eMedicine Specialties > Sports Medicine > Foot and Ankle
Metatarsal Stress Fracture: Treatment & Medication
Updated: Aug 12, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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.
Other Treatment (Injection, manipulation, etc.)
Albisetti et al reported their experience with diagnosing and treating stress fractures at the base of the second and third metatarsals in young ballet dancers from 2005-2007.29 Of 150 trainee ballet dancers, 19 had stress fractures of the metatarsal bone bases. All of the dancers were recommended to rest, but external shockwave therapy (ESWT) was also used in 18 and electromagnetic fields (EMF) and low-intensity ultrasonography was used in 1, with good results in each case.29
Albisetti advised the best approach to metatarsal stress fractures is early diagnosis with clinical examination and radiologic studies such as x-ray and MRI. The investigators also noted ESWT led to good results, with a relatively short time of rest from the patients' activities and a return to dancing without pain.29 However, further study is warranted given the small study size and that all but one of the young dancers received ESWT.
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
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.
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.
Ibuprofen (Advil, Motrin)
DOC for mild to moderate pain, if there are no contraindications. Ibuprofen inhibits inflammatory reactions and pain by inhibiting the activity of cyclooxygenase, which reduces prostaglandin synthesis.
Adult
200-800 mg PO q6-8h; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided q6h
>12 years: Administer as in adults
May decrease effects of loop diuretics with coadministration; coadministration with anticoagulants may increase PT duration (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity; probenecid may increase toxicity of NSAIDs
Documented hypersensitivity to ibuprofen, other NSAIDs, or aspirin; avoid in peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients who have congestive heart failure, hypertension, and decreased renal and hepatic function; caution in patients with anticoagulation abnormalities or during anticoagulant therapy
Ketoprofen (Orudis, Actron, Oruvail)
For relief of mild to moderate pain and inflammation. Small dosages are indicated initially in patients with small body size, elderly patients, and those with renal or liver disease. Doses >75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe patient for response.
Adult
25 to 50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
May decrease effects of loop diuretics with coadministration; coadministration with anticoagulants may increase PT duration (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate and phenytoin toxicity; probenecid may increase toxicity of NSAIDs
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients who have congestive heart failure, hypertension, and decreased renal and hepatic function; caution in patients with anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Aleve, Naprelan, Naprosyn, Anaprox)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.
Adult
500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Probenecid may increase toxicity of NSAIDs; coadministration with ibuprofen may decrease effects of loop diuretics; coadministration with anticoagulants may increase PT duration (watch for signs of bleeding); NSAIDs may increase serum lithium levels and risk of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity)
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion, risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrant further evaluation and may require discontinuation of drug
Flurbiprofen (Ansaid)
May inhibit cyclooxygenase enzyme, which in turn inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Adult
200-300 mg/d PO divided bid/qid
Pediatric
Not established
May decrease effects of loop diuretics with coadministration; coadministration with anticoagulants may increase PT duration (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity; probenecid may increase toxicity of NSAIDs
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May decrease effects of loop diuretics with coadministration; coadministration with anticoagulants may increase PT duration (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity; probenecid may increase toxicity of NSAIDs
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.
Acetaminophen (Tylenol, Panadol, Paracetamol)
DOC for pain in patients with documented hypersensitivity to aspirin, NSAIDs, diagnosed with upper GI disease or on oral anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G6PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Rifampin can reduce analgesic effects of acetaminophen
Hydrocodone bitartrate with acetaminophen (Vicodin, Lortab, Lorcet HD)
Drug combination indicated for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 750 mg PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24h
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity to acetaminophen or hydrocodone; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite which may cause hypersensitivity; caution in patients who are dependent on opiates since this substitution may result in acute opiate withdrawal symptoms; caution in patients with severe renal or hepatic dysfunction
Propoxyphene and acetaminophen (Darvocet-N 100, Wygesic)
Drug combination indicated for mild to moderate pain.
Adult
1-2 tab PO q4h prn; not to exceed 600 mg/d
Pediatric
Not established
May increase serum concentrations of MAO inhibitors, tricyclic antidepressants, carbamazepine, phenobarbital, and warfarin
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients who are dependent on opiates, as substitution may result in acute opiate withdrawal symptoms; caution in patients with severe renal or hepatic dysfunction
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 |
| « Previous Page | Next Page » |
References
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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].
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
