Metatarsal Stress Fractures – Causes, Symptoms, Treatment

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Metatarsal Stress Fractures was first described in 1855, termed after the foot pain and swelling experienced by Prussian soldiers on long marches. March fractures are metatarsal fractures, caused by repetitive stress. Intrinsic patient and extrinsic environmental risk factors can both contribute to the development of these fractures. A combination of historical features and physical evaluation with imaging can help make the diagnosis. These stress fractures are typically managed conservatively but can be complicated by nonunion. In such instances, surgical fixation may be warranted.

Pathophysiology

Common in new military recruits, a pervading theory is that osteoblastic activity lags behind osteoclastic activity during initial increases of exercise stress, leading to an increased incidence of stress fractures. March fractures occur secondary to bone fatigue or bone insufficiency. Bone fatigue occurs when normal bone is unable to resist excessive mechanical demands. Bone insufficiency occurs when normal strain occurs on abnormal bone. Intrinsic risk factors as nutritional deficiencies as vitamin D or calcium increase the risk of these fractures. In addition, extrinsic risk factors as the training type or shoe type can also contribute to an increased risk of metatarsal stress fractures.

Classification System

Kaeding and Miller’s 5-Tier Grading System

Grade of Stress Fracture/Radiographic Finding

  • Asymptomatic radiographic findings
  • Pain with no fracture on imaging
  • Nondisplaced fracture on imaging
  • Displaced fracture on imaging
  • Sclerotic nonunion on imaging

Causes of Metatarsal Stress Fractures

March fractures are metatarsal fractures, most commonly second and third metatarsal fractures caused by an overuse injury.

  • The repetitive impact – to the metatarsals with weight-bearing exercises cause microfractures, which consolidate to stress fractures.
  • The most common location of metatarsal stress fractures – is the second metatarsal neck as it is less flexible and prone to torsional forces given its strong ligamentous attachment to the 1 and 2 cuneiforms.  In addition, the second metatarsal is the longest of the metatarsals, subjected to the most force.
  • Heavy impact – The force of a jump or fall can result in a broken ankle. It can happen even if you jump from a low height.
  • Missteps – You can break your ankle if you put your foot down awkwardly. Your ankle might twist or roll to the side as you put weight on it.
    Sports – High-impact sports involve intense movements that place stress on the joints, including the ankle. Examples of high-impact sports include soccer, football, and basketball.
  • Car collisions – The sudden, heavy impact of a car accident can cause broken ankles. Often, these injuries need surgical repair. The crushing injuries common in car accidents may cause breaks that require surgical repair.
  • Falls – Tripping, and falling can break bones in your ankles, as can landing on your feet after jumping down from just a slight height.
  • Missteps – Sometimes just putting your foot down wrong can result in a twisting injury that can cause a broken bone.

Symptoms of Metatarsal Stress Fractures

Symptoms of fractures include

  • Pain with or after normal activity
  • Pain that goes away when resting and then returns when standing or during activity
  • Pinpoint pain (pain at the site of the fracture) when touched
  • Swelling but no bruising
  • Bruising or discoloration that extends to nearby parts of the foot
  • Pain with walking and weight-bearing
  • Swelling in the heel area
  • Pain at the site of the fracture, which in some cases can extend from the foot to the knee.
  • Significant swelling, which may occur along the length of the leg or maybe more localized.
  • Blisters may occur over the fracture site. These should be promptly treated by a foot and ankle surgeon.
  • Bruising that develops soon after the injury.
  • Inability to walk; however, it is possible to walk with less severe breaks, so never rely on walking as a test of whether or not a bone has been fractured.
  • Change in the appearance of the ankle—it will look different from the other ankle.
  • Bone protruding through the skin—a sign that immediate care is needed. Fractures that pierce the skin require immediate attention because they can lead to severe infection and prolonged recovery.

