A metatarsal stress fracture is a condition characterized by an incomplete crack in one of the metatarsal bones. There are five metatarsal bones each of which is located in the forefoot. Several muscles attach to the metatarsal bones. When these muscles contract, a pulling force is exerted on the respective bones. Furthermore, weight bearing activity places load through the metatarsals. When these forces are excessive or too repetitive and beyond what the bone can withstand, bony damage can gradually occur. This initially results in a bony stress reaction, however, with continued damage may progress to a metatarsal stress fracture. Of the metatarsals, the second metatarsal (next to the big toe) is most commonly affected.
A stress fracture of the metatarsal typically occurs over time with excessive weight bearing activity such as running, sprinting, jumping or dancing. They often occur following a recent increase in activity or change in training conditions. Patients with this condition typically experience pain at the top of the foot that increases with impact activity such as running, dancing or standing on toes. Occasionally, patients may notice redness and swelling at the stress fracture site. In more severe cases, walking may be enough to aggravate symptoms and patients may experience pain with rest. Other symptoms may include night ache, pain on squeezing the forefoot or pain on firmly touching the affected metatarsal bone.
Diagnosis of a metatarsal stress fracture
A thorough subjective and objective examination from a physician may be sufficient to diagnose a metatarsal stress fracture. Further investigations such as an X-ray, MRI, CT scan or bone scan are usually required to confirm diagnosis and determine the severity of injury.
Treatment for a metatarsal stress fracture
Treatment for a stress fracture of the metatarsal typically involves an initial period of 4 – 8 weeks rest from weight bearing activity with crutches. Following this, a gradual increase in weight bearing activity and exercise can usually occur as tolerated, provided symptoms do not increase. This should take place over a period of weeks to months with direction from the treating physiotherapist and will vary depending on the severity of the injury.
Patients should also perform pain-free flexibility and strengthening exercises under guidance by the treating therapist as part of their rehabilitation to ensure an optimal outcome. Alternative exercises placing minimal force through the affected bone should be performed to maintain fitness such as swimming. The treating therapist can advise which exercises are most appropriate for the patient and when they should be commenced.
Contributing factors to the development of a metatarsal stress fracture
There are several factors which may contribute to the development of this condition. These need to be assessed and corrected with direction from the treating therapist. Some of these factors include:
- poor foot posture (especially flat feet)
- muscle weakness
- poor flexibility
- ankle joint stiffness
- inappropriate footwear (especially high heels or tight shoes)
- inadequate diet
- inappropriate or excessive training (particularly on hard or uneven surfaces).
Therapy for a metatarsal stress fracture
Therapy treatment for patients with this condition is vital in to hasten healing, prevent injury recurrence and ensure an optimal outcome. Treatment may comprise:
soft tissue massage
- joint mobilization
- electrotherapy (e.g. ultrasound)
- dry needling
- the use of crutches
- activity modification advice
- biomechanical correction
- exercises to improve strength, balance and flexibility
- a gradual return to activity plan
Other intervention for a metatarsal stress fracture
Despite appropriate management, some patients with this condition do not improve and require other intervention to ensure an optimal outcome. The treating 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, extended periods of non weight bearing immobilization, review with a podiatrist for possible orthotics or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the metatarsal stress fracture. Occasionally, patients with this condition may require surgery to stabilize the stress fracture and aid healing.