March (Metatarsal Stress) Fracture


Article Author:
Alex Koo


Article Editor:
Dedra Tolson


Editors In Chief:
Amie Kim
Todd May
Matthew Varacallo


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
5/13/2019 11:27:41 PM

Introduction

March fractures (metatarsal stress fractures) were first described in 1855, termed after the foot pain and swelling experienced by Prussian soldiers on long marches.[1] March fractures are metatarsal fractures, caused by repetitive stress. Intrinsic patient and extrinsic environmental risk factors can both contribute to the development of these fractures. A combination of historical features and physical evaluation with imaging can help make the diagnosis. These stress fractures are typically managed conservatively but can be complicated by nonunion. In such instances, surgical fixation may be warranted.

Etiology

March fractures are metatarsal fractures, most commonly second and third metatarsal fractures caused by an overuse injury. The repetitive impact to the metatarsals with weight-bearing exercises cause microfractures, which consolidate to stress fractures.[2]

The most common location of metatarsal stress fractures is the second metatarsal neck as it is less flexible and prone to torsional forces given its strong ligamentous attachment to the 1 and 2 cuneiforms.  In addition, the second metatarsal is the longest of the metatarsals, subjected to the most force.[3]

Epidemiology

March fractures occur commonly with sports and sudden increases in physical activity over 6 to 8 weeks. Metatarsal stress fractures are common in college athletes and the military, accounting for 25% of all stress fractures.[2] Overall data suggest that females have a higher incidence of march fractures than men. In addition, those with prior stress fractures are more likely to develop another. Sixty percent of patients with a stress fracture will have had a previous one.[4]

Pathophysiology

Common in new military recruits, a pervading theory is that osteoblastic activity lags behind osteoclastic activity during initial increases of exercise stress, leading to an increased incidence of stress fractures. March fractures occur secondary to bone fatigue or bone insufficiency. Bone fatigue occurs when normal bone is unable to resist excessive mechanical demands. Bone insufficiency occurs when normal strain occurs on abnormal bone. Intrinsic risk factors as nutritional deficiencies as vitamin D or calcium increase the risk of these fractures. In addition, extrinsic risk factors as the training type or shoe type can also contribute to an increased risk of metatarsal stress fractures.[1]

Classification System[3][5]

Kaeding and Miller’s 5-Tier Grading System

Grade of Stress Fracture/Radiographic Finding

  1. Asymptomatic radiographic findings
  2. Pain with no fracture on imaging
  3. Nondisplaced fracture on imaging
  4. Displaced fracture on imaging
  5. Sclerotic nonunion on imaging

History and Physical

During an interview, patients indicate that there is an inciting activity or exercise subjecting the patient to repetitive stress. Activity-related, insidious onset of pain at the site of fracture is often elicited from the history. Pain may improve transiently with rest but increases again with activity. Pain often is described as dull and aching. It is important to obtain a thorough medical history with particular attention to potential intrinsic risk factors. This may include an interview on a patient’s diet, endocrine disorders, and menstrual history in female patients.

Physical examination consists of palpation of the pain site, eliciting boney tenderness. If the fracture is in the proximity of a joint, the joint motion will aggravate the pain. Patients may have a limping gait with weight bearing.

Evaluation

March fractures are diagnosed based on historical clues, physical examination, and confirmed with diagnostic imaging. Plain radiographs are the initial imaging modality of choice. However, plain radiographs have a high rate of false negative for metatarsal stress fractures early on and may not demonstrate fractures until 2 to 4 weeks after the onset of pain.[6][7] While a clear fracture through the metatarsal may be seen on a radiograph, subtle periosteal reactions and blurring of the cortex may be the only clues of a stress fracture. More mature fractures may demonstrate callus formation or cortical lucency.[1]

Occult, suspected fractures not visible on plain radiographs can be imaged using 3three-phase bone scans with technetium-99 or magnetic resonance imaging (MRI). Both advanced imaging modalities have been proven to be sensitive to these fractures up to 24 hours after onset of pain. While bone scans are considered sensitive, but not specific, MRI is both sensitive and specific for metatarsal stress fractures.[1][2][3][4][7]

Lastly, thorough testing of the patient’s intrinsic risk factors may be needed. For example, measuring serum 25(OH), vitamin D concentration can be considered in those suspected of nutritional deficiencies.[3]

Treatment / Management

In most cases, analgesia and rest are all that is needed for metatarsal stress fracture healing. Acetaminophen and ice are implemented for pain and swelling. The effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on fracture healing remains contested.[1]

