Stress Fracture from Minimalist Shoes?

author : AMSSM

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I was running and after about half a mile in I started to feel some pain on the outside of my left foot. I was running in Vibram's on soft trail and this was not the first time I have done this.

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About three weeks ago I was running and after about half a mile in I started to feel some pain on the outside of my left foot. I was running in Vibram's on soft trail and this was not the first time I have done this. I stopped running after this mostly because it was too painful to run and am still waiting to see how long it would take for this pain to go away. 

From the videos and instructions, I see that it is not a stress fracture. There is no swelling and no pain when I push on any metatarsal bones. 
 The only pain I have is when pushing outside in on the part where the pinky meets the metatarsal bone. The pain is only present when pushing and my foot is relaxed. When I tense the foot, the pain is not there. 

Thank you all for your help!  I cannot wait to get back to running so this time off is brutal for me.

Answer from Carl Rasmussen, MD and Melissa Novak, DO
Member AMSSM

I am sorry to hear about your running injury. Your question is a good one, and the use of minimalist running shoes adds an interesting layer to your case.

Foot pain in a runner without a specific inciting injury is always concerning for a stress fracture. Thus, your immediate consideration of this as the cause of your pain was appropriate. Other possible causes include: a bunion, a bone contusion, tendinitis, capsulitis, metatarsalgia, or an acute fracture.

A bunion is a painful callus that develops over a bony prominence. A Tailor’s bunion can develop over the head of the 5^th metatarsal – the area where you describe your pain. A thickened, painful callus can develop over this bone from the rubbing of your shoe. The callus develops gradually over time and is usually obvious when examining the foot. A bone contusion, or bone bruise, of the head of the 5^th metatarsal would be possible with direct trauma to the area. Tendinitis – inflammation of muscle tendons – is a common foot injury in runners. Capsulitis is a similar injury as tendinitis but is isolated inflammation of the joint capsule. These diagnoses are usually seen in patients who have pain on flexion or extension of a joint rather than “point tenderness” - pain when pressing on a specific area – as you describe. Metatarsalgia is generalized pain affecting the front of the foot; however, this condition usually involves pain in the ball of the foot rather than the side. An acute fracture is a break in the bone from specific injury or trauma to the area. Metatarsal fractures usually occur from a direct blow or a twisting force. Simple x-rays of the foot can assess for such a fracture.

However, a stress fracture is the most likely consideration in a runner who develops localized pain over a metatarsal bone over time while running without known trauma or injury to the area. Stress fractures are common injuries in runners that begin with repetitive and excessive stress on the bone. This most frequently occurs in runners who are over-training and not allowing for sufficient rest in their training schedule. This stress on bone leads to the acceleration of normal bone remodeling and the production of microfractures. These microfractures cause localized pain at the affected area that worsens with weight-bearing or exercise. Edema or swelling may be present, but its absence does not rule out a stress fracture. In fact, less than 50% of metatarsal stress fractures exhibit noticeable swelling on examination of the foot.¹

Stress fractures of the 5^th metatarsal – the location of your pain – require special care considerations as certain types of these fractures tend to heal poorly. Fractures involving the tuberosity of the 5^th metatarsal – the bony protrusion closest to the ankle – generally heal well and can be treated similarly to other metatarsal stress fractures by taking a break from the inciting activity for 4-8 weeks and using a hard sole shoe or walking boot. However, fractures distal, or towards the toes, from this point that involve the shaft of the 5^th metatarsal bone do not tend to heal well and are prone to delayed or non-union (failure of the broken bone to reconnect). Such fractures require more aggressive management. The first step in diagnosis of such fractures are foot x-rays in addition to a history and exam performed by a physician. If initial x-rays are negative (or show no signs of fracture), your physician may recommend refraining from any substantial physical activity and repeating the x-ray in two weeks. If follow-up x-rays are negative at two weeks and clinical suspicion remains high for a stress fracture of the 5th metatarsal shaft, an MRI may be needed to make a definitive diagnosis. For elite athletes who initially present with clinical symptoms or signs of such a fracture and are unwilling to limit their activity without a definitive diagnosis, the physician may order an MRI if initial x-rays are negative given the potential complications of these injuries.²

