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METATARSAL STRESS FRACTURES
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What is it?

The metatarsal bones are the five long, skinny foot bones in the foot that connect the tarsal bones to the toes. The metatarsals sustain the greatest impact on the foot during walking, running or jumping. The metatarsals are the second most common site for stress fractures, which are small cracks in the bone.

Most stress fractures are caused by overuse and repetitive activity. As the demand placed on a bone exceeds the bone’s ability to withstand that force, a stress fracture occurs. Unlike breaking a bone after trauma, stress fractures develop slowly over time. The initial weakening of the bone is called a stress reaction, which can develop into a stress fracture if repetitive loading continues. Stress fractures are common in runners, dancers, military personnel and other running and jumping sports.

 

Symptoms/Risks

The most common symptom of a stress fracture is pain, which can progress from a dull ache to a sharp pain when untreated. In the early stages, pain diminishes with rest, but later it can occur at rest and during the night. Swelling and bruising of the foot may also be present.

There are three main risk factors for developing metatarsal stress fractures:

1. Sudden change in activity: increasing the amount or intensity of activity too rapidly or changing the surface of your workout.

2. Low bone density or insufficient nutrition to maintain bone strength: if osteoporosis or another nutrient deficiency has weakened the bones, even everyday activities may result in a stress fracture.

3. Improper body mechanics.

 

Sports Medicine Evaluation & Treatment

If you visit a sports medicine physician, he/she will perform a history and physical exam and determine if imaging is necessary. The doctor will ask about the type and amount of your physical activity, including any recent changes. He/she will review your medical history, medications, eating habits, history of stress injuries to the bone, menstrual history (for females), family history of osteoporosis or other bone related disorders and footwear.

Your doctor will perform a physical examination with a focus on the foot and ankle, including palpating for tenderness in areas at risk for stress fracture. He/she may analyze your gait and footwear as well.

Your doctor may order imaging to assist in diagnosis. An x-ray of the foot will often appear normal for many weeks, despite the presence of a stress fracture. The injury will not become evident until weeks later when the bone has started healing and there is callus formation (new bone formation) at the site of the stress fracture. If a stress fracture is suspected, but not seen on an x-ray, an ultrasound, bone scan or a magnetic resonance imaging (MRI) scan may be recommended. These tests can detect stress fractures earlier than x-rays. These scans are not always necessary if your doctor is confident in the diagnosis.

Treatment includes rest from any painful activities, which often starts with using crutches or a walking boot. Rarely, a stress fracture may require surgery to properly heal. It is important that you and your doctor work together in treating both the root cause and the acute injury. You may need a DEXA scan to measure your bone density, and blood work to measure your calcium and vitamin D levels. You may require physical therapy or orthotics to correct your body mechanics.

 

Injury Prevention

1. Gradually increase your activity intensity and distance.

2. Eat a healthy diet. Ask your doctor if you should supplement with vitamin D, calcium, or iron.

3. Wear proper footwear.

4. Add strength training to your workout routine to prevent early muscle fatigue and the loss of bone density that comes with aging.

 

Return to Play

Stress fractures typically take 6-8 weeks to heal. During this time, your doctor will guide you through a progression back to activity. You will need clearance from your doctor before returning to impact activities or team sports.

AMSSM Member Authors
Morgan B. Anderson MD and Karl V. Reisig MD

References
Clugston JR and Hatch RL. Stress fractures of the metatarsal shaft. In: UpToDate, Eiff P, Asplund CA, Grayzel J (ed). Waltham, MA, 2018.
Mayer SW, et al. Stress fractures of the foot and ankle in athletes. Sports Health. 2014. 6(6): 481-491.

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