Metatarsal Fracture Risk Factors and Diagnosis

A metatarsal fracture is a condition characterized by a break in one of the long bones of the mid foot known as the metatarsals.

The foot comprises of many small bones, 5 of which are the long bones known as the metatarsals which are situated beside each other in the mid section of the foot.

These bones form joints with the proximal phalanges and tarsal bones.

During certain activities such as landing from a jump, or when rolling an ankle, stress is placed on the metatarsal bones.

When this stress is traumatic and beyond what the bones can withstand a break in one or more of the metatarsals may occur. This condition is known as a metatarsal fracture.

Often a metatarsal fracture occurs in combination with other injuries such as a sprained ankle or other fractures of the foot, ankle or lower leg (such as following trauma).

Of the metatarsal bones, the 5th metatarsal is the most commonly affected.

Metatarsal fractures can vary in location, severity and type including avulsion fracture, stress fracture, Jones’ fracture, displaced fracture, un-displaced fracture, spiral fracture, greenstick, comminuted etc.

Causes of a metatarsal fracture

A metatarsal fracture commonly occurs in association with a rolled ankle, particularly when the ankle has rolled inwards, and when significant weight bearing forces are involved.

They may also occur due to an awkward landing from a jump (particularly on uneven surfaces), due to a fall or following a direct blow to the foot.

Metatarsal fractures are relatively common in running and jumping sports involving change of direction such as football, soccer, rugby, basketball and netball and in dancing (e.g. ballet).

A metatarsal stress fracture may occur due to repetitive stress associated with excessive running or overuse.

Signs and symptoms of a metatarsal fracture

Patients with this condition typically experience a sudden onset of sharp, intense foot or ankle pain at the time of injury. Sometimes the patient may have heard an audible snapping sound at the time of injury.

The pain often causes the patient to limp or be unable to weight bear so as to protect the foot. Pain is usually felt in the foot or ankle and can occasionally settle quickly leaving patients with an ache at the site of injury that may be particularly prominent at night or first thing in the morning.

Patients with a metatarsal fracture may also experience swelling, bruising and pain on firmly touching the affected region of bone.

Pain may also increase during certain movements of the foot or ankle or when standing or walking (particularly up hills or on uneven surfaces).

In severe metatarsal fractures (with bony displacement), an obvious deformity may be noticeable.

Diagnosis of a metatarsal fracture

A thorough subjective and objective examination from a physiotherapist is essential to assist with diagnosis of a metatarsal fracture.

An X-ray is usually required to confirm diagnosis and assess the severity. Further investigations such as an MRI, CT scan or bone scan may be required, in some cases, to assist with diagnosis and assess the severity of the injury.

Treatment of Metatarsal Fractures

Breaks in the metatarsal bones may be either stress or traumatic fractures. Certain kinds of fractures of the metatarsal bones present unique challenges.

For example, sometimes a fracture of the first metatarsal bone (behind the big toe) can lead to arthritis.

Since the big toe is used so frequently and bears more weight than other toes, arthritis in that area can make it painful to walk, bend, or even stand.

Another type of break, called a Jones fracture, occurs at the base of the fifth metatarsal bone (behind the little toe).

It is often misdiagnosed as an ankle sprain, and misdiagnosis can have serious consequences since sprains and fractures require different treatments.

Your foot and ankle surgeon is an expert in correctly identifying these conditions as well as other problems of the foot.

Treatment of metatarsal fractures depends on the type and extent of the fracture, and may include:

Rest. Sometimes rest is the only treatment needed to promote healing of a stress or traumatic fracture of a metatarsal bone.

Avoid the offending activity. Because stress fractures result from repetitive stress, it is important to avoid the activity that led to the fracture.

Crutches or a wheelchair are sometimes required to offload weight from the foot to give it time to heal.

Immobilization, casting, or rigid shoe. A stiff-soled shoe or other form of immobilization may be used to protect the fractured bone while it is healing.

Surgery. Some traumatic fractures of the metatarsal bones require surgery, especially if the break is badly displaced.

Follow-up care. Your foot and ankle surgeon will provide instructions for care following surgical or non-surgical treatment. Physical therapy, exercises and rehabilitation may be included in a schedule for return to normal activities.

Prognosis of a metatarsal fracture

Patients with a metatarsal fracture usually make a full recovery with appropriate management (whether surgical or conservative).

Return to activity or sport can usually take place in weeks to months and should be guided by the treating physiotherapist and specialist. In patients with severe injuries involving damage to other bones, soft tissue, nerves or blood vessels, recovery time may be significantly prolonged.

In patients with only very minor fractures that are un-displaced (such as an avulsion fracture) return to sport can sometimes occur in as little as 6 – 8 weeks as guided by the treating physiotherapist.

Physiotherapy for a metatarsal fracture

Physiotherapy treatment is vital in all patients with this condition to hasten healing and ensure an optimal outcome. Treatment may comprise:

  • soft tissue massage
  • joint mobilization
  • electrotherapy (e.g. ultrasound)
  • taping or bracing
  • the use of a protective boot
  • the use of crutches
  • exercises to improve strength, flexibility and balance
  • hydrotherapy
  • education
  • activity modification
  • a graduated return to activity plan

Other intervention for a metatarsal fracture

Despite appropriate physiotherapy management, some patients with this condition do not improve adequately and may require other intervention.

The treating physiotherapist or doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, CT scan, MRI or bone scan, periods of plaster cast immobilization or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the metatarsal fracture.

Occasionally, patients who were initially managed conservatively may require surgery to stabilize the fracture and/or a bone graft to aid fracture healing.

Exercises for a metatarsal fracture

The following exercises are commonly prescribed to patients with a metatarsal fracture following confirmation that the fracture has healed or that pain free mobilization can commence as directed by the surgeon or physiotherapist.

You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.

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