The five metatarsal bones are the long bones of the midfoot. A metatarsal fracture occurs when one of these long bones is broken. This may be due to sudden injury (an acute fracture), or due to repeated stress (stress fracture). Stress fractures often affect athletes and sportsmen, but can affect any runners, even those who only run a little.
In acute fractures you may hear a sound at the time of the break, and experience pain, swelling, bruising and difficulty putting weight on the affected foot. (It's not true that if you can walk on it it's not broken.) Stress fractures have similar symptoms, although there is usually no bruising. Treatment depends on the type and site of the fracture.
Some anatomy of your foot
The foot is a complicated part of the body, made up of multiple bones, muscles, tendons and soft tissues. Your feet have to bear the weight of your body when you stand and move, and to make constant balancing adjustments to allow you not to fall over as you do so. There are 26 bones in your foot:
- Fourteen toe bones (phalanges): three each for the small toes and two for the big toe.
- Five long metatarsal bones, named from the first (connected to the big toe) to the fifth.
- Seven tarsal bones which make up the back part of the foot (hindfoot) and heel (calcaneum).
Each metatarsal bone has a base (nearest to the heel), a shaft (the straight part of the bone), a neck and a head. The fifth metatarsal differs slightly as it also has a bulge (tuberosity) at its base. The bones, ligaments and tendons of your foot form arches, one lengthways and one across the foot. These arches are called the longitudinal and transverse arches of the foot. It is your foot arches that allow your foot to hold up the weight of your body. When the foot is healthy and the arches are as they should be, your wet footprint is not a footprint of the whole of the underside of your foot, as they hold a part of the foot off the ground.
Types of metatarsal fracture
The metatarsal bones are some of the most commonly broken (fractured) bones in the foot. There are two main types of metatarsal fracture:
- Acute fracture - due to a sudden (acute) injury to the foot (typically dropping a heavy object on to the foot, a fall, or a sporting injury).
- Stress fracture - due to overuse or repetitive injury to a normal metatarsal bone.
Metatarsal fractures occur much more easily if the metatarsal bones are weakened due to 'thinning' of the bones (osteoporosis). See separate leaflet called Osteoporosis for more detail.
Fractures may also in general be:
- Open or closed: an open fracture is one where the skin is broken over the fracture so that there is a route of possible infection from the outside into the broken bones. This is obviously a more serious type of fracture, with damage to the soft tissues around the ankle making treatment and healing more complicated, and it needs specialist assessment.
- Displaced or not displaced: a displaced fracture is one where, following the break, the bones have slipped out of line. A displaced fracture also needs specialist care, as the bones will need to be properly lined up and stabilised. This may involve an anaesthetic and some kind of metal pinning or plating to the bones.
Acute metatarsal fractures
Acute metatarsal breaks (fractures) can be displaced or non-displaced. They may be open or closed. Open metatarsal fractures are normally caused by severe trauma such as a road accident.
The fifth metatarsal bone is the most common metatarsal bone to be fractured in sudden (acute) injury to the foot. It may be broken at various points along its length, depending on the mechanism of injury. The other metatarsal bones can also be broken. The first, second and fifth metatarsals are the most commonly injured in sport. Several English footballers have had metatarsal fractures in recent years.
What causes acute metatarsal fractures?
Acute metatarsal fractures can be caused by direct injury to the foot. This may happen, for example, through someone stepping on or kicking the foot, by dropping something on to the foot or by falling on to the foot. Twisting of the foot or the ankle can also cause fractures of the base of the fifth metatarsal. In this injury, the twisting mechanism pulls on a strong ligament that attaches to the base of the fifth metatarsal which then pulls off a fragment of bone. The shaft of the metatarsal is commonly injured because of twisting of the foot on landing from a jump. This is a common problem in ballet dancers.
What are the symptoms of an acute metatarsal fracture?
You may hear a sound at the time of the break, and will usually have immediate pain and tenderness around the area of the fracture. The pain is often called 'pinpoint pain' as it is quite well localised at the site of impact to the bone. Broken bones bleed, so bruising and swelling can develop and you may have difficulty putting weight on the affected foot. Movement of your foot may also be limited. Surprisingly, however, pain can settle within a few hours.
Do I need any investigations?
Most acute metatarsal fractures can be seen easily on X-ray. CT scanning or MRI scanning is occasionally needed.
How are acute metatarsal fractures treated?
This depends on:
- Which metatarsal bone is broken
- Which part of the metatarsal bone is broken.
- How severe the damage is.
It also depends on:
- Whether the fractured bone is displaced or non-displaced (see above).
- Whether the tissues of the foot around the break are also badly injured causing the fracture to be an open fracture.
The basic principles of treating metatarsal fractures
- Simple painkillers: such as paracetamol and non-steroidal anti-inflammatory painkillers such as ibuprofen which may help to relieve pain.
- Ice: applying ice to your foot can also be helpful as pain relief. Ice should be applied as soon as possible after injury, for 10-30 minutes. (Less than 10 minutes has little effect. More than 30 minutes may damage the skin.) Make an ice pack by wrapping ice cubes in a plastic bag or towel, or by using a bag of frozen peas. Do not put ice directly next to skin, as it may cause ice burn. Gently press the ice pack on to the injured part. The cold is thought to reduce blood flow to the damaged ligament. This may limit pain, inflammation and bruising. Some doctors recommend re-applying for 15 minutes every two hours (during daytime) for the first 48-72 hours. Do not leave ice on while asleep.
