From the Guidelines
Management of metatarsal stress fractures should prioritize a combination of rest, activity modification, and supportive care to minimize morbidity, mortality, and improve quality of life. The initial treatment should focus on reducing weight-bearing activities for 4-6 weeks, with the use of a walking boot, stiff-soled shoe, or in more severe cases, a non-weight-bearing cast, as suggested by the most recent guidelines 1. Patients should follow the RICE protocol (Rest, Ice, Compression, Elevation) during the acute phase, with ice applied for 15-20 minutes several times daily to reduce swelling and pain.
Pain management typically includes NSAIDs such as ibuprofen (400-600mg three times daily) or naproxen (500mg twice daily) for 1-2 weeks. Gradual return to activities should begin only after the patient is pain-free during daily activities, usually after 6-8 weeks, with a progressive increase in weight-bearing exercises over 2-4 weeks.
- Key considerations include:
- Identifying high-risk patients, such as those with osteoporosis or on bisphosphonate therapy, who may require more aggressive management to prevent fracture completion 1.
- Recognizing high-risk stress fracture locations, including the fifth metatarsal base, which may have a higher risk of nonunion or delayed union and potentially require surgical intervention 1.
- Implementing preventive strategies, such as modifying risk factors and providing nutritional assessment, particularly for female athletes, to address potential deficiencies in calcium and vitamin D 2, 1.
- The goal of treatment is to promote healing, prevent complications, and allow for a gradual return to activities, with the understanding that healing time may vary based on fracture location and individual patient factors, as noted in recent updates on stress fracture management 1.
From the Research
Metatarsal Stress Fracture Management
- Initial treatment strategies for metatarsal stress fractures involve rest, ice, nonweight bearing, and avoidance of exercise to prevent fracture displacement, nonunion, and other complications 3.
- Nonoperative treatment is usually successful, but surgery may be recommended for certain cases, such as fifth metatarsal stress fractures or Torg-type-II or III injuries 4.
- Activity modification, including the use of nonweight-bearing crutches if needed for pain relief, is a key component of treatment, along with analgesics to relieve pain and pneumatic bracing to facilitate healing 5.
Diagnosis and Treatment
- Diagnosis of metatarsal stress fractures depends on a careful history and physical examination, with select use of imaging techniques such as plain radiography, MRI scans, and CT scans 4, 6.
- Management of metatarsal stress fractures relates to the site of injury, with high-risk fractures (e.g. navicular, talus, and hallucal sesamoids) requiring more aggressive management, often including surgical intervention 6.
- Nondisplaced fractures of the metatarsal shaft usually require only a soft dressing followed by a firm, supportive shoe and progressive weight bearing, while stress fractures of the first to fourth metatarsal shafts typically heal well with rest alone 7.
Prevention and Risk Factors
- Factors that commonly influence metatarsal stress fractures include an acute increase in new repetitive physical activity, muscle fatigue, training errors, and improper athletic techniques 6.
- Decreased bone marrow density (BMD) and vitamin D deficiency are also major biologic causes for developing stress fractures, and may contribute to poor healing 6.
- The female athlete triad, comprising eating disorder, amenorrhea, and osteoporosis, also predisposes to stress fractures 6.