Immobilization is often unnecessary, and a stiff-soled orthopedic boot or walking boot may be used for 4 to 8 weeks. Weight-bearing is allowed as long as the patient is pain-free. Thus, exercise may resume with lower impact exercises as swimming, cycling, or deep water running. The exception to this treatment is areas higher risk for nonunion, consisting of the base of the fifth metatarsal and neck of the second metatarsal. Special consideration should be given to pain elicited at these areas for advanced imaging if radiographs are negative. In addition, if a fracture at these sites is present, non-weight bearing status can be achieved with crutches and casting. Additionally, a referral to an orthopedic surgeon should be placed in cases of nonunion that may need surgical fixation.[2][3][4]

Modifiable risk factors should be treated. Nutritional deficiencies as low levels of vitamin D, calcium, or calories should be addressed by ensuring adequate intake and supplementation as needed. Environmental changes should be considered. Shock-absorbing insoles for shoes or boots can distribute force during weight-bearing exercises. The type of training activity, surface, and intensity can be adjusted.[3][7]

As a march fracture heals, a graded return to activity should be employed. When the patient is fully weight-bearing and pain-free with low-intensity exercise, the patient gradually increases their exercise intensity by 10% every week to avoid further stress fractures.[3]

Prevention of march fractures includes stretching with gradual increments in exercise intensity and duration to avoid abrupt changes in stress. In addition, correcting predisposing biomechanical conditions as gait training and arch supports can be beneficial.

Complications

Nonunion is a complication of march fractures with symptoms of chronic pain, swelling, or instability. In such cases, surgery with intramedullary nailing may be warranted. Post-operatively, healing can be arduous, sometimes taking months to years.[3]

Enhancing Healthcare Team Outcomes

March fractures are best managed by a multidisciplinary team that also includes nurses and therapist. The key is to prevent them in the first place. Patients need to be educated on the importance of stretching prior to exercise. In addition, correcting predisposing biomechanical conditions as gait training and arch supports can be beneficial.

The outcomes for most patients are good but recurrence is not uncommon. Failure to diagnose a march fracture can lead to non-union and moderate disability.


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March (Metatarsal Stress) Fracture - Questions

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What is the most common location of metatarsal stress fractures?



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What is the best treatment for a stress fracture of the second metatarsal?



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A march fracture in an adult is associated with pain in which of the following bones?



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A 37-year-old marathon runner presents with midfoot pain. The patient states that she has been running marathons her whole life, so she does not understand what is different. She recently increased her weekly mileage to 40-45 miles per week as she prepares for her next marathon in 2 months. On exam, she has tenderness of her third metatarsal. Radiographs are normal in appearance. What is the best next step in management?



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A runner is referred for physical therapy for foot pain and is not responding to treatment. Which of the following studies would be best to correctly diagnose the condition?



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An 18-year-old male returned a day prior from a backpacking trip, complaining of midfoot pain without an acute traumatic event. X-rays of his foot show a stress fracture at the neck of the second metatarsal. What is a complication of fractures at this area?



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What is true about the imaging options for metatarsal stress fractures?



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Which of the following are not modifiable risk factors of metatarsal stress fractures?



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A patient has a metatarsal stress fracture. What is the best next step in management?



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March (Metatarsal Stress) Fracture - References

References

Jacobs JM,Cameron KL,Bojescul JA, Lower extremity stress fractures in the military. Clinics in sports medicine. 2014 Oct     [PubMed]
Sanderlin BW,Raspa RF, Common stress fractures. American family physician. 2003 Oct 15     [PubMed]
Pegrum J,Dixit V,Padhiar N,Nugent I, The pathophysiology, diagnosis, and management of foot stress fractures. The Physician and sportsmedicine. 2014 Nov     [PubMed]
Patel DS,Roth M,Kapil N, Stress fractures: diagnosis, treatment, and prevention. American family physician. 2011 Jan 1     [PubMed]
Miller TL,Jamieson M,Everson S,Siegel C, Expected Time to Return to Athletic Participation After Stress Fracture in Division I Collegiate Athletes. Sports health. 2018 Jul/Aug     [PubMed]
Bolin D,Kemper A,Brolinson PG, Current concepts in the evaluation and management of stress fractures. Current sports medicine reports. 2005 Dec     [PubMed]
Patel DR, Stress fractures: diagnosis and management in the primary care setting. Pediatric clinics of North America. 2010 Jun     [PubMed]

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