Diagnosis of Metatarsal Stress Fractures

During an interview, patients indicate that there is an inciting activity or exercise subjecting the patient to repetitive stress. Activity-related, insidious onset of pain at the site of fracture is often elicited from history. Pain may improve transiently with rest but increases again with activity. Pain often is described as dull and aching. It is important to obtain a thorough medical history with particular attention to potential intrinsic risk factors. This may include an interview on a patient’s diet, endocrine disorders, and menstrual history in female patients.

Physical examination consists of palpation of the pain site, eliciting boney tenderness. If the fracture is in the proximity of a joint, the joint motion will aggravate the pain. Patients may have a limping gait with weight-bearing.

History and Physical

  • These patients typically present with pain about the lateral aspect of the forefoot that is worse with weight-bearing activity. This pain may occur in the setting of acute trauma or repetitive microtrauma over weeks to months. One should be suspicious of stress fracture with antecedent pain or pain of worsening quality or duration over time. The examiner must obtain a thorough past medical history and social history to make treatment decisions and optimize patients with surgical indications. It is important to evaluate the skin for open injuries that may require more urgent debridement.
  • Physical examination may reveal tenderness to palpation, swelling, and ecchymosis at the site of injury. Patients will also have pain with resisted foot eversion. It is critical to evaluate the patient for other injuries, including injury to the lateral ankle ligamentous structures and Lisfranc injury.
  • An exam of the circulatory system, feeling for pulses, and assessing how quickly blood returns to the tip of a toe after it is pressed and the toe turns white (capillary refill).
  • A neurologic exam, assessing sensation such as light touch and pinprick sensations
  • Motor function, asking the patient to move the injured area. This assists in assessing muscle and tendon function. The ability to move the foot means only that the muscles and tendons work, and does not guarantee bone integrity or stability. The concept that “it can’t be broken because I can move it” is not correct.
  • A range of motion exam of the foot may be helpful in assessing ligament stability. However, if the fracture is obvious, the health care practitioner may choose to keep the foot immobilized to prevent further pain.

Imaging

  • X-rays – are often taken to evaluate the status of the bones in the foot and to check for a fracture. Usually, three views are taken to help the health care professional and radiologist adequately view the bones. Special views may be taken if there is a concern for a fracture of the calcaneus. X-rays may not be taken for simple toe injuries, since the result may not affect the treatment plan.
  • For some foot fractures, X-rays – may not be adequate to visualize the injury. This is often true for metatarsal stress fractures, where bone scans may be used if the history and physical examination suggest a potential stress fracture, but the plain X-rays are normal.
  • Computerized tomography (CT) – may be used to assess fractures of the calcaneus and talus, since it may better be able to illustrate the anatomy of the ankle and midfoot joint and potential associated injuries. Magnetic resonance imaging (MRI) may be used in some cases of foot fractures.
  • The Lisfranc joint describes  – the connection between the first, second, and third metatarsals and the three cuneiform bones. A Lisfranc fracture-dislocation often requires a CT scan to evaluate this region of the foot. While X-rays may hint at the damage in this type of injury, the CT scan delineates the numerous bones and joints that may be damaged.
  • Clinical tests – such as the use of therapeutic ultrasound and tuning forks are also useful in diagnostic investigations on stress fractures. When used directly on the site of the suspected lesion, they may trigger or worsen the pain because of the great local osteoclastic reabsorption, which results in injury to the periosteum., In addition, the skipping rope test (hop test) can be used: this consists of asking the patient to hop on the spot while putting weight on the limb that is under investigation. The test is positive when it triggers strong or incapacitating pain in the region injured.,
  • Some laboratory tests – may be useful in investigating stress fractures: serum levels of calcium, phosphorus, creatinine, and 25(OH)D3. Nutritional markers should be requested in the presence of clinical conditions of weight loss and anorexia. Hormonal levels (FSH and estradiol) should be investigated when there is a history of dysmenorrhea.
  • Computed tomography (CT) – is used mainly when there is a contraindication against using magnetic resonance imaging., , , Chronic and quiescent lesions may be more evident in this examination than on magnetic resonance imaging or bone scintigraphy because they present low bone turnover. Single-photon emission CT (SPECT) has been particularly more useful in investigating stress fractures involving the dorsal spine, and specifically in pars interarticularis (spondylolysis)., ,
  • Nuclear medicine using triple-phase scintigraphy – (technetium-99 m) presents significant sensitivity (74–100%) to bone remodeling and shows imaging alterations three to five days after the start of symptoms. , , , The radiopharmaceutical becomes concentrated in the regions affected and detects areas of bone remodeling, microfractures of the trabecular bone, periosteal reaction, and formation of bone callus.
  • Magnetic resonance imaging (MRI) – is the most sensitive and specific imaging examination for diagnosing stress fractures. It is recommended by the American College of Radiology as the preferred examination in the absence of radiographic alterations. The abnormalities caused by the fracture can be identified one to two days after the start of the symptoms, with early detection of edema in the bone tissue and adjacent areas., , This examination makes it possible to differentiate medullary damage from cortical, endosteal, and periosteal damage allows gradation of the lesions regarding their severity and prognosis. Intramedullary endosteal edema is one of the first signs of bone remodeling and may continue to be present for up to six months after the fracture has been diagnosed and treated, while the cortical maturation and remodeling take place., Medullary edema or signs of bone stress may also be present in asymptomatic physically active patients, without any correlation with an increased incidence of stress fractures, especially in the tibia in marathon runners. The fracture line is less commonly visible. It presents sensitivity slightly greater than or equal to that of scintigraphy, but it is considered to be a more specific examination., ,

