You have five metatarsal bones in your foot. A metatarsal fracture is when one of these bones is broken. There are two main types of metatarsal fractures: acute fractures (due to sudden injury) and stress fractures (due to overuse injury). Several English footballers have had metatarsal fractures in recent years. You may experience pain, swelling and difficulty putting weight on the affected foot. Treatment depends on the type and site of the fracture.
Some anatomy of your foot
Your feet have to bear the weight of your whole body. There are many bones in your foot. They are divided into the tarsal bones, the metatarsal bones and the phalanges.
The tarsal bones are the larger bones that form the back section of your foot, with the calcaneum being the largest. There are five metatarsal bones and these are given names from the first to the fifth. The first metatarsal bone is the largest and is the bone that joins to your big toe. Each toe has three phalanges, except the big toe which only has two. This means that there are three joints in the toes (two joints in the big toe). There are also many muscles, tendons and ligaments within your foot.
The bones, ligaments and tendons within your foot form the foot arches. These arches are called the longitudinal and transverse arches. It is your foot arches that allow your foot to hold up the weight of your body. Nerves also provide sensation to the skin of your foot.
Types of metatarsal fracture
The metatarsal bones are some of the most commonly fractured (broken) bones in the foot. There are two main types of metatarsal fractures:
- Acute fractures - due to an acute (sudden) injury to the foot (commonly dropping a heavy object on to the foot, a fall, or a sporting injury).
- Stress fractures - due to overuse, or repetitive, injury to a normal metatarsal bone.
Metatarsal fractures can also sometimes occur because the metatarsal bones are weakened due to osteoporosis. See separate leaflet called 'Osteoporosis' for more detail.
Acute metatarsal fractures
The fifth metatarsal bone is the most common metatarsal bone that is fractured in acute (sudden) injury to the foot. However, other metatarsal bones may also be broken. The first, second and fifth metatarsals are the most commonly injured in sport. Several English footballers including David Beckham and Wayne Rooney have had metatarsal fractures in recent years.
The fifth metatarsal bone may be broken at various points along its length, depending on the mechanism of injury causing the fracture. Briefly, the fifth metatarsal bone has a base (nearest to the heel of the foot), a tuberosity (a bony prominence that protrudes from the base), a shaft (the main body of the bone), a neck and a head.
Acute metatarsal fractures can also be displaced or non-displaced. If the fracture is displaced, the bone is broken in such a way that it has changed, or moved, its position.
What causes acute metatarsal fractures?
Acute metatarsal fractures can be caused by direct injury to the foot - for example, someone stepping on, or kicking, your foot. Twisting of the foot or the ankle can typically 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 will usually have pain and tenderness around the area of the fracture. Bruising and swelling can develop and you may have difficulty putting weight on the affected foot. Movement of your foot may also be limited.
Do I need any investigations?
Most acute metatarsal fractures can be seen easily on X-ray. CT or MRI scanning is occasionally needed.
How are acute metatarsal fractures treated?
This depends on which metatarsal bone is broken and which part of the metatarsal bone is broken. It also depends on whether the fractured bone is displaced or non-displaced (see above).
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. Occasionally, surgery may be necessary depending on the area of the fracture and/or to re-align any portion of bone that has moved out of position. Your doctor will advise which treatment is most suitable for your metatarsal fracture.
Simple painkillers such as paracetamol and non-steroidal anti-inflammatory drugs may help to relieve pain. Applying ice to your foot and elevating your foot can also be helpful as pain relief in the initial stages after your injury.
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) fracture
What is a metatarsal stress fracture?
A stress fracture is a type of incomplete fracture in a bone. Stress fractures tend to occur as a result of overuse and are known as overuse injuries. A metatarsal stress fracture is a stress fracture in one of the metatarsal bones in the foot. Historically, a metatarsal stress fracture has been called a march fracture because it was seen in soldiers who were marching for long periods of time. However, metatarsal stress fractures are not only seen in military recruits. They are commonly seen in athletes (especially runners), ballet dancers and gymnasts. Metatarsal stress fractures can affect anyone, not just olympic athletes. They are seen in runners of all levels.
What causes a metatarsal stress fracture?
Metatarsal stress fractures generally occur due to 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 tend to occur in people who have recently increased the intensity, duration or frequency of their exercise. They can occur after new footwear, or insufficient rest, or continuing to exercise despite the presence of foot pain. Sometimes metatarsal stress fractures can occur in someone who has an underlying problem affecting the bones, such as rheumatoid arthritis or osteoporosis. They can also occur in people who have lost sensation in their feet due to neurological problems - for example, diabetes that has affected the nerves in the feet.
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 be continuous. Pain tends to be more widespread in the foot when it starts. As the stress fracture progresses, it then tends to become more localised to the area of the fracture. So, this typically means along the line of the second or third metatarsal bone in the foot. Your foot may be tender to touch around the area of the fracture. You may have some swelling of your foot.
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 initially. In fact, about half of them never show up on a normal X-ray. Most metatarsal stress fractures can be seen by using a bone scan to look at your foot. A 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 most important treatment is to rest your foot. This means avoiding any exercise or activity that may have caused your stress fracture. Elevating your foot can help to relieve pain. Your doctor may also suggest that you take simple painkillers such as paracetamol or non-steroidal anti-inflammatory painkillers such as ibuprofen. Special shoes are available to help to immobilise the fracture and support your foot so that you are able to walk. If pain is severe, your doctor may suggest that you have a below-the-knee plaster cast until the fracture is healed. Surgery for metatarsal stress fractures is rarely needed.
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 may take up to six to twelve weeks. When you do start exercising again, you should gradually build up your activity levels after a stress fracture.
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. You should be aware of the symptoms of stress fractures. If they are treated quickly, this can reduce the amount of time that you need to stay away from activities. You should make sure that your equipment is of good quality and is properly fitted, particularly footwear.
Dr Michelle Wright
Dr Colin Tidy
Dr John Cox