What is a Fifth Metatarsal Fracture?
The metatarsals are long bones in the feet which end at the base of the toes. Breaks in the bone, or fractures, are common in the fifth metatarsal – the long bone on the outside of the foot that connects to the little toe. These fractures usually occur from a sharp twist in the foot and ankle, or as a result of trauma (for example, dropping something on your foot).
The bone can break in a number of different places – through the centre of the bone, through the end, or through the tip. While these breaks may look similar, they can involve very different treatment and rehabilitation options, and hence you will need to talk to your doctor, physiotherapist or surgeon about the details of your therapy.
In most cases, a number of weeks of careful non-weight-bearing and gradual progression through physiotherapy is necessary. Of the different types of fractures shown below, only Jone’s fractures are likely to need surgery.
Diagram of the Foot looking from above. It shows various types of fractures that involve the fifth metatarsal.
Fractures of the 5th Metatarsal can affect any part of the bone. Three of the more common types are:
- Jones fracture. Jones fractures occur in the end of the bone. This area recieves less blood than other parts of the bone, and hence Jones fractures require careful treatment to help the bone heal as quickly as possible. For more information on one type of surgery used, see Surgery for Jones Fractures.
- Avulsion fracture. This fracture involves the tip of the metatarsal bone. In an avulsion fracture, a small piece of bone is pulled off by a tendon (in this case, the peroneus tendon). This type of fracture is the result of an injury in which the ankle rolls inwards. After the break, the tendon will continue to pull the tip of bone away from the rest of the metatarsal, and so this type of fracture requires careful positioning of the ankle and strict immobilisation (no movement).
- Mid-shaft fracture. These are usually stress fractures, ie injury resulting from overuse of the foot (for example, in runners).
Symptoms
Avulsion and Jones fractures have the same symptoms. These include:
- Pain, swelling, and tenderness on the outside of the foot
- Difficulty walking
- Bruising may occur on the outer edge of the foot
Stress fractures, or those affecting just the central part of the bone, may have more subtle signs, like ongoing pain on the edge of the foot and difficulty walking.
Diagram of the Foot looking from above.
It shows various types of fractures that involve the fifth metatarsal.
Causes
There are a number of causes of breaks in this bone, including:
- Twisting forces on the foot & ankle. This can occur during sports or dancing, as well as during high-energy trauma like car accidents. The twisting can either break the bone directly (Jones injury), or cause the muscle running around the outside of your ankle (peroneus brevis) to pull hard on the end of the bone. When the muscle is pulled hard enough it breaks off a section of bone (avulsion fracture).
- Overuse. Repetitive actions like running or dancing.
- Direct trauma. Dropping something heavy onto your foot can lead to this type of fracture.
Diagram of the Foot looking from above. It shows various types of fractures that involve the fifth metatarsal.
Risk Factors
People involved in activities which increase the risk of twisting an ankle are at an increased risk of fractures of the 5th Metatarsal. These include dancing and sports which involve a lot of jumping such as basketball and Australian rules football. Diagram of the Foot looking from above. It shows various types of fractures that involve the fifth metatarsal.
Investigations
If you have symptoms of a fracture you should see a GP, physiotherapist and potentially a foot and ankle surgeon as soon as possible for proper diagnosis and treatment.
To arrive at a diagnosis, the doctor will ask how the injury occurred or when the pain started. The foot will be examined, with the doctor gently pressing on different areas of the foot to determine where there is pain.
The doctor will also order x-rays. Because a Jones fracture sometimes does not show up on initial x-rays, additional imaging studies like CT scans, MRI or bone scans may be needed. Diagram of the Foot looking from above. It shows various types of fractures that involve the fifth metatarsal.
Complications
Most fractures of the 5th metatarsal heal without any complications.
There are however several complications to be aware of, including:
- Delayed healing or non-union. This is a complication that sees the break take longer than normal to heal. In extreme cases, the fracture may not heal at all, leading to the need for more aggressive treatment, like surgery, or longer-term immobilization and physiotherapy.
- Compartment syndrome. This syndrome is potentially very dangerous and occurs when the swelling in your foot and ankle causes a build up of pressure in the leg. This pressure can stop the flow of vital blood and nutrients to and from your foot. Compartment syndrome usually occurs in high-impact injuries, such as a car or motorcycle accidents, or heavy crushing injuries. Your surgeon will be
- Damage to the nerves or arteries around the bone. Sometimes, nerves and blood vessels are damaged when the bone breaks. In other cases, the swelling that occurs after the break can cause injury.
It’s important to be aware that any treatment will have it’s own complications. These include:
- Irritation, stiffness and itchiness from the cast or boot. When your plaster technician or doctor applies these, they can talk to you about the potential problems and warning signs to look for (see Cast Care).
- Weakness and stiffness after weeks of not using your foot and ankle.