Treatment of Metatarsal Stress Fractures

Fractures of the toe bones are almost always traumatic fractures. Treatment for traumatic fractures depends on the break itself and may include these options:

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Initial Treatment Includes

  • Get medical help immediately – If you fall on an outstretched leg, get into a car accident or are hit while playing a sport and feel intense pain in your leg area, then get medical care immediately. Cause significant pain in the front part of your leg closer to the base of your leg. You’ll innately know that something is seriously wrong because you won’t be able to lift your leg up above the heart level. Cleaning and treating any wounds on the skin of the injured hand.
  • Aggressive wound care – as needed for contaminated wounds. Clear with disinfectant material 
  • ICE and elevation – It help for prevention swelling, edema
  • Rest – Sometimes rest is all that is needed to treat a traumatic fracture of the toe.mSometimes rest is the only treatment needed to promote healing of a stress or traumatic fracture of a metatarsal bone.
  • Elevation – Elevation initially aims to limit and reduce any swelling. For example, keep the foot up on a chair to at least hip level when you are sitting. When you are in bed, put your foot on a pillow. Sometimes rest is the only treatment that is needed, even in traumatic fracture.
  • Splinting – The toe may be fitted with a splint to keep it in a fixed position.
  • Rigid or stiff-soled shoes – Wearing a stiff-soled shoe protects the toe and helps keep it properly positioned. Use of a postoperative shoe or boot walker is also helpful.
  • Buddy taping the fractured toe to another toe is sometimes appropriate, but in other cases, it may be harmful.
  • 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 another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
  • Casting, or rigid shoe A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
  • Stop stressing the foot – If you’ve been diagnosed with a stress fracture, avoiding the activity that caused it is important for healing. This may mean using crutches or even a wheelchair.

Medication

The following medications may be considered doctor to relieve acute and immediate pain

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Surgery

Treatment decisions have their basis on the anatomic zone of injury, the social and medical history of the injured patient, and evidence of radiographic signs of healing.

