fractures of the metacarpal bones in adolescent tennis players: a case series. Am J Sports Med. 2010 Jun. 38(6):1215-20. [Medline].

  7. Hetsroni I, Nyska M, Ben-Sira D, Mann G, Segal O, Maoz G, et al. Analysis of foot structure in athletes sustaining proximal fifth metatarsal stress fracture. Foot Ankle Int. 2010 Mar. 31(3):203-11. [Medline].

  8. Polzer H, Polzer S, Mutschler W, Prall WC. Acute fractures to the proximal fifth metatarsal bone: development of classification and treatment recommendations based on the current evidence. Injury. 2012 Oct. 43(10):1626-32. [Medline].

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

  10. Fujitaka K, Taniguchi A, Isomoto S, Kumai T, Otuki S, Okubo M, et al. Pathogenesis of Fifth Metatarsal Fractures in College Soccer Players. Orthop J Sports Med. 2015 Sep. 3 (9):2325967115603654. [Medline].

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

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

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

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

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

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

  17. 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. 2002 Mar. 43(2):207-12. [Medline].

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

  19. 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. 2009 Jun 30. epub ahead of print. [Medline].

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

  21. Tsukada S, Ikeda H, Seki Y, Shimaya M, Hoshino A, Niga S. Intramedullary screw fixation with bone autografting to treat proximal fifth metatarsal metaphyseal-diaphyseal fracture in athletes: a case series. Sports Med Arthrosc Rehabil Ther Technol. 2012 Jul 20. 4(1):25. [Medline]. [Full Text].

  22. 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. 2009 May 5. epub ahead of print. [Medline].

  23. Smith JT, Halim K, Palms DA, Okike K, Bluman EM, Chiodo CP. Prevalence of vitamin D deficiency in patients with foot and ankle injuries. Foot Ankle Int. 2014 Jan. 35(1):8-13. [Medline].

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

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

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

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

  28. 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. 2007 Aug. 41(8):510-4. [Medline].

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

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

  31. 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. 2006 Nov. 35(11):532-6. [Medline].

  32. 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. 2007 Jan-Feb. 97(1):81-4. [Medline].

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

  34. 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. 2007 Feb 2. epub ahead of print. [Medline].

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

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

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

  38. Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M. 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. 1984 Feb. 66(2):209-14. [Medline]. [Full Text].

  39. Ferguson KB, McGlynn J, Jenkins P, Madeley NJ, Kumar CS, Rymaszewski L. Fifth metatarsal fractures - Is routine follow-up necessary?. Injury. 2015 Aug. 46 (8):1664-8. [Medline].

  40. Weel H, Mallee WH, van Dijk CN, Blankevoort L, Goedegebuure S, Goslings JC, et al. The effect of concentrated bone marrow aspirate in operative treatment of fifth metatarsal stress fractures; a double-blind randomized controlled trial. BMC Musculoskelet Disord. 2015 Aug 20. 16:211. [Medline].

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