Thesis: Metatarsal Stress Fracture and Complications

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Metatarsal Stress Fracture and Complications

Because of the metatarsals' location, they are exposed to high stresses during many types of athletics, particularly those involving frequent jumping, pivoting, and repeated changes of direction. The metatarsals are susceptible to chronic stress-induced fractures from a combination of factors including foot anatomy, footwear, playing surface, specific maneuvers, previous injury to surrounding tissue, and more general variables such as frequency of sports activity.

Acute treatment involves the traditional use of rest, ice, compression, and elevation (RICE), the use of crutches, a gradual return to normal activities, and any necessary changes or augmentation to footwear. Generally, recovery is complete after nine weeks but complications from insufficient rest include increased trauma to the area and prolongation of total recovery time. With adequate attention, metatarsal stress fractures heal completely without subsequent recurrence of symptoms unless specific underlying factors continue to impose unusual stresses on the area.

Among stress-related skeletal fracture injuries, metatarsals are not frequently involved and among metatarsal stress fractures, the vast majority involve the second or third metatarsal with only a very small minority involving the fifth metatarsal. As with stress fractures generally, onset of symptoms associated with metatarsal stress fractures are gradual rather than sudden and rarely involve any specific instantaneous motion or acute injury. Rather, they manifest themselves through soreness caused by the same athletic activities responsible for their development and often do not interfere with ordinary ambulation and other non-athletic daily activities.

Metatarsal Stress Fractures: Complications of a Complete Fracture


The ankle is the most primitive and most stable joints in the human body, primarily because it only moves in one direction (i.e. up and down) and without any lateral or rotational motion in any other plane (Iazetti & Rigutti, 2007). While this design is functional for the ankle joint, it renders other tissues of the foot comparatively susceptible to increased chronic stress-related injury from repeated athletic movements, because the ankle does not provide as much assistance in the dissipation of dynamic muscular stresses or, especially, those related to ground-reactive sources in the same manner that other more flexible joints, such as the knee, absorb stress loads (Frankel & Difiori, 2007; Iazetti & Rigutti, 2007).

Thesis Statement:

With accurate diagnosis and adequate acute treatment, rehabilitation, and a gradual return to athletic activity, metatarsal fractures are readily treatable without lasting effects after return to full activity. However, inappropriate return to full activity before healing is complete generally results in prolongation of acute symptoms and retardation of recovery and return to full activity levels. In the most serious cases, premature return to competition, particularly in the absence of a graduated rehabilitation program strategy, can transform a stress fracture into a complete break necessitating a full surgical repair and much more extensive post-repair convalescence and prolonged period of rehabilitation before full recovery.

Definition of Anatomy & Terminology:

The metatarsals are the longest bones of the foot, which in and of itself, predisposes them to the greatest stress loads during ambulation and many athletic movements involving the foot. Each metatarsal connects the bones of one toe to the rest of the foot by strong ligaments and to the muscles responsible for their movement by tendons. Bursa sacks consisting of fluid-filled cushions are positioned directly below the proximal head of each metatarsal to provide some protection against ambulatory stresses but are not always sufficient to protect the metatarsals from stress fractures (Jaukovi?,

Ajdinovi?, Gardasevi?, et al., 2006).

Generally, stress fractures represent the cumulative effects on skeletal bone from repeated load bearing and other mechanical stresses that produce micro-traumas or micro-fractures within the bone tissue (Howe, 2007). In most cases, rest and the elimination of the source of mechanical stresses is sufficient to heal stress fractures without subsequent recurrence or complications. However, in some instances, prolonged exposure to repeated stresses without adequate rest for healing and reparative bone cell formation can eventually produce a complete break in the area of significant micro-trauma (Howe, 2007).

Mechanism of Injury:

Bone stress

In general, the skeletal bones of the legs and lower extremities are exposed to regular mechanical loads that produce high stresses on the internal structure of bone cells (Logan, 2009; Saremi, 2009). Repeated stress and mechanical loading from weight bearing triggers increased bone cell growth and functions as a protective mechanism by increasing bone density and decreasing the relative amount of empty microscopic spaces in-between individual bone cells (Iazetti & Rigutti, 2007). This process varies in different individuals in relation to age, genetic factors, and nutritional intake, particularly with respect to calcium and vitamin D which facilitates calcium absorption into skeletal tissues (Howe, 2007).