  • Nondisplaced zone 1 injuries – can be treated conservatively with protected weight-bearing in a hard-soled shoe, walking boot, or walking cast. Progression to weight-bearing as tolerated can initiate as pain and discomfort subside over 3 to 6 weeks. Fractures involving 30% of the articular surface or with an articular step off over 2 mm have treatment with open reduction and internal fixation, closed reduction, and percutaneous pinning, or excision of the fragment.
  • Nondisplaced zone 2 injuries or Jones fractures – may also be treated conservatively with 6 to 8 weeks of non-weight bearing in a short leg cast. The physician may advance weight-bearing status as radiographic evidence of bone healing appears. Indications for surgical interventions include the high-performance athlete, the informed patient who elects to proceed with surgical treatment, or displaced fractures. There are many forms of surgical interventions, including intramedullary screw fixation, tension band constructs, and low profile plates and screws. Surgical management of high-performance athletes minimizes the risk of nonunion and prevents prolonged restriction from physical activity.
  • Diaphyseal zone 3 stress fractures – paint a more complicated picture for the patient and physician. A trial of conservative management with non-weight bearing in a short leg cast may be the initial therapy, however, immobilization for up to 20 weeks may be necessary before there is observable radiographic union, and even then, nonunion development is not uncommon. High-performance athletes or individuals with Torg Type II or III fractures may require surgical interventions. Surgical options include intramedullary screw fixation, bone grafting procedures, or a combination of the two.
  • The bone grafting inlay technique – requires removing a 0.7 by 2.0 cm rectangular section of bone at the fracture site and replacing it with an autogenous cortical cancellous bone graft of the same dimensions taken from the anteromedial distal tibia. The medullary cavity must be curetted or drilled until all of the sclerotic bone has been removed and the medullary canal reestablished prior to inserting the donor graft.
  • Nondisplaced dancer’s fractures – and other fractures of the fifth metatarsal shaft and neck receive the same treatment as nondisplaced zone 1 injuries. Weight-bearing status can advance as tolerated by pain. If evidence of delayed union or nonunion exists, surgical interventions may be required. If there is more than 3 mm of displacement or angulation exceeds 10 degrees, the fracture should be reduced and splinted. If the fracture remains mal reduced or there is evidence of loss of reduction on follow-up radiographs, surgical interventions with percutaneous pinning or plate and screw fixation should be a consideration.

Patients treated with intramedullary screw fixation or bone graft inlay technique should remain non-weight bearing in a plaster splint or short leg cast for six weeks with a gradual return to sport or activity.

Other Treatments

Bisphosphonates

Bisphosphonates have the potential to decrease the incidence of stress fractures by decreasing bone turnover by inhibiting osteoclast function. However, a prospective, randomized trial of 324 military recruits showed no difference in the incidence of stress fractures of the lower extremities between those receiving prophylactic risedronate and placebo. There was a trend toward a harmful effect of alendronate treatment in an animal study, possibly due to inhibition of the remodeling of microfractures from woven to the lamellar bone. The 25-year experience of the Israeli Army on prevention of stress fractures showed sleep minimums and training modifications, but not bisphosphonate treatment, decreased the incidence of stress fractures.

Bone Stimulators

There are 2 types of stimulators, electromagnetic stimulators, and ultrasound simulators.

Electromagnetic stimulators generate electromagnetic fields with coils on either side of the fracture. Mechanical stresses cause fluid flow around and through bones that induce electrical currents around cells, which can open calcium channels in cell membranes increasing calmodulin, thus increasing cell proliferation. Very few controlled studies are available that evaluate the efficacy of these stimulators in stress fractures. One such study found no significant difference in time to healing between placebo and those using an electromagnetic simulator. However, when higher grade stress fractures were compared exclusively, there was a significantly shorter time to healing noted, though power was not sufficient to draw conclusions. When compliance was adequate, electromagnetic stimulators correlated to shorter healing times. Despite some early promising results, electromagnetic stimulators have not been shown conclusively to enhance healing in stress fractures.

Pulsed ultrasound bone stimulators – can increase vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF), which promote angiogenesis, and increase alkaline phosphatase, bone sialoprotein, and intracellular calcium (markers of bone metabolism). Most studies report on acute fractures. A systematic review of pulsed ultrasound showed low to moderate grade evidence for a positive effect: there was a 33.6% decrease in radiographic healing time. Stress fractures may respond differently to pulsed ultrasound because they heal through intramembranous remodeling instead of endochondral remodeling as acute fractures do. Literature specifically on stress fractures treated with pulsed ultrasound is sparse. In a military study of 43 tibial shaft stress fractures, there was no significant difference in time to healing using low-intensity pulsed ultrasound. In a rat ulnar stress fracture model, low-intensity pulsed ultrasound alone produced better results than ultrasound and NSAIDs combined as well as controls.

