Metatarsal Stress Fracture
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.
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.
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.
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
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.
Increased intensity, duration, or frequency of exercise
Insufficient rest periods
Continuing to train despite pain
Female athletic triad