Current Insights on Metatarsal Stress Fractures

The first description of metatarsal stress fractures appeared in the literature in 1855, coining them “March fractures,” as the original authors noted them in soldiers experiencing debilitating pain and swelling from the repetitive stress of long marches.¹ Most commonly impacting the second metatarsal, these injuries are prevalent in military and other athletic populations.¹ Sources cite metatarsal stress fractures as accounting for one-quarter of all stress fractures and one-fifth of all sports medicine clinic visits.¹ Up to 40% of athletes may experience a stress fracture of some kind during their careers, and female athletes are more likely to develop metatarsal stress fractures compared to males.¹ Etiology and contributing risk factors are vital to understand in this pathology, as 60% of patients with a stress fracture have also experienced one before.¹

Dr. Karen Langone, a Past President of both the American Academy of Podiatric Sports Medicine, and the American Association for Women Podiatrists, is a biomechanics and sports medicine specialist in Hampton Bays, NY. Recently, she sat down with Podiatry Today to dive into her experience with metatarsal stress fractures, contemporary observations, and related factors providers should consider in these clinical scenarios.

In your experience, what is the typical patient profile when it comes to stress fractures, and under what circumstance do they usually arise?

“Lately, I think these fall into 2 primary categories,” said Dr. Langone. “One is the female athlete, and the other is the patient with a significant hallux valgus, who then develops a (lesser) metatarsal stress fracture.”

She also notes that she receives some referrals to her practice from physical therapists to perform lower extremity evaluations for young men with histories of vertebral stress fractures.

What have you observed with respect to symptom presentation and examination findings in metatarsal stress fractures?

The patients in question often present with foot pain of at least several weeks’ duration, Dr. Langone shared. They’ve often tried various home interventions without success, and their activities are now limited. From the patient’s point of view, she explains, there isn’t noticeable swelling or bruising present to raise their level of concern.

“We notice it because we look at the contralateral side,” she noted. “But the patient doesn’t always see the subtle edema that’s present there. So, after having changed their shoes, switching their exercise routine, and recognizing that the issue is not getting better, they finally decide to have somebody take a look at it.”

As far as the visual analog pain scale, Dr. Langone observes patients reporting between 2 and 8 out of 10, depending on the shoe gear and activity type. They may also experience stiffness when first rising, generally increasing as the day goes on, and increasing with activity level.

What imaging findings might one expect to see with metatarsal stress fractures?

Clinicians will find that if these patients present early, they will not see much on plain radiographs in those initial phases, she noted.

“Oftentimes, the first thing that we’ll really see is just some cortical thickening in that area,” she commented. “And then, if it’s been more longer standing, we start to see more significant changes, (such as a) cortical break. From there, we may look and see if we pick something up on the ultrasound, or send them out for [magnetic resonance imaging] MRI.”

What is your typical treatment protocol for a metatarsal stress fracture?

Immobilization is the first intervention she said she pursues, with a controlled ankle motion (CAM) walker and limitation of weight-bearing activity.  

“Unless it’s a metatarsal fracture I don’t put them totally off weight-bearing. I will allow them, depending on the severity, to do upper body exercises or some seated weightlifting,” she explained. “Sometimes I will allow them to lightly cycle, but only lightly. I prefer, if they cycle, that they’re clipped in, and that they have a cycling shoe, so we take advantage of the graphite component.”

Dr. Langone shared that finding these safer, controlled ways for the athlete to remain in motion during their treatment course may contribute to supporting their mental health, as well. Aquatic therapy under the supervision of a physical therapist is another option to consider.

Where does bone quality come into the equation?
 
Dr. Langone said she does incorporate bone quality into her treatment algorithm, generally evaluating bone quality on plain radiographs and MRI. If there are any concerns for or evidence of osteopenia, she begins a workup at that time.

“I start to see it in women over 45 (and as a result) I become a lot more cognizant of that factor, as well as with the athletes in sports that focus on weight and appearance. These can be dancers, wrestlers, gymnasts, etc.,” she explained.

When diving deeper into bone health, Dr. Langone said she will investigate if the patient has had dual energy X-ray absorptiometry (DEXA) scans and obtain the reports. If not, she will order a DEXA scan. Additionally, she will review recent bloodwork if available or order bloodwork for tests such as vitamin D levels.
 

How do you go about determining timeframes and circumstances for return to activity or return to sport?