- Elevation: this 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.
- Rest: sometimes rest is the only treatment that is needed, even in traumatic fracture.
- Avoiding the offending activity: this is true of all metatarsal fractures but is particularly true in the case of stress fractures. This is because these result from repetitive overuse. It is important to remove all stress from the foot to allow it to heal. This may mean using crutches or even a wheelchair.
- Immobilisation: some fractures just need support to help healing. For example, a supportive Tubigrip®-type dressing with a supportive, rigid shoe or boot. Progressive weight-bearing on the foot can then follow as pain allows. Other fractures may need treatment with a below-the-knee plaster cast.
- Surgery: occasionally, surgery may be necessary - for example, to re-align any part of the bone that has moved out of position.
- Follow-up care: physical therapy and a gradual return to exercise are a part of good follow-up care.
Acute metatarsal fractures generally take around six to eight weeks to heal. However, it may be longer than this before a sportsperson is fully back in action.
Metatarsal stress (march) fractures
What is a metatarsal stress fracture?
A metatarsal stress fracture is a hairline break in a bone, caused by repetitive stress. Stress fractures tend to occur as a result of overuse and are known as overuse injuries.
Metatarsal stress fractures have been called march fractures because they were seen in soldiers who marched for long periods of time.
What causes a metatarsal stress fracture?
Metatarsal stress fractures generally occur due to repeated stress to the bone, which is also termed overuse. They most commonly affect the second and third metatarsal bones, as these bones have the most amount of stress placed on them when you are moving.
They are common in runners who:
- Suddenly increase their running mileage or intensity.
- Run in poor footwear that doesn't suit their feet.*
- Have just changed their running shoes and not 'broken them in' carefully.
- Continue to exercise despite having foot pain.
They are also frequently seen in ballet dancers and gymnasts.
Abnormalities of the structure of the foot, and abnormalities of the bones and joints, such as rheumatoid arthritis or 'thinning' of the bones (osteoporosis), can make stress fractures more likely. Stress fractures can also occur in people who have lost nerve sensation in their feet due to neurological problems - for example, diabetes that has affected the feet.
*People's choices and needs for running shoes vary. However, before choosing something unusual such as barefoot shoes or corrective shoes, make sure you have some advice. For example, for barefoot running you need to be taught the right technique. Break in new running shoes gradually - many injuries result from a sudden change in running shoes.
What are the symptoms of a metatarsal stress fracture?
At the beginning, there may just be pain in the foot during exercise that is relieved by rest. After a while, the pain may not be relieved on resting and may become continuous. Pain tends to be more widespread and diffuse in the foot at first. As the stress fracture progresses, it tends to become more localised to the area of the fracture. Typically the stress fracture then causes a tender area along the line of the second or third metatarsal bone. There may be some swelling but typically there is no bruising.
Do I need any investigations?
Your doctor may suggest an X-ray of your foot if they suspect a metatarsal stress fracture. However, not all stress fractures show up on X-rays, particularly early on. Half of them never show up on a normal X-ray. Metatarsal stress fractures can usually be seen by using a bone scan to look at your foot. This bone scan involves an injection of a very small amount of radioactive material, usually into a vein in your arm. A gamma camera is then used that can detect the radiation emitted by the injected material. This can show up a stress fracture. MRI scanning is also sometimes used.
How are metatarsal stress fractures treated?
The principles of treatment are the same as for acute metatarsal fractures (see above). The most important treatment is to rest your foot. This means avoiding any exercise or activity that may have caused your stress fracture. Lifting (elevating) the foot can help to relieve pain. Special shoes are available to help to immobilise the fracture and support the foot so that you are able to walk. If pain is severe, your doctor may suggest a below-the-knee plaster cast until the fracture has healed. Surgery for metatarsal stress fractures is rarely needed. Its purpose would be to pin the bones to stop the fracture displacing, but this would be very unusual in the case of metatarsal stress fracture.
When can I return to activity?
Stress fractures normally heal without any complications and, in time, people are able to return to their previous activities fully. You can return to your activities when you can perform them without pain. This will typically take six to twelve weeks. When you do start exercising again, you should gradually build up your activity levels. A sudden return to high-intensity exercise after a break may cause a repeat or a new stress fracture, or other injury.
Can stress fractures be prevented?
There are a number of things that you can do to help prevent stress fractures. Exercise intensity and duration should be built up slowly and gradually. Rest and recovery time needs to be built in to any training schedule. Footwear should be well fitting and suit your running style. If changing - eg, from supportive training shoes to barefoot running shoes - you should be shown how to adapt your style. You should practise this gradually. You should be aware of the symptoms of stress fractures, and should not continue to run on a painful foot.
If stress fractures are recognised and treated quickly, this can reduce the amount of time that you need to stay away from activities.
If properly treated then metatarsal fractures should settle down without long-term consequences.
If not recognised and treated then problems can occur:
- A fracture of the first metatarsal bone can lead to later arthritis of the big toe joint.
- A fracture at the base of the fifth metatarsal bone is often mistaken for an ankle sprain. This would usually result in it not being rested or supported enough. This could lead to problems in healing and continuing pain.
- The consequences of not treating broken bones well can also include:
- The bone not healing 'straight (permanent deformity).
- The two ends of the bones not healing together at all (non-union).
- Both of these may cause ongoing pain and limitation of use, and may lead to later arthritis.
Dr Michelle Wright
Dr Mary Lowth
Dr John Cox