Sports Medicine
Sports Injury Prevention & Rehabilitation

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5th Metatarsal Fracture

(Also known as a Fractured 5th Metatarsal, Base of 5th Metatarsal Fracture, Avulsion Fracture of the Base of the Fifth Metatarsal, Jones Fracture)
What is a 5th metatarsal fracture?
A 5th metatarsal fracture is a relatively common condition characterized by a break in the long bone situated at the outer aspect of the foot known as the 5th metatarsal.
The foot comprises of many small bones, five of which are the long bones known as the metatarsals which are situated beside each other. The 5th metatarsal bone lies on the outer aspect of the foot and forms joints with the 5th proximal phalanx and the cuboid bone.
During certain activities such as landing from a jump, or when rolling an ankle, stress is placed on the 5th metatarsal. When this stress is traumatic and beyond what the bone can withstand a break in the 5th metatarsal may occur. This condition is known as a 5th metatarsal fracture.
A 5th metatarsal fracture is relatively common among the elderly, but can also occur in the younger patient. Often a fracture of the 5th metatarsal occurs in combination with a sprained ankle or other fractures of the foot, ankle or lower leg (such as following trauma).
5th metatarsal fractures can vary in location, severity and type including avulsion fracture, stress fracture, Jones' fracture, displaced fracture, un-displaced fracture, spiral fracture, greenstick, comminuted etc.

Causes of a 5th metatarsal fracture

A 5th metatarsal fracture commonly occurs in association with a rolled ankle, particularly when the ankle has rolled inwards and when significant weight bearing forces are involved. They may also occur due to an awkward landing from a jump (particularly on uneven surfaces), due to a fall or following a direct blow to the outer foot. 5th metatarsal fractures are common in running and jumping sports involving change of direction such as football, soccer, rugby, basketball and netball and in dancing (e.g. ballet).

Signs and symptoms of a 5th metatarsal fracture
Patients with this condition typically experience a sudden onset of sharp, intense outer foot or ankle pain at the time of injury. Sometimes the patient may have heard an audible snapping sound at the time of injury. The pain often causes the patient to limp or be unable to weight bear so as to protect the foot. Pain is usually felt at the outer aspect of the foot or ankle and can occasionally settle quickly leaving patients with an ache at the site of injury that may be particularly prominent at night or first thing in the morning.
Patients with a 5th metatarsal fracture may also experience swelling, bruising, stiffness and pain on firmly touching the affected region of bone. Pain may also increase during certain movements of the foot or ankle or when standing or walking (particularly up hills or on uneven surfaces). In severe 5th metatarsal fractures (with bony displacement), an obvious deformity may be noticeable.

Diagnosis of a 5th metatarsal fracture

A thorough subjective and objective examination from a physician is essential to assist with diagnosis of a 5th metatarsal fracture. An X-ray is usually required to confirm diagnosis and assess the severity. Further investigations such as an MRI, CT scan or bone scan may be required, in some cases, to assist with diagnosis and assess the severity of the injury.

Treatment for a 5th metatarsal fracture

For those 5th metatarsal fractures that are displaced or involve the shaft of the bone (i.e. diaphysis - Jones' fracture), treatment typically involves anatomical reduction (i.e. orthopaedic re-alignment of the fracture by careful manipulation under anaesthetic) followed by either cast immobilization for a number of weeks or surgical internal fixation to stabilize the fracture (using plates and screws). This may be followed by or supplemented with the use of a protective boot or crutches for a number of weeks.
For those fractures that are not displaced and do not involve the shaft of the 5th metatarsal, (particularly the commonly seen 'non-displaced avulsion fractures of the base of the 5th metatarsal') treatment typically involves the use of a protective boot or crutches for a number of weeks.
Evaluation of the fracture with follow up X-rays is important to ensure the fracture is healing in an ideal position. Once healing is confirmed, rehabilitation can progress as guided by the treating therapist.
One of the most important components of rehabilitation following a 5th metatarsal fracture is that the patient rests sufficiently from any activity that increases their pain (crutches and / or a protective boot are often required). Activities which place large amounts of stress through the 5th metatarsal should also be avoided, particularly excessive weight bearing activity such as running, jumping, standing or walking excessively (especially up hills or on uneven surfaces). Rest from aggravating activities allows the healing process to take place in the absence of further damage. Once the patient can perform these activities pain free, a gradual return to these activities and weight bearing forces is indicated provided there is no increase in symptoms. This should take place over a period of weeks to months with direction from the treating therapist.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to cause further damage and may slow healing or prevent healing of the 5th metatarsal fracture altogether.
Patients with a 5th metatarsal fracture should perform pain-free flexibility, strengthening and balance exercises as part of their rehabilitation to ensure an optimal outcome. This is particularly important, as balance, soft tissue flexibility and strength are quickly lost with inactivity. The treating therapist can advise which exercises are most appropriate for the patient and when they can commence.
In the final stages of rehabilitation, a gradual return to activity or sport can occur as guided by the treating therapist provided there is no increase in symptoms. The use of a protective brace or strapping tape may be indicated to provide additional stability to the ankle during this phase of rehabilitation and as an ongoing form of injury prevention.

Prognosis of a 5th metatarsal fracture
Patients with a 5th metatarsal fracture usually make a full recovery with appropriate management (whether surgical or conservative). Return to activity or sport can usually take place in weeks to months and should be guided by the treating physiotherapist and specialist. In patients with severe injuries involving damage to other bones, soft tissue, nerves or blood vessels, recovery time may be significantly prolonged. In patients with only very minor fractures that are un-displaced (such as an avulsion fracture) return to sport can sometimes occur in as little as 6 - 8 weeks as guided by the treating physician.

Physical therapy for a 5th metatarsal fracture
Physical therapy treatment is vital in all patients with this condition to hasten healing and ensure an optimal outcome. Treatment may comprise:
  • soft tissue massage
  • joint mobilization
  • electrotherapy (e.g. ultrasound)
  • taping or bracing
  • the use of a protective boot
  • the use of crutches
  • exercises to improve strength, flexibility and balance
  • hydrotherapy
  • education
  • activity modification
  • a graduated return to activity plan

Other intervention for a 5th metatarsal fracture

Despite appropriate management, some patients with this condition do not improve adequately and may require other intervention. The treating doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, CT scan, MRI or bone scan, periods of plaster cast immobilization or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the 5th metatarsal fracture. Occasionally, patients who were initially managed conservatively may require surgery to stabilize the fracture and/or a bone graft to aid fracture healing.