An exact trajectory for any given patient will develop based on a few factors, Dr. Langone said, such as how adherent they are to limiting weight-bearing.

“I like to tell them if they can give me a good 10 days of really limited activity, that will really start to increase their healing rate,” she shared. “So, if they can be careful for that period of time, then we start to see a turnaround a lot quicker.”

Dr. Langone said she generally immobilizes for about 3 weeks. However, one thing she does right away for patients with a stress fracture is pursue a custom orthotic. In fact, she said she does not take them out of the CAM walker until the orthotic is ready.

What challenges do you think clinicians should keep in mind when addressing stress fractures?

“I think the biggest thing when we’re dealing with the athlete is the fact that they don’t want to be injured, and they are going to come up with every proposed scenario under the sun (trying to remain active),” she explained. “‘Could I hop on one leg? Can I complete the marathon, if I only run slowly?’ So, it’s really managing the mental aspect of the injury.”

She also noted some patterns in the treatment course that she has come to expect over time.

“I say that my favorite thing to treat is a fracture, because people get better,” said Dr. Langone. “And my least favorite thing to treat is a fracture around week 3 and 4, because by then people have had it. They’re bored. They’ve binged every streaming show that they can binge, and the mental aspect becomes really difficult for them to deal with.”

The bone health dimension of the pathology can also be challenging to connect with patients on, she said. She noted that sometimes the patients find it difficult to accept or understand, especially those who are active—for instance, those who walk daily for exercise. Therefore, she said she focuses on educating patients on the importance of strength training, flexibility, and protein inclusion at every meal.

“They have to take adequate calories in, and in order to improve bone health they need multidirectional activity,” she explained.

“So just walking in a straight line 3 miles a day is not going to do it. Having that whole conversation with them is very important.”

Another challenge she commented on is that the subtle changes clinicians can appreciate on a plain film X-ray may not always resonate with patients. Additionally, an ultrasound can be just as challenging to translate in a patient’s eyes.

“That can be really tricky … those subtle changes don’t always register all that well with them, and that can be hard for them to understand and grasp the diagnostic tests.”

Sometimes the written radiology report, when available, can be a more concrete educational tool, she said.

What is the recent literature telling us about metatarsal stress fractures?

Most of what Dr. Langone said she sees deals with who is most susceptible to stress fractures, including, but not limited to, women over 60 years old, patients with low body mass index, previous bone stress injury, and those with hormonal or nutritional issues.^1-3

From your point of view, what do you think the future will look like regarding metatarsal stress fractures?

Dr. Langone projects seeing both younger and older patients present with this concern.

“I think we’re going to see stress fractures in younger and younger athletes because kids are doing one-sport specialization at such a young age, going 7 days a week, or 5 days a week year-round, with no alternate activities,” she said. “When I first started in practice, I never saw kids before high school age with athletic injuries, and now, I’ve got 8-year-olds coming in, starting to develop issues. I think we’re going to see more and more of that because athletics has become so competitive.

This trend is not limited to youth athletes, however. Dr. Langone said she has observed a different generation emerging also dealing with these injuries.

“More and more Baby Boomers are reluctant to give up exercise, and think that things they can do at 65, the things they did at 25 (years old),” she shared. “So I think we will see that more and more. Now you’ve got people in their 80s who are exercising. Our lifespan is improving, and I think it’s so imperative that we recognize those stress fractures early, so that we really help these people to get on the right path and to avoid these major life changing events or life ending events.”

There is another, likely under-recognized population of patients to consider and learn more about when it comes to metatarsal stress fractures that Dr. Langone pointed out.

“So many women are on estrogen blockers post–breast cancer … and these do cause bone changes, moving people towards osteopenia and osteoporosis,” she said.⁴ Women are on these medications for several years, more women are diagnosed with breast cancer, and lifespan is increasing. Therefore, I think that we will see more and more of these patients with stress fractures, and managing them is very nuanced.”

As far as diagnosis or treatment, do you think there’s anything emerging that clinicians should be aware of?

Dr. Langone said that focusing on available imaging options is likely a smart tactic. She pointed out that images from various modalities continue to improve, which she hopes will result in being able to detect stress fractures earlier, in the office, and at a decreased cost for patients compared to options like MRI.

“We can then hopefully get the patient started on the treatment plan and then hopefully get them back to activity a lot faster as well,” she added.

