Metatarsal Stress Fractures (long bones of the foot)
What is a Metatarsal Fracture?
Metatarsal fracture is a break in one of the long bones of your foot that connect the ankle to the toe. It is a common foot injury among those with an active lifestyle, and it requires careful assessment and management depending on the type and position of the fracture. Call our clinic in Gold Coast or Brisbane if you are experiencing metatarsal pain and symptoms like difficulty walking, swelling, bruising, or tenderness in your foot.
Types of Metatarsal Fractures
There are 5 metatarsals numbered 1 through 5 with each corresponding to a toe. The 1st metatarsal corresponds to the big toe and the 5th metatarsal corresponds to the little toe and is most commonly broken. Many metatarsal fractures occur at the base of the fifth metatarsal in line with the little toe. This bone more often fractures at the proximal end closer to the ankle than the distal end closer to the toe or shaft.
5th Metatarsal Fracture
5th metatarsal fractures can often be managed with non-surgical treatment such as protected weight-bearing, that is avoiding pressure through the front of the foot. They can take longer to heal if repetitive pressure is applied (through walking or “weight bearing”). Sometimes these fractures extend into the joint where the fifth metatarsal joins onto the adjacent bones (either the 4th metatarsal or cuboid bone). Fractures into the joint (intra-articular fractures) that are displaced often require surgery. However most occur through the base of the metatarsal not through the joint. Sometimes a CT scan is performed to check if the fracture extends into the joint.
2nd, 3rd and 4th Metatarsal Stress Fractures
Proximal 4th, 3rd and 2nd metatarsal fractures often need to be checked for underlying ligament injuries with an MRI scan or CT scan. A Lisfranc injury can sometimes go unnoticed and may require surgery with problems down the track if it doesn’t heal appropriately.
Distal fractures of the 2nd and 3rd metatarsals occur from repetitive walking, running or from bone issues, and cause pain in the front of the foot. They seldom show up on an x-ray, and usually require an MRI or bone scan to be diagnosed. These fractures require non-surgical treatment with protected weight bearing. Acute metatarsal stress fractures take much longer to heal and can require months of monitoring and strict avoidance of pressure through the front of the foot.
Acute Metatarsal Fracture Assessment & Management
The initial management of acute metatarsal fractures focuses on:
- RICE protocol (Rest, Ice, Compression, Elevation)
- Metatarsal stress fracture pain and swelling management.
- Neurovascular assessment of foot circulation and nerve function.
- X-rays evaluation including weight-bearing views when possible.
- Fracture pattern, displacement, and stability assessment.
Metatarsal Stress Fracture Treatment
Non-invasive Management
Most metatarsal stress fractures can be managed with non-invasive treatments like immobilisation or protected weight bearing depending on the fracture location and pattern.
Protected weight-bearing devices reduce the weight on the foot allowing the metatarsal bone to heal. Typical weight bearing treatments can take 6-8 weeks. The initial 2-3 weeks is with crutches to avoid any stress on the foot. This is followed by partial weight-bearing, and eventually graduating to full weight-bearing as tolerated. Here are the main weight-bearing devices used in treating metatarsal stress fractures:
- CAM walker boot or moon boot
- Post-operative shoe with rigid sole (looks like a sandal)
- Hard-sole shoe with metatarsal pad
- Custom-made orthoses (expensive)
- Pneumatic walking boot (pumps up with air cushion)
Immobilisation (less common):
- Elastic bandaging
- Below-knee cast for unstable fractures
- Moon boot and CAM walkers
- Forefoot offloading devices (a shoe with a large heel to prevent weight bearing on the front of the foot)
Surgical Management
Metatarsal fracture symptoms that indicate surgical treatment:
- Displaced metatarsal fractures
- Fractures with ligament involvement (Lis-Franc injuries)
- Multiple metatarsal fractures
- Intra-articular fractures (displaced fractures in the joints)
- Unstable fracture patterns
- Failed non-surgical management (not healing)
- 5th metatarsal “Jones” fractures
- Professional athletes who may desire expedited return
Surgical Techniques:
- K-wire fixation (temporary pins)
- Plate and screw fixation
- Intramedullary screw fixation (rods or pins inside the bone)
- External fixation in complex cases
Regular Monitoring and Follow-up:
- Initial X-rays at presentation
- Follow-up X-rays at 1 or 2 weeks to ensure alignment
- Further imaging at 6-12 weeks to assess healing
- Final imaging prior to physiotherapy and graduated return to activities
Metatarsal fractures take months to rehabilitate and regain normal function after healing.
Metatarsal Stresss Fracture Rehabilitation Protocol
Early Phase (0-6 weeks):
- Protected weight-bearing
- Regular wound care if surgical
- Toe mobilisation exercises
- Ankle pump exercises
- Ice therapy for swelling
Intermediate Phase (6-12 weeks – if fracture healed):
- Progressive weight-bearing
- Gentle range of motion exercises
- Proprioception training
- Graduated strengthening exercises
- Gait training
Late Phase (3-6 months):
- Sport-specific exercises
- Impact activity progression
- Return to running program
- Functional training
- Balance and proprioception advancement
Physiotherapy Program
Initial Phase
- Pain management
- Oedema control
- Maintaining mobility of unaffected joints
- Gait training with assistive devices
Progressive Phase
- Joint mobilisation
- Soft tissue techniques
- Strengthening exercises
- Balance training
- Proprioception exercises
Return to Activity Phase
- Sport-specific training
- Impact absorption exercises
- Agility drills
- Functional movement patterns
Potential Complications in Metatarsal Stress Fractures Recovery
Early Complications
- Displacement
- Delayed union
- Stiffness
- Compartment syndrome
- Infection due to surgery
- Complex regional pain syndrome
Late Complications
- Nonunion
- Malunion
- Post-traumatic arthritis
- Chronic pain
- Transfer metatarsalgia
Management of Complications
- Physiotherapy for stiffness
- Surgery if required
- Extended immobilisation for delayed union
- Custom orthotics for residual symptoms
- Pain management programs
- Modified activity programs
Return to Activity Guidelines
- Gradual return based on fracture healing
- Pain-free walking without aids
- Adequate strength restoration
- Normal range of motion
- Sport-specific conditioning achieved
- Typically 8-12 weeks for non-invasive cases and 12-16 weeks for surgical cases
Prevention of Future Injuries
- Appropriate footwear
- Regular stretching
- Gradual activity progression
- Attention to training surfaces
- Proper warm-up routines
- Regular bone health assessment
The successful management of metatarsal fractures requires a comprehensive approach with careful attention to initial assessment, appropriate choice of treatment modality, and structured rehabilitation. Regular monitoring and adjustment of the treatment plan ensures optimal outcomes and minimises complications.
How can I book an appointment at the Fracture Clinic?
You can call their phone number or make an appointment online via their website. The clinic is open from 8 a.m. to 4 p.m., Monday through Friday.
Do you accept insurance?
We work with multiple health insurance providers. We offer Medicare rebates where applicable and can assist you in understanding your potential coverage. We recommend:
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Checking your specific insurance policy for physiotherapy, or orthopaedic specialist coverage
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Bringing your Medicare card and private health insurance details to your consultation
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Consulting with our team for precise rebate information, especially if you have DVA or WorkCover coverage
We are committed to transparent pricing and we will provide a comprehensive breakdown of potential costs and rebates during your initial consultation. For patients with eligible Medicare, DVA, WorkCover and/or private health insurance, out-of-pocket expenses can be significantly reduced.
