Fifth Metatarsal Fracture
1. Introduction
Fifth metatarsal fractures are the most commonly fractured bone within the foot and typically present with pain located to the outside of the foot. They can be classified by location as metatarsal base fractures (zone 1, zone 2, zone 3), shaft fractures, dancer’s fractures and stress fractures (3).
- Zone 1 injuries are tuberosity avulsion fractures (where the muscle attachment area of the bone is affected).
- Zone 2 injuries have the name “Jones” fractures.
- Zone 3 injuries are commonly stress fractures.
Frequently Asked Questions
- The metatarsals are the long bones in the feet that start in the middle and run to the base of the toes. A fifth metatarsal fracture is a break to the bone on the very outside of the foot.
- Metatarsal fractures represent between 3% to 6% of all fractures presented within GP practice (1,3).
- The fifth metatarsal is the most commonly fractured bone within the foot (1).
- No.
- Although the pain will affect function for a while, metatarsal fractures have a high recovery rate once identified and managed correctly (3,6).
- Athletes, Overweight individuals, Smokers, Diabetics (3,4).
- Those suffering from osteoporosis (3).
- In the younger population men; and the older population women based on the above risk factors (3).
- Those with rheumatoid arthritis (5).
- A fifth metatarsal fracture will typically present with pain to the outer aspect of the foot and may have swelling, bruising and difficulty walking (6).
- For stress fractures, pain generally has a gradual onset and initially occurs only with activity. A specific point of tenderness is often present over the fracture site (6).
- Seek advice from a medical professional or qualified physiotherapist to help with diagnosis and appropriate onward referral (3).
- Seek physiotherapy after fracture management to help restore your strength and function(6).
- This will depend on the type of fracture it is and any other medical/lifestyle factors that may influence your recovery.
- Most metatarsal fractures will recover within 6 weeks (3,6).
- After x-ray confirmation of the location and extent of the fracture some cases may take longer with a non-weight-bearing cast for 6 to 8 weeks (3,6).
- Potential surgery (6).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
All fifth metatarsal fractures present with outer foot pain; and most will present with difficulty walking due to this discomfort.
The classification of a fifth metatarsal fracture is detailed in the causes section:
- Zone 1 and 2 fractures usually provide a sudden onset of pain, with associated swelling, difficulty walking and bruising.
- Zone 3 (stress fractures) usually have a gradual onset and cause a progressive increase in pain that is worse with activity (6).
3. Causes
A fifth metatarsal fracture occurs following a trip, fall, sometimes a sprained ankle; or overtime with repetitive weight bearing activities such as dancing or running.
It can be classified by location as a metatarsal base fracture (zone 1, zone 2, zone 3), shaft fracture or dancers’ fracture (3).
The different types of fracture of the fifth metatarsal typically have a different mechanism of injury.
- Zone 1 fractures usually result from ankle inversion (rolling in) while the foot is pointing down slightly.
- Zone 2 injuries can occur with a sudden change of direction by an athlete.
- Zone 3/stress fractures are chronic injuries of repetitive microtrauma, causing increasing pain with activity over months. Recognising the gradual onset of symptoms is key to correctly diagnosing fifth metatarsal stress fractures.
- Dancer’s fracture (or long spiral fracture of the distal metatarsal) is typically caused by the dancer rolling over their foot while in the demi-pointe position or sustained while landing a jump (6).
4. Risk Factors
- Athletes and dancers (3).
- Obesity/high BMI (3).
- Osteoporosis (3).
- Rheumatoid arthritis (5).
- Sudden rise in training intensity/volume or repetitive overuse (3,4).
- Smokers (3).
- Diabetes (3).
5. Prevalence
Metatarsal fractures represent between 3%-6% of all fractures presented within primary care, with the fifth metatarsal being the most commonly affected. In males, the incidence of the fifth metatarsal fractures peaks in the third decade of life. In females, there is a peak in the seventh decade of life (1,3).
6. Assessment & Diagnosis
A musculoskeletal physiotherapist can provide you with an accurate and timely diagnosis by obtaining a detailed history of your symptoms. A series of tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
If a fracture of the fifth metatarsal is suspected an X-ray will be recommended as the initial imaging of choice used to evaluate for these injuries (3, 6).
7. Self-Management
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your fracture. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.
8. Rehabilitation
If a fracture of the fifth metatarsal has been confirmed, your treatment plan will depend upon the location and extent of the fracture, plus any medical or lifestyle considerations.
Most non-displaced metatarsal shaft and zone 1 fractures require only a soft elastic dressing or firm, supportive shoe and progressive weight-bearing.
Management of zone 2 may differ depending on your consultant; a non-weight-bearing cast for 6 to 8 weeks is usually used. Surgery may be required if the fracture is displaced, or if non-union occurs. Once the fracture has healed, it is recommended to see a physiotherapist to regain mobility and strength of the foot and ankle, especially if a cast/immobilisation was used.
9. Fifth Metatarsal Fracture
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme focuses on maintaining and restoring range of motion to the ankle and foot complex. All exercises should be kept to a tolerable level of pain. This should not exceed more than 4/10 on your perceived pain scale.
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- 910
This is the next progression. More focus is given to progressive loading of the foot and ankle to rebuild strength, stability and proprioception (proprioception refers to the body’s ability to perceive its own position in space). This should not exceed more than 4/10 on your perceived pain scale.
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- 910
This programme is a further progression with challenging progressive loading of the foot and ankle complex, which aims to begin your safe return to recreational activity. This should not exceed more than 4/10 on your perceived pain scale.
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- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to the sport, a rehabilitation programme should incorporate plyometric-based exercises; this might include things like bounding, cutting, and sprinting exercises.
11. Other Treatment Options
Surgery may be required depending on the type and location of the fracture, and if non-union is present. Non-union means that the fracture is failing to heal properly. The normal process of bony healing is delayed or interrupted for some reason. It maybe connected to poor blood or worse case infection. Those at risk are smokers, those previously diagnosed with vascular disease, diabetics, or those with hormonal or vitamin deficiencies such as low vitamin D and calcium (2).
References
- Brogan K, Bellringer S, Akehurst H, Gee C, Ibrahim N, Cassidy L, Rogers B, Gibbs J. Virtual fracture clinic management of fifth metatarsal, including Jones’, fractures is safe and cost-effective. Injury. 2017 Apr;48(4):966-970. doi: 10.1016/j.injury.2017.02.003. Epub 2017 Feb 12. PMID: 28284470.
- Chloros GD, Kakos CD, Tastsidis IK, Giannoudis VP, Panteli M, Giannoudis PV. Fifth metatarsal fractures: an update on management, complications, and outcomes. EFORT Open Rev. 2022 Jan 11;7(1):13-25. doi: 10.1530/EOR-21-0025. PMID: 35073515; PMCID: PMC8788151.
- Hatch RL, Alsobrook JA, Clugston JR. Diagnosis and management of metatarsal fractures. Am Fam Physician. 2007 Sep 15;76(6):817-26. PMID: 17910296.
- Kane JM, Sandrowski K, Saffel H, Albanese A, Raikin SM, Pedowitz DI. The Epidemiology of Fifth Metatarsal Fracture. Foot Ankle Spec. 2015 Oct;8(5):354-9. doi: 10.1177/1938640015569768. Epub 2015 Feb 9. PMID: 25666689.
- Kay LJ, Holland TM, Platt PN Stress fractures in rheumatoid arthritis: a case series and case-control study Annals of the Rheumatic Diseases 2004;63:1690-1692.
- Smidt KP, Massey P. 5th Metatarsal Fracture. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544369/
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