Oral Contraceptives

Low levels of sex steroids are associated with low bone mineral density. Abnormally low levels of sex hormones are seen for 24 to 48 hours in endurance athletes following rigorous training sessions, and secondary amenorrhea causes a hormone-deficient state. Hormone replacement therapy via oral contraceptive pills (OCPs) is controversial. Data suggest that hormone replacement in amenorrheic women and endurance athletes improves bone mineral density. Stress fracture incidence trended lower in the OCP group but was not significant. A military study of female recruits found a fivefold increase in lower extremity stress fractures in women who had been amenorrheic, though OCP use did not have a significant protective effect.

If OCPs are used in exercise-induced hypoestrogenic amenorrhea, other factors such as nutrition status or other hypothalamic perturbations should be worked up and may require treatment, as energy status, calcium intake, and body mass index have proven to be independent predictors of improved BMD and normal bone turnover.

Calcium and Vitamin D

Calcium and vitamin D can improve BMD but are not definitively proven to prevent stress fractures., In track and field athletes and military recruits, no significant difference was found with increased calcium and vitamin D intake and the incidence of all types of stress fractures. One of the largest studies on the topic showed that in female military recruits, 2000 mg of calcium and 800 IU of vitamin D daily had a 20% lower incidence of stress fractures during basic training than those taking a placebo. Another group found that each cup of skim milk consumed daily by female distance runners lowered the rate of stress fracture by 62%. These reports support several previous studies suggesting that low dietary calcium and vitamin D is associated with increased risk of a stress fracture, and adequate intake or supplementation can reduce the risk of stress fractures., The recommended daily dose of calcium depends on age, while vitamin D intake is more controversial. A specific amount of calcium and vitamin D needed to prevent stress fractures has not been determined. In some studies, daily supplementation of 500 to 800 mg of calcium and 400 to 800 IU vitamin D improves BMD and decreases fracture (not specifically stress fracture) risk significantly.,

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Calcitonin

Calcitonin inhibits osteoclasts, the offending agent in the imbalanced remodeling process of stress fractures.,, Increased BMD and biomechanical properties have been shown with calcitonin, but its role in stress fracture prevention or healing is controversial.,,

Orthotics

Several biomechanical studies have shown predictable, repetitive stress patterns in the foot and ankle with weight-bearing., However, there is inconclusive data to support orthotics for the prevention of stress fractures of the foot and ankle. A systematic review of 5 articles on orthotics and stress fractures concluded that orthotic use reduced the overall rate of stress fractures of the proximal femur and tibia in military personnel; no conclusion could be made regarding prevention in stress fractures of the foot and ankle.

New types of therapy

Some new types of therapy for stress fractures are being studied with the aim of achieving faster consolidation and an earlier return to physical activities. These can be divided into biological and physical methods.

Oxygen supplementation therapy (hyperbaric oxygen therapy)

In vitro studies have demonstrated that administration of 100% oxygen is capable of stimulating osteoblasts and consequently bone formation However, there is still no consensus in the literature regarding its benefits for treating stress fractures.,

Bisphosphonates

Bisphosphonates suppress bone reabsorption and inactivate osteoclasts through their bonding with calcium phosphate crystals.,  Their high cost and various side effects may be the deciding factor with regard to choosing and attempting to use this therapeutic method. There is not yet any scientific basis for their prophylactic use.,

Growth factors and growth factor-rich preparations

Growth factors are applied directly to diseased tissues with the aim of accelerating and promoting their repair. The preliminary results from muscles, tendons, and ligaments have been encouraging., There are only a few studies on treating stress fractures. Some of them have reported that when these factors are used during surgical treatment of high-risk fractures, they may accelerate and improve the recovery

Bone morphogenic proteins

Bone morphogenic proteins contain bioactive factors that are responsible for inducing bone matrix activity with an osteoinductive function. Their primary activity is in relation to the differentiation of mesenchymal cells into bone and cartilage tissue-forming cells, through direct and osteochondral ossification. They have an important function in repairing bone lesions. Studies on animals have demonstrated acceleration of the injury cure process in cases of traumatic fractures, but little can be concluded regarding their use in stress fractures.

