Metatarsal Stress Fractures in the Athletic Population
Original Editors - Heba Riyaz Abdulla as part of The University of Waterloo Clinical Biomechanics Project
Definition/ Description[edit | edit source]
A metatarsal stress fracture is when a metatarsal bone of the foot experiences a crack or break due to biomechanical stresses applied to the tissue. This can take place in multiple metatarsals at the same time and can be at the head, shaft or base of the bone. Theses fractures are very common in athletes such as runners, basketball players, and ballet dancers, and soccer players. They are also more common in adolescents as their bones are still developing. The metatarsals bear most of the body’s weight while walking and running, subsequently, the repetitive, submaximal loading of a bone, leads to microfractures which are unable to heal due to bone resorption and bone formation imbalances, causing a stress reaction leading to fractures.
Figure 1. Types of forces
The most common way to fracture the metatarsal is when shear forces are acting on the bone. In comparison to the other types, metatarsals are most vulnerable to shear forces. The fifth metatarsal the most susceptible bone to these shear forces. This combination puts the fifth metatarsal at the highest likelihood of fracture – 59%. Stress fractures of the medial malleolus are generally found in athletes involved in running, jumping, and kicking sports.
Runners[edit | edit source]
While running, there are increased shear forces on the first and second metatarsals. The fixed bases and proximal hinged metatarsophalangeal joints create a bending moment at the proximal diaphysis during the stance phase of gait. A relatively long second metatarsal and an excessively mobile first ray (Morton foot) increase this force even further.
Additionally women have a higher middle forefoot loading force than men. These anatomical and biomechanical characteristics may play a role in the development of stress fractures in runners.
Basketball Players[edit | edit source]
Another common fracture is an avulsion fracture, which is caused by tensile forces. These forces can pull apart the axial end of the bone. The avulsion fracture is more often due to peroneus brevis tugging on the fifth metatarsal. When the ankle is plantar flexed, an avulsion fracture can occur if the metatarsal is suddenly jerked into a different position, creating high tension in muscle and the plantar fascia.
Fractures like this are very often found in basketball players while running and jumping. When they experience repetitive tensile forces or sudden tensile forces, this could lead to a stress fracture.
Clinical studies show distal metatarsal stress fractures are initially treated conservatively with activity modification for 6 to 8 weeks with gradual return to sports when asymptomatic. Use of orthotics like stiff-soled shoe, walker boot, or short leg walking cast along with midfoot taping has also proved beneficial.
Ballet Dancers[edit | edit source]
Repetitive compressive forces can lead to stress fractures and these ones are oblique in nature. The second and third metatarsals are most at risk during ballet in the en pointe position due to the locking of the second metatarsal base and cuneiforms in extreme plantar flexion . The strain caused by this on the ligaments and bones of the foot, especially around the Lisfranc – tarso-metatarsal joints. When dancing en pointe, the centre of gravity gets shifted more anteriorly to the shaft of the metatarsals, which puts more compressive forces on the metatarsals. When these forces are sudden or they are repetitive – where the muscles and bones are not strong enough yet – this could lead to a stress fracture.
Figure 2. Lis Franc Fracture to the second and fourth metatarsal
Studies show successful return to dancing at a mean 4.6 weeks and return to full pointe at a mean 18 days later without subsequent pain or nonunion, when treated with medium energy external shock wave and ultrasound and a period of 3 to 5 weeks of weightbearing rest. Nonsurgical management with non-weightbearing or weightbearing in a regular shoe or short leg cast showed great improvement and surgical treatment of nonunion often include drilling procedures and open reduction internal fixation. A recent systematic review shows that physiotherapeutic interventions have positive effects in several domains, including pain, ROM, and functional status, thus have a potential role in the treatment of ballet dancers after injuries. However, the small evidence base and methodological limitation of the review calls for a cautious approach while considering the physiotherapy as option for managing injuries in a ballet dancer
Soccer Players[edit | edit source]
Torsion can also cause stress fractures. It was found that the insertions of peroneus longus and peroneus tertius induce strain on the fifth metatarsal. Due to their position, there is torsion created on the metatarsal. When the metatarsal is exposed to these forces repetitively, it leads to a stress fracture. This particular fracture happens at the base of the fifth metatarsal and is known as a Jones’ fracture and commonly found in basketball and soccer players.
