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Stress fractures of the metatarsal shaft

James R Clugston, MD, MS
Robert L Hatch, MD, MPH
Section Editor
Patrice Eiff, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM


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".)


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 [3].

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 [3]. 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).


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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Literature review current through: Sep 2016. | This topic last updated: Sep 19, 2016.
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  1. Simons SM, Sloan BK. Foot injuries. In: Pediatric Sports Medicine for Primary Care, Birrer RB, Griesemer BA, Cataletto MD (Eds), Lippincott Williams & Wilkins, Baltimore 2002. p.431.
  2. Clinical Sports Medicine, 2nd ed, Brukner P, Khan K (Eds), McGraw-Hill, New York 2001. p.596.
  3. Simons SM. Foot injuries in the runner. In: Textbook of Running Medicine, O'Connor FG, Wilder RP (Eds), McGraw-Hill, New York 2001. p.213.
  4. DiGiovanni CW, Benirschke SK, Hansen ST. Metatarsal fractures. In: Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries, Browner BD, Jupiter JB, Levine AM, Trafton PG (Eds), WB Saunders, Philadelphia 2002. p.2458.
  5. Early JS. Metatarsal fractures. In: Rockwood and Green's Fractures in Adults, Bucholz RW, Heckman JD, Rockwood CA, Green DP (Eds), Lippincott Williams & Wilkins, Philadelphia 2001. p.2215.
  6. Sanderlin BW, Raspa RF. Common stress fractures. Am Fam Physician 2003; 68:1527.
  7. Jones BH, Thacker SB, Gilchrist J, et al. Prevention of lower extremity stress fractures in athletes and soldiers: a systematic review. Epidemiol Rev 2002; 24:228.
  8. Chuckpaiwong B, Cook C, Pietrobon R, Nunley JA. Second metatarsal stress fracture in sport: comparative risk factors between proximal and non-proximal locations. Br J Sports Med 2007; 41:510.
  9. Childers RL Jr, Meyers DH, Turner PR. Lesser metatarsal stress fractures: a study of 37 cases. Clin Podiatr Med Surg 1990; 7:633.
  10. Shindle MK, Endo Y, Warren RF, et al. Stress fractures about the tibia, foot, and ankle. J Am Acad Orthop Surg 2012; 20:167.
  11. Nielsen, Lindblad, Faun. Long-term results after fracture of the fifth metatarsal. J Foot Ankle Surg 1998; 4:227.
  12. Eiff MP, Hatch RL. Fracture Management for Primary Care, 3rd ed, WB Saunders, Philadelphia 2011.
  13. Banal F, Gandjbakhch F, Foltz V, et al. Sensitivity and specificity of ultrasonography in early diagnosis of metatarsal bone stress fractures: a pilot study of 37 patients. J Rheumatol 2009; 36:1715.
  14. Niemeyer P, Weinberg A, Schmitt H, et al. Stress fractures in adolescent competitive athletes with open physis. Knee Surg Sports Traumatol Arthrosc 2006; 14:771.
  15. Patel DR. Stress fractures: diagnosis and management in the primary care setting. Pediatr Clin North Am 2010; 57:819.
  16. Heyworth BE, Green DW. Lower extremity stress fractures in pediatric and adolescent athletes. Curr Opin Pediatr 2008; 20:58.
  17. Rome K, Handoll HH, Ashford R. Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults. Cochrane Database Syst Rev 2005; :CD000450.
  18. House C, Reece A, Roiz de Sa D. Shock-absorbing insoles reduce the incidence of lower limb overuse injuries sustained during Royal Marine training. Mil Med 2013; 178:683.