Metatarsal Stress Fractures

author : AMSSM

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Learn about how metatarsal stress fractures form, how long the healing time is, what medicine to take for pain and how long until you can return to training.

Member question

I was diagnosed with a 4th matatarsal stress fracture about three weeks ago.  I stopped running at that point.  

Question:  Is there a doctor that can shed some light on the stages of healing?  I have probably had this for many months and was running through it.  For the first few weeks I was biking and swimming a little, but my foot still seems to be sore.  I have kept my foot in a boot as much as possible, but still walking on it.

It is better than three weeks ago, but it's still painful and sore sometimes.  What should I expect for each week?  When should I be feeling better (even if I can run yet).  Is it normal to be sore for weeks after stopping running?  Am I just being impatient and the bone is healing? 

Answer from Matt Ziegler, MD
Member AMSSM 

Allowing enough time for an injury to heal is very important, although waiting seems to be more painful than the actual injury in many cases. Stress fractures occur due to repetitive impact forces that weaken bone. They usually occur with an increase in intensity or duration of training, new footwear, insufficient rest periods, continuing to train despite pain, neurologic problems or underlying rheumatologic problems.  The process of bone weakening occurs over a period of weeks to months and in the first stages there is no pain.  If the impact forces continue, the damage eventually progresses to a stress fracture with pain that starts diffusely and then localizes to the site of injury. At first the pain occurs with exercise and then eventually hurts at rest as well.     

Make sure your doctor has the right diagnosis and has ruled out other causes such as soft tissue injury, mortons neuroma, etc. The diagnosis is usually straightforward with history and physical exam alone but MRI or bone scan can aid in the diagnosis. Keep in mind that stress fractures may not be evident on plain Xrays for as long as three months after onset of symptoms and half are never seen on Xray at all.  Women should be evaluated for female athlete triad syndrome which can lead to weakening of the bones, also called osteopenia. Flat feet (pes planus) may predispose to increase force along the midfoot leading to higher incidence of metatarsal stress fractures. Orthotics, however, have not been shown to reduce stress fractures.  Your doctor can inspect your shoes for signs of excessive supination or wear under the metatarsal heads.

The location of a metatarsal stress fracture is important for prognosis and treatment. Certain fractures that occur at the base of the 2^nd or 5^th metatarsals require non-weight bearing for weeks and potentially surgery. Fourth metatarsal stress fractures usually heal completely with rest and a gradual return to activity.

A period of rest for 6-8 weeks is usually needed for the stress fracture to heal well. During that time you can use Tylenol or a short course (< 2 weeks) of NSAIDS such as Ibuprofen or Naproxen for pain relief.  There is some evidence that longer courses of NSAIDs may inhibit bone healing.  Elevate the foot and apply ice.  Occasionally a walking boot or short leg cast is necessary to alleviate pain and provide support.  Cycling, swimming, aqua-running and resistance training are OK as long as you can do these pain free and avoid stressing the foot.

When you are pain free at rest, a gradual return to sport can be started with a slow buildup of intensity and duration. Some physicians recommend no more than a 10% increase in intensity per week. So you can see that the recovery period takes awhile, but it is important to be patient.  Any pain with activity should prompt a rest period. Once you are pain free, start again with activity at a lower intensity level.  The biggest risk with this type of injury is a non-healing stress fracture or stress fracture that progresses to full fracture. These often have a longer recovery and some need surgery.  In order to prevent stress fractures, any changes in your training regimen should be gradual so that the bone can adapt to the increased forces.

As always, don’t hesitate to contact your sports medicine physician with any questions. 

Matt Ziegler, MD
University of Utah

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date: August 21, 2012