- Physiotherapy, especially intensive physiotherapy, is likely to cause an increase in discomfort, even pain. It’s important you talk to you physio about this, as they can provide pain-relief. They may also direct you to your GP for medications to help. It’s vital that your pain is well controlled so you can continue with your rehabilitation.
- There are many complications of surgery, however note that the risk of most of these is minimal in surgery for fifth metatarsal fractures.
Diagram of the Foot looking from above. It shows various types of fractures that involve the fifth metatarsal.
Treatment
Until you are able to see a doctor or surgeon, follow the “P.R.I.C.E.” rules:
- Protect your injured foot from further injury.
- Rest: Stay off the injured foot. Walking may cause further injury.
- Ice: Apply an ice pack to the injured area, placing a thin towel between the ice and the skin. Use ice for 20 minutes and then wait at least 40 minutes before icing again.
- Compression: An elastic wrap should be used to control swelling.
- Elevation: The foot should be raised slightly above the level of your heart to reduce swelling.
You can take simple over the counter pain-killers like panadol. In general, it’s recommended you try to avoid using anti-inflammatories (like nurofen) in the early recovery period.
Simple stress fractures affecting the middle of the bone will often heal with basic care, including staying off your foot as much as possible, and wearing protective insoles or just thick shoes. The pain will then tend to gradually improve over weeks to months.
Physical Therapy
In breaks affecting the end and tip of the bone (Jones & avulsion fractures), the bone will often heal without needing surgery. You may however need to see a physiotherapist, who may suggest one or more of the following:
- Immobilization – keeping the foot and ankle still. Depending on the severity of the injury, the foot is kept in position with a cast, cast boot (sometimes called a ‘moon boot’), or stiff-soled shoe. Crutches may also be needed to avoid placing weight on the injured foot (see non-weight-bearing).
- Progressive exercises. Exercises to strengthen the muscles and maintain the flexibility of the joints are very important. If you need to stay off your foot for long periods of time you may also need balance or ‘proprioception’ exercises.
- Manual therapy. The physiotherapist may feel you need specific massages or movements in the foot to keep muscles and joints felxible and supple.
- Bone stimulation. A machine applied for a short time to the outside of the foot is used to speed the healing of the bones – this is pain free. Bone stimulation, most commonly used for Jones fractures, may be used as part of the treatment or following an inadequate response to immobilization.
When is Surgery Needed?
Generally, surgery is only required when the break is severe or complicated. This may be due to:
- Poorly aligned bone fragments (displaced bone)
- Multiple breaks through or around the bone,
- When the break has failed to heal with a cast or shoe.
There are a number of different surgical options, and the appropriate choice will depend on your injury and individual wishes. This can be discussed with your surgeon at the time.
For more information on one type of surgery, see Surgery for Jones Fractures.
Seeking Advice
Physiotherapist
Your physiotherapist can help prescribe a range of exercises that will promote healing and strengthen the foot and ankle.
Physiotherapists can also provide information on how to avoid putting weight through your foot, and assist with getting the right crutches.
Your Family Doctor (GP)
Your Family Doctor will be able to diagnose and help treat your problem. He or she will be able to
- tell you about your problem
- advise you of the best treatment methods
- prescribe you medications
- and refer you to physiotherapists and, if needed, a surgeon for further treatment
You may initially seek treatment in an emergency room or urgent-care clinic. If the pieces of broken bone aren’t lined up properly to allow healing with immobilization, you may be referred to a doctor specializing in orthopaedic surgery.
What you can do
You may want to write a list that includes:
- Detailed descriptions of your symptoms
- Information about medical problems you’ve had
- Information about the medical problems of your parents or siblings
- All the medications and dietary supplements you take
- Questions you want to ask the doctor
Prevention
These basic sports and safety tips may help prevent this injury:
- Wear proper shoes.
- Replace your shoes when the tread is worn out.
- Build stronger bones. Osteoporosis can weaken your bones. It is important is exercise regularly and eat a healthy well balanced diet with enough calcium.
F.A.Q. | Frequently Asked Questions
How soon can I return to my normal activities?
This will depend on your normal activities (eg high-impact sports) and the whether you have surgery or just a cast. A cast will generally need to be left on for several weeks, and then you can gradually build up strength around your foot until you feel able to return to normal activities. If you have surgery, your surgeon and physiotherapist will know when you are ready, and this is usually confirmed with X-Rays.
If you are an athlete, dancer or participate in any other high demand activities, you should consult with your physiotherapist in detail about which activities are safe and which should be avoided. Your physiotherapist may need to prescribe exercises that rebuild the sensation in your joints (proprioception), improve your balance and special ‘functional’ exercises that enable you to perform movements safely.
Can I drive?
This will vary depending on the injury, so you will need to speak to your doctor or surgeon.
In general, driving is limited by whether you are able to perform an emergency stop. In most cases, you will feel able to drive a few weeks before you’re medically cleared to drive. It’s important that you don’t drive during this period, as your insurance will not cover damage to your car or the third party.