Recombinant parathyroid hormone

Parathormone acts toward regulating serum calcium levels through gastrointestinal absorption, calcium and phosphorus reabsorption in the kidney, and calcium release from the skeletal tissue. Although this initially promotes stimulation of osteoclasts through regular administration, when it is done intermittently in a controlled manner, it gives rise to anabolic stimulation of osteoblasts and results in the formation of bone with increased strength and density, followed by remodeling. Studies have demonstrated that this hormone stimulates bone repair through both endochondral and membranous mechanisms.

Low-intensity pulsatile ultrasonography

High-frequency sound waves that are above the audible limit of human beings interact with bone tissue and the adjacent soft tissues and generate micro stress and tension that are capable of stimulating consolidation., , However, their exact mechanism of action remains unknown. Some studies have demonstrated its efficacy in treating stress fractures., Other studies have completely supported its use for treating these fractures.

Application of magnetic fields

Magnetic fields can be applied by means of direct current at the focus of the fracture through surgical placement of electrodes, use of an electrical capacitation field device or use of electromagnetic field pulses. There is still no concrete evidence regarding its use in stress fractures.,

More About Your Injury

  • There are five metatarsal bones in your foot. The 5th metatarsal is the outer bone that connects to your little toe. It is the most commonly fractured metatarsal bone.
  • A common type of break in the part of your 5th metatarsal bone closest to the ankle is called a Jones fracture. This area of the bone has low blood flow. This makes healing difficult.
  • An avulsion fracture occurs when a tendon pulls a piece of bone away from the rest of the bone. An avulsion fracture on the 5th metatarsal bone is called a “dancer’s fracture.”

What to Expect

If your bones are still aligned (meaning that the broken ends meet), you will probably wear a cast or splint for 6 to 8 weeks.

  • You may be told not to put weight on your foot. You will need crutches or other support to help you get around.
  • You may also be fitted for a special shoe or boot that may allow you to bear weight.

If the bones are not aligned, you may need surgery. A bone doctor (orthopedic surgeon) will do your surgery. After the surgery, you will wear a cast for 6 to 8 weeks.

Relieving Your Symptoms

You can decrease swelling by

  • Resting and not putting weight on your foot
  • Elevating your foot

Make an ice pack by putting ice in a plastic bag and wrapping a cloth around it

  • DO NOT put the bag of ice directly on your skin. Cold from the ice could damage your skin.
  • Ice your foot for about 20 minutes every hour while awake for the first 48 hours, then 2 to 3 times a day.

For pain, you can use ibuprofen (Advil, Motrin, and others) or naproxen (Aleve, Naprosyn, and others)

  • DO NOT use these medicines for the first 24 hours after your injury. They may increase the risk of bleeding.
  • Talk with your health care provider before using these medicines if you have heart disease, high blood pressure, kidney disease, liver disease, or have had stomach ulcers or internal bleeding in the past.
  • DO NOT take more than the amount recommended on the bottle or more than your provider tells you to take.

Activity

As you recover, your provider will instruct you to begin moving your foot. This may be as soon as 3 weeks or as long 8 weeks after your injury. When you restart an activity after a fracture, build up slowly. If your foot begins to hurt, stop and rest.

Some exercises you can do to help increase your foot mobility and strength are:

  • Write the alphabet in the air or on the floor with your toes.
  • Point your toes up and down, then spread them out and curl them up. Hold each position for a few seconds.
  • Put a cloth on the floor. Use your toes to slowly pull the cloth toward you while you keep your heel on the floor.

Follow-up

As you recover, your provider will check how well your foot is healing. You will be told when you can:

  • Stop using crutches
  • Have your cast removed
  • Start doing your normal activities again

References

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