Still, among athletic stress fractures, the metatarsals are involved in only approximately one-tenth to one-fifth of all stress fractures with fully four-fifths involving the second and third metatarsals; by contrast, the fifth metatarsal is the site of stress fracture injury least often (Frankel & DiFiori, 2004). The reason becomes obvious when one analyzes the mechanism by which athletes orient their feet during jumps, landings, pivots, and other stress-inducing foot movements. Specifically, the greatest load is borne by the center of the foot in the area of the middle, precisely where the second and third metatarsals are most involved in the generation and dissipation of dynamic forces (Frankel & DiFiori, 2004).

As is the case with other substances under load-bearing stresses (i.e. both anatomical tissues and inanimate materials), microscopic irregularities in the internal structure can present local areas of weakness and increased susceptibility to damage from repeated stress (Barsom, 2005). In that regard, the relative inflexibility of the human ankle (compared with other joints), the small size of the metatarsal bones, and the nature of the specific stresses associated with various athletic movements can result in the eventual development of fault lines representing a linear connection of bone cells that feature microscopic irregularities and micro-fractures of individual cells (Logan, 2009; Iazetti & Rigutti, 2007).

Plyometric action is particularly significant in relation to the formation of stress fractures in the metatarsal bones because the rapid acceleration, deceleration and angular stresses associated with jumping, landing, (and quick changes in direction in which the proximal head of the metatarsals provide the fulcrum for the movement) subject the tissues involved to as much as five times the body weight of the athlete (Frankel & DiFiori, 2007).

Poor technique such as in terms of insufficient incorporation of the knee and hip joints during plyometric movements increase the point load on the metatarsal primarily by eliminating links in the natural shock-absorbing mechanism of coordinated movements involving multiple joints. Similarly, insufficient flexibility in the ankle, knee, and hips also contribute to higher loading under the dynamic stresses of athletic movements involving jumping and rapid changes of direction. Frequently, poor form or balance transfers higher loads to the fifth metatarsal in particular, where, in some circumstances, it is exposed to stresses ordinarily shared between the middle metatarsals in a manner that reduces the load on each individual bone (Iazetti & Rigutti, 2007).

On the other hand, ironically, more-highly-skilled athletes and those with higher natural proportions of fast-twitch muscle fibers are at somewhat increased risk of developing metatarsal stress fractures (Laker, Saint-Phard, Tyburski, et al., 2007). Plyometric analysis reveals that highly skilled athletes tend to spend less time on the ground (or other playing surface) during sports-specific acceleration, deceleration such as that associated with jumps and changes of direction. Their greater skill level, neuromuscular efficiency, and ability to generate mechanical energy allows them to spend less time generating the energy necessary to propel them in their direction of travel. Because less time is available for acceleration and deceleration, the tissues responsible for absorbing the stresses under the load experience higher mechanical stress by virtue of the reduced time available for its dissipation or absorption (Barsom, 2005). In principle, however, this is not a contradiction when one considers the mechanical reasons that account for the increased stresses involved. In that respect, highly-skilled athletes typically subject the metatarsals to greater loads solely by virtue of the compressed time available for load dissipation; but the specific anatomical structures under the load are not affected by that variable. Meanwhile, poor technique transfers increased loads to different regions of the foot from those that are more anatomically efficient and ordinarily subject to those stresses produced in good form (Frankel & DiFiori, 2007).


Anatomical variation also contributes to the relative susceptibility of athletes to metatarsal fractures. Specifically, wider metatarsal regions allow for correspondingly greater surface area available to distribute the mechanical loads to which the foot is subjected during plyometric motion and instantaneous stops, starts, and changes in the direction of intended movement. Similarly, athletes with longer feet in relation to their body weight are predisposed to metatarsal stresses (Vu, McDiarmid, Brown, et al., 2006) because of the increased leverage on the fulcrum area exerted by comparatively longer levers (Barsom. 2005). Flat-footedness is also believed to contribute to the development of metatarsal fractures because that condition also reduces the natural shock-absorbing function of the arch structure of the foot (Cullen… [END OF PREVIEW]

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