In your estimation, do you feel that treatment will lean to earlier versus later return to activity? Do you feel it will become more conservative or more aggressive compared to current trends?

“I would think more aggressive because we keep pushing that envelope on the minimal time that we need with some kind of protective intervention and well-designed return to activity program,” Dr. Langone said. “I think the issue is always getting people back to their lives faster. Because we have to consider the flip side of the coin—if we take somebody with osteopenia and we immobilize them for 8 weeks, now we’ve worsened that condition.”

Previously, you mentioned assessing bone health in patients with stress fractures. Can you elaborate more on how you handle this and related concerns in your practice?

Dr. Langone shared she uses the calcaneus as a target bone on radiographs to begin to evaluate bone health in her patients. From these clinical observations, she may order further testing, as she previously mentioned, such as a DEXA scan. Specifically, she noted that she has nutritional handouts prepared for patients that show evidence of osteopenia, including calcium content of select foods.

“It’s really difficult for any of us through our diet to get 1200 milligrams of calcium a day, which is the recommended dose. It’s really, really difficult. In my experience, a good, healthy diet will probably get about 600 milligrams a day, so generally we probably need to do some supplementation with that as well,” she said.

She added that vitamin D is also a key factor in her patient bone health workup. She observes that patients often wear sunscreen and avoid the sun, which is a positive for skin cancer risk, but can be a detriment to vitamin D levels. Supplementation can be key here, she said, as can dosed time outdoors (even 20 minutes at a time).

Are there any other concurrent conditions that can impact the course of a metatarsal stress fracture?

Overall, Dr. Langone encouraged clinicians to think about factors like age, medical history, medication history, and others when determining treatment, as this may impact length of immobilization, among other aspects of the treatment course. In addition to those previously mentioned, she notes that parathyroid issues, nutritional quality, and relative energy deficiency in sport (RED-S) are worth consideration.

What one thing do you hope that podiatrists will add or change in their practices today to improve outcomes when it comes to metatarsal stress fractures?

Dr. Langone advocates for clinicians to look at the complete picture of each patient in these scenarios, and not just focus on diagnosis and immobilization.

“Start to look deeper,” she stressed. “Keep in mind that these can really be the early warning signs of osteoporosis or RED-S. Remember that there are many etiologies we need to identify and address. We really need to look at the bigger picture and intervene to the maximum that we can to optimize outcomes.”

Dr Langone is a Diplomate of the American Board of Podiatric Medicine and a Fellow of the American Academy of Podiatric Sports Medicine, for which she is also a Past President. Dr. Langone is also a Fellow of the National Academy of Practitioners, and is the Immediate Past President of the American Association for Women Podiatrists. She is the Lead Clinical Director for the New York State Fit Feet Program of Special Olympics international and lectures extensively nationally and internationally on topics in sports medicine.

Published in partnership with the American Association for Women Podiatrists

Editor’s Note: For related learning, read the following pieces:

• Consider Relative Energy Deficiency in Sport (RED-S) as a Differential Diagnosis This High School Sports Season
• Relative Energy Deficiency in Sport (RED-S): Beyond the Female Triad
• Treating Calcaneal Stress Fractures in Athletes
• Stress Fractures and Stress Reactions: Applications to Orthotics Programs
• Orthotics Considerations in Stress Fractures podcast

References

1.    Koo AY, Tolson DR. March Fracture (Metatarsal Stress Fractures) [Updated 2023 Nov 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
2.    Tenforde AS, Ackerman KE, Bouxsein ML, et al. Factors associated with high-risk and low-risk bone stress injury in female runners: implications for risk factor stratification and management. Orthop J Sports Med. 2024 May 21;12(5):23259671241246227. doi: 10.1177/23259671241246227. PMID: 38779133; PMCID: PMC11110515.
3.    Paavana T, Rammohan R, Hariharan K. Stress fractures of the foot - current evidence on management. J Clin Orthop Trauma. 2024 Feb 22;50:102381. doi: 10.1016/j.jcot.2024.102381. PMID: 38435398; PMCID: PMC10904895.
4.    Lee S, Yoo JI, Lee YK, et al. Risk of osteoporotic fracture in patients with breast cancer: meta-analysis. J Bone Metab. 2020 Feb;27(1):27-34. doi: 10.11005/jbm.2020.27.1.27. Epub 2020 Feb 29. PMID: 32190606; PMCID: PMC7064363.