A referral from your primary care physician to a sports medicine or orthopedic expert is recommended if a 5^th metatarsal shaft stress fracture is diagnosed. If there is concern that the stress fracture is old (based on its appearance on imaging), surgical fixation of the fracture will likely be needed. New stress fractures, on the other hand, can be managed conservatively (without surgery), but usually require a short-leg cast and non-weight-bearing status (using crutches and not bearing weight on the cast) for up to 20 weeks. Patients may be able to avoid surgical intervention with this treatment. However, these fractures require close monitoring as there is an increased risk for non-union compared to most stress fractures. Even after 20 weeks of non-weight-bearing treatment, non-union is still possible. Thus, many athletes hoping for a quicker recovery and return to activity opt for surgical intervention. Early surgical fixation allows the patient to avoid prolonged non-weight-bearing immobilization, thereby decreasing deconditioning and enabling a quicker return to competition. Once the fracture has healed on imaging and the pain is resolved, the patient may begin gradual, progressive weight-bearing and range-of-motion exercises. Physical therapy may be considered if the period of immobilization exceeded two to three months. Return to regular physical activity and running should be very gradual and occur in a step-wise fashion, as advancing activity too rapidly may cause a recurrence of the fracture.³ 

Your case raises interesting questions regarding the use of minimalist running shoes and running injuries. It has been proposed that minimalist running shoes decreased overuse injuries by promoting shorter strides and midfoot-forefoot strike. While there is evidence that minimalist shoes do promote such biomechanics and disperse impact forces on the foot, there is no clinical evidence proving a reduction in running injuries.⁴ In fact, certain studies have shown increased injuries, specifically involving metatarsal stress fractures, in runners using minimalist shoes.^5,6 However, overall there is a lack of clinical evidence surrounding the risks or benefits of minimalist footwear, thus no definitive conclusions can be made to support or discount this style of running shoe.⁷ Runners who are making the transition from traditional running shoes to minimalist footwear are recommended to make this transition slowly and avoid over-training to prevent injuries – good advice for any runner to avoid overuse injuries, such as stress fractures.

Best wishes for a healthy and complete recovery,

Carl Rasmussen, MD
Family Medicine Resident
Oregon Health and Science University

Melissa Novak, DO
Primary Care Sports Medicine Physician
Oregon Health and Science University

1. Sanderlin BW, Raspa RF. Common Stress Fractures. Am Fam Physician. 2003 Oct 15;68(8): 1527-32 

2. Hatch RL, Alsobrook JA, Clugston JR. Diagnosis and Management of Metatarsal Fractures. Am Fam Physician. 2007 Sept 15;76(6): 817-26

3. Alsobrook J, Hatch RL. (2014). Proximal 5^th metatarsal fractures. In P. Eiff (Ed.),UpToDate. Available from http://www.uptodateonline.com. 

4. Rixe JA, Gallo RA, Silvis ML. The barefoot debate: can minimalist shoes reduce running-related injuries?. Curr Sports Med Rep. 2012 May-Jun;11(3):160-5

5. Salzler MJ, Bluman EM,Noonan Set al. Injuries observed in minimalist runners. Foot Ankle Int. 2012 Apr;33(4):262-6

6. Ryan M, Elashi M, Newsham-West R et al. Examining injury risk and pain perception in runners using minimalist footwear. Br J Sports Med. 2014 Aug; 48(16):1257-62

6. Perkins KP, Hanney WJ, Rothschild CE. The risks and benefits of running barefoot or in minimalist shoes: a systematic review. Sports Health. 2014 Nov 6;(6):475-80

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date: March 16, 2015