What is a metatarsal fracture?
A metatarsal fracture is a condition characterized by a break in one of the long bones of the mid foot known as the metatarsals (figure 1).
The foot comprises of many small bones, 5 of which are the long bones known as the metatarsals which are situated beside each other in the mid section of the foot. These bones form joints with the proximal phalanges and tarsal bones (figure 1).
Figure 1 – Relevant anatomy for a metatarsal fracture
During certain activities such as landing from a jump, or when rolling an ankle, stress is placed on the metatarsal bones. When this stress is traumatic and beyond what the bones can withstand a break in one or more of the metatarsals may occur. This condition is known as a metatarsal fracture.
Often a metatarsal fracture occurs in combination with other injuries such as a sprained ankle or other fractures of the foot, ankle or lower leg (such as following trauma). Of the metatarsal bones, the 5th metatarsal is the most commonly affected.
Metatarsal fractures can vary in location, severity and type including avulsion fracture, stress fracture, Jones’ fracture, displaced fracture, un-displaced fracture, spiral fracture, greenstick, comminuted etc.
Causes of a metatarsal fracture
A metatarsal fracture commonly occurs in association with a rolled ankle, particularly when the ankle has rolled inwards, and when significant weight bearing forces are involved. They may also occur due to an awkward landing from a jump (particularly on uneven surfaces), due to a fall or following a direct blow to the foot. Metatarsal fractures are relatively common in running and jumping sports involving change of direction such as football, soccer, rugby, basketball and netball and in dancing (e.g. ballet). A metatarsal stress fracture may occur due to repetitive stress associated with excessive running or overuse.
Signs and symptoms of a metatarsal fracture
Patients with this condition typically experience a sudden onset of sharp, intense foot or ankle pain at the time of injury. Sometimes the patient may have heard an audible snapping sound at the time of injury. The pain often causes the patient to limp or be unable to weight bear so as to protect the foot. Pain is usually felt in the foot or ankle and can occasionally settle quickly leaving patients with an ache at the site of injury that may be particularly prominent at night or first thing in the morning.
Patients with a metatarsal fracture may also experience swelling, bruising and pain on firmly touching the affected region of bone. Pain may also increase during certain movements of the foot or ankle or when standing or walking (particularly up hills or on uneven surfaces). In severe metatarsal fractures (with bony displacement), an obvious deformity may be noticeable.
Diagnosis of a metatarsal fracture
A thorough subjective and objective examination from a physiotherapist is essential to assist with diagnosis of a metatarsal fracture. An X-ray is usually required to confirm diagnosis and assess the severity. Further investigations such as an MRI, CT scan or bone scan may be required, in some cases, to assist with diagnosis and assess the severity of the injury.
Treatment for a metatarsal fracture
For those metatarsal fractures that are displaced or involve the shaft of the bone (i.e. diaphysis), treatment typically involves anatomical reduction (i.e. orthopaedic re-alignment of the fracture by careful manipulation under anesthetic) followed by either cast immobilization for a number of weeks or surgical internal fixation to stabilize the fracture (using plates and screws). This may be followed by or supplemented with the use of a protective boot and / or crutches for a number of weeks.
For those fractures that are not displaced and do not involve the shaft of the metatarsal, (such as the commonly seen ‘non-displaced avulsion fractures of the base of the 5th metatarsal’) treatment typically involves the use of a protective boot and / or crutches for a number of weeks.
Evaluation of the fracture with follow up X-rays is important to ensure the fracture is healing in an ideal position. Once healing is confirmed, rehabilitation can progress as guided by the treating physiotherapist.
One of the most important components of rehabilitation following a metatarsal fracture is that the patient rests sufficiently from any activity that increases their pain (crutches and / or a protective boot are often required). Activities which place large amounts of stress through the metatarsal should also be avoided, particularly excessive weight bearing activity such as running, jumping, standing or walking excessively (especially up hills or on uneven surfaces). Rest from aggravating activities allows the healing process to take place in the absence of further damage. Once the patient can perform these activities pain free, a gradual return to these activities and weight bearing forces is indicated provided there is no increase in symptoms. This should take place over a period of weeks to months with direction from the treating physiotherapist.
Ignoring symptoms or adopting a ‘no pain, no gain’ attitude is likely to cause further damage and may slow healing or prevent healing of the metatarsal fracture all together.
Patients with a metatarsal fracture should perform pain-free flexibility, strengthening and balance exercises as part of their rehabilitation to ensure an optimal outcome. This is particularly important, as balance, soft tissue flexibility and strength are quickly lost with inactivity. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they can commence.
In the final stages of rehabilitation, a gradual return to activity or sport can occur as guided by the treating physiotherapist provided there is no increase in symptoms. The use of a protective brace or strapping tape may be indicated to provide additional stability to the ankle during this phase of rehabilitation and as an ongoing form of injury prevention.
Prognosis of a metatarsal fracture
Patients with a metatarsal fracture usually make a full recovery with appropriate management (whether surgical or conservative). Return to activity or sport can usually take place in weeks to months and should be guided by the treating physiotherapist and specialist. In patients with severe injuries involving damage to other bones, soft tissue, nerves or blood vessels, recovery time may be significantly prolonged. In patients with only very minor fractures that are un-displaced (such as an avulsion fracture) return to sport can sometimes occur in as little as 6 – 8 weeks as guided by the treating physiotherapist.
Physiotherapy for a metatarsal fracture
Physiotherapy treatment is vital in all patients with this condition to hasten healing and ensure an optimal outcome. Treatment may comprise:
- soft tissue massage
- joint mobilization
- electrotherapy (e.g. ultrasound)
- taping or bracing
- the use of a protective boot
- the use of crutches
- exercises to improve strength, flexibility and balance
- activity modification
- a graduated return to activity plan
Other intervention for a metatarsal fracture
Despite appropriate physiotherapy management, some patients with this condition do not improve adequately and may require other intervention. The treating physiotherapist or doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, CT scan, MRI or bone scan, periods of plaster cast immobilization or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the metatarsal fracture. Occasionally, patients who were initially managed conservatively may require surgery to stabilize the fracture and/or a bone graft to aid fracture healing.
Exercises for a metatarsal fracture
The following exercises are commonly prescribed to patients with a metatarsal fracture following confirmation that the fracture has healed or that pain free mobilization can commence as directed by the surgeon or physiotherapist. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.
Foot and Ankle Up and Down
Move your foot and ankle up and down as far as possible and comfortable without pain (figure 2). Repeat 10 – 20 times provided there is no increase in symptoms.
Foot and Ankle In and Out
Move your foot and ankle in and out as far as possible and comfortable without pain (figure 3). Repeat 10 times provided there is no increase in symptoms.
Foot and Ankle Circles
Move your foot and ankle in a circle as large as possible and comfortable without pain (figure 4). Repeat 10 times in each direction provided there is no increase in symptoms.
Physiotherapy products for a metatarsal fracture
Some of the most commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with this condition include:
To purchase physiotherapy products for a metatarsal fracture click on one of the above links or visit the PhysioAdvisor Shop.
- View more Ankle Flexibility Exercises.
- View more Ankle Strengthening Exercises.
- View Balance Exercises.
- Read about How to Use Crutches correctly.
Find a Physio for a metatarsal fracture
Find a physiotherapist in your local area who can treat a metatarsal fracture.
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