Figure 3. Peroneus Muscles
There are studies that show correlations between decreased muscular strength and increased chance of fracture. If the muscles are strong and flexible, it improves the foot stability and allows them to stretch enough without tearing. A study with soccer players showed that those who had less toe grip strength were significantly more prone to stress fractures. The metatarsals can only sustain a certain amount of load depending on the strength of the muscles surrounding them as well as the bones itself. These muscles include flexor hallucis longus, flexor hallucis brevis, flexor digitorum longus, flexor digitorum brevis, and the lumbricals.
Summary[edit | edit source]
Metatarsal stress fractures can occur over time or due to sudden force. Different forces lead to distinctive fractures. While these can happen to anyone, they are more likely to emerge in the athletic population as they experience more strain than people performing daily activities. These fractures have been found to transpire in people who have weaker muscles and consequently there is not enough support given to the metatarsals and they are more liable to stress fractures. Education and risk factor modification/optimization play a key role in prevention of these fractures.
References[edit | edit source]
- Mayer SW, Joyner PW, Almekinders LC, Parekh SG. Stress fractures of the foot and ankle in athletes. Sports Health. 2014 Nov;6(6):481-91. doi: 10.1177/1941738113486588.
- Hatch R, Alsobrook J, Clugston J. Diagnosis and Management of Metatarsal Fractures. 2017. Available from: https://www.aafp.org/afp/2007/0915/p817.html
- Cakir H, Van Vlit-Koppert ST, Van Lieshout EM, De Vries MR, Van Der Elst M, Schepers T, Demographics and outcome of metatarsal fractures. Archives of Orthopaedic and Trauma Surgery (2011); 131: 241-245.
- Prather JL, Nusynowitz ML, Snowdy HA, Hughes AD, McCartney WH, Bagg RJ. Scintigraphic findings in stress fractures. J Bone Joint Surg Am. 1977 Oct; 59(7):869-74
- Gehrmann RM, Renard RL. Current concepts review: stress fractures of the foot. Foot Ankle Int. 2006;27:750-757
- Albisetti W, Perugia D, De Bartolomeo O, Tagliabue L, Camerucci E, Calori G. Stress fractures of the base of the metatarsal bones in young trainee ballet dancers. International Orthopaedics,2009 ;34(1):51-55. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899256/
- [Internet]. 2021 [cited 19 April 2021]. Available from: https://commons.wikimedia.org/wiki/File:Lisfranc_fracture.jpg
- Sarimo J, Orava S, Alanen J. Operative treatment of stress fractures of the proximal second metatarsal. Scand J Med Sci Sports. 2007;17:383-386
- Skwiot M, Śliwiński Z, Żurawski A, Śliwiński G. Effectiveness of physiotherapy interventions for injury in ballet dancers: A systematic review. PLoS one. 2021 Jun 24;16(6):e0253437.
- Vertullo C, Glisson R, Nunley J. Torsional Strains in the Proximal Fifth Metatarsal: Implications for Jones and Stress Fracture Management. Foot & Ankle International. 2004;25(9):650-656. Available from: https://pubmed.ncbi.nlm.nih.gov/15563388/
- Bowes J, Buckley R. Fifth metatarsal fractures and current treatment. World Journal of Orthopedics . 2016;7(12):793. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5155254/
- Russell J. Preventing dance injuries: current perspectives. Open Access Journal of Sports Medicine. 2013, 199. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3871955/
- Fujitaka K, Taniguchi A, Isomoto S, Kumai T, Otuki S, Okubo M et al. Pathogenesis of Fifth Metatarsal Fractures in College Soccer Players. Orthopaedic Journal of Sports Medicine. 2015;3(9):232596711560365. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3871955/
- Soma M, Murata S, Kai Y, Nakae H, Satou Y. Strength and muscle activities during the toe-gripping action: comparison of ankle angle in the horizontal plane between the sitting upright and standing positions. Journal of Physical Therapy Science. 2016 ;28(3):992-995. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4842480/#:~:text=Toe%20gripping%20is%20defined%20as,%2C%20and%20flexor%20longus1).