Stress fractures of the metatarsal shaft
- James R Clugston, MD, MS
James R Clugston, MD, MS
- Assistant Professor of Community Health and Family Medicine
- University of Florida College of Medicine
- Robert L Hatch, MD, MPH
Robert L Hatch, MD, MPH
- Professor of Family Medicine
- University of Florida College of Medicine
Metatarsal stress fractures were first described by Briethaupt in 1855 and termed "march fractures" since they commonly occur in military recruits. This topic will discuss stress fractures of the metatarsal shaft, not including the fifth metatarsal. An overview of stress fractures, a detailed discussion of fifth metatarsal fractures, and non-stress fractures of the metatarsals are discussed separately. (See "Overview of stress fractures" and "Proximal fifth metatarsal fractures" and "Metatarsal shaft fractures" and "Metatarsal and toe fractures in children".)
CLINICAL ANATOMY AND BIOMECHANICS
For reference purposes, the metatarsals are numbered from first (largest) to fifth (smallest) (figure 1 and figure 2A and figure 2B and figure 2C and figure 3 and figure 4). The first metatarsal is larger than the others and less likely to develop a stress fracture. A disproportionate number of stress fractures occur in the second metatarsal shaft, especially at the neck. Several anatomic mechanisms are proposed to explain this phenomenon. The base of the second metatarsal is recessed and more firmly fixed at the tarsal-metatarsal joint, via ligamentous attachment to the first and second cuneiforms, than the other metatarsals [1,2]. The resulting increased rigidity probably allows less motion in the sagittal plane at the metatarsal base and increases bending forces in the second metatarsal diaphysis .
According to an alternative mechanism, if the second metatarsal is longer than the first (ie, Morton foot), the second metatarsal is subjected to greater amounts of stress [2,4,5]. It is debated whether this increased stress is due to the increased length of the second metatarsal or to the decreased mobility of the first metatarsal . As the forefoot pronates during normal gait, the first metatarsal dorsiflexes and transfers load to the lesser metatarsals. The second metatarsal receives a greater share of this load than the other metatarsals.
Dorsal and plantar metatarsal arteries run adjacent to the metatarsals, while branches of the lateral and medial plantar nerves run in the vicinity of the metatarsals (figure 5 and figure 6 and figure 7).
EPIDEMIOLOGY AND RISK FACTORS
A range of factors that increase weight-bearing loads on particular metatarsals or decrease the ability of metatarsals to handle such loads predispose individuals to stress fractures [4-9]. These factors include the following:
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- CLINICAL ANATOMY AND BIOMECHANICS
- EPIDEMIOLOGY AND RISK FACTORS
- MECHANISM OF INJURY
- CLINICAL PRESENTATION AND EXAMINATION
- DIAGNOSTIC IMAGING
- DIFFERENTIAL DIAGNOSIS
- Initial treatment
- Follow-up care
- Fifth metatarsal stress fractures
- PEDIATRIC CONSIDERATIONS
- SUMMARY AND RECOMMENDATIONS