Metatarsal Fractures in Active People
Metatarsal fractures are one of the most common foot injuries in active people. They are especially frequent in runners, court and field sport athletes, and military recruits, and they also occur in everyday accidents such as twisting the foot or dropping a heavy object on it (Paavana et al., 2024; Sun et al., 2024).
This article summarizes current evidence from systematic reviews and high-quality research in a way that both clinicians and patients/athletes can understand and use together in the clinic or gym.
Anatomy and Epidemiology
The five metatarsal bones run from the midfoot to the toes and act as levers for walking, running, and jumping. The first metatarsal plays a key role in push-off, the second to fourth share central load, and the fifth (lateral) metatarsal is particularly important in cutting and side-to-side movements (Paavana et al., 2024).
Most stress fractures in the forefoot occur in the second and third metatarsals, which are considered relatively “low-risk” locations. In contrast, the proximal fifth metatarsal is a “high-risk” site with higher rates of delayed union and non-union (Paavana et al., 2024; Chloros et al., 2022).
Types of Metatarsal Fractures
Acute (Traumatic) Fractures
Acute fractures follow a single event: a direct blow, a twist, or a mis-step landing from a jump. The fracture may be non-displaced (bone pieces remain aligned) or displaced (pieces shift and may require reduction or surgery). These injuries are well described in orthopaedic reviews and clinical series (Chloros et al., 2022).
Stress Fractures
Stress fractures are micro-cracks produced by repetitive loading that outpaces bone recovery. They typically present with gradually increasing pain, initially only with activity and later with everyday walking (Warden et al., 2014).
A 2024 systematic review of metatarsal stress fractures found that most cases involved athletes engaging in repetitive sports activities such as running and soccer, with the second and third metatarsals most commonly affected (Sun et al., 2024).
High-Risk Fifth Metatarsal Fractures
Fractures at the base of the fifth metatarsal (including “Jones fractures”) are classified as high-risk bone stress injuriesdue to limited blood supply and higher rates of delayed or non-union. Systematic reviews and meta-analyses consistently highlight that competitive athletes with these injuries often benefit from early surgical management (Chloros et al., 2022; Mallee et al., 2015; Wang et al., 2020).
Risk Factors
Training Load and Sport Demands
Across multiple reviews, sudden spikes in volume, intensity, or frequency of training are among the strongest extrinsic risk factors for bone stress injuries (Beck & Drysdale, 2021; Warden et al., 2014).
Sun et al. (2024) reported that metatarsal stress fractures are associated with:
- High weekly running mileage or repetitive cutting/jumping
- Rapid changes in training load (e.g., preseason, camps, tournaments)
- Hard, unforgiving surfaces and inadequate footwear
Paavana et al. (2024) also emphasised that foot and ankle stress fractures often cluster around periods of increased competition or training without adequate recovery.
Anatomical and Biomechanical Factors
Intrinsic factors identified in the 2024 metatarsal stress fracture review include:
- Foot posture (high arches shifting load laterally; low arches shifting load medially)
- Metatarsal length and alignment
- Gait patterns that increase forefoot loading
These factors do not guarantee injury, but they alter where forces are concentrated, influencing which metatarsal is at risk.
Systemic and Biological Factors
Bone stress injury reviews highlight systemic contributors such as low energy availability, menstrual dysfunction, and reduced bone mineral density, collectively encompassed by Relative Energy Deficiency in Sport (RED-S) (Beck & Drysdale, 2021; Hoenig et al., 2023).
Adolescents, endurance athletes, and athletes in aesthetic sports are particularly vulnerable when high training loads are combined with inadequate nutrition (Beck & Drysdale, 2021).
Clinical Assessment and Diagnosis
A thorough history and examination remain central. Key points include:
- Onset and pattern of pain (sudden vs gradual, activity-related vs constant).
- Recent changes in training load, footwear, or playing surface.
- Site-specific tenderness over a metatarsal shaft or base and difficulty weight-bearing.
For suspected stress fractures, imaging guidance from foot and bone stress literature recommends:
- Plain radiographs as the first step for most suspected fractures.
- MRI as the gold standard for early bone stress injuries or when X-rays are normal but clinical suspicion remains high.
- More urgent imaging and orthopaedic review for high-risk locations (e.g., proximal fifth metatarsal) or inability to weight-bear.
Management Strategies
Low-Risk Metatarsal Fractures
For non-displaced shaft fractures and most low-risk metatarsal stress fractures, evidence supports conservative care:
- Short period of immobilisation in a stiff-soled shoe or walking boot
- Protected or partial weight-bearing, progressing based on symptoms
- Gradual return to activity once pain settles and clinical signs of healing are present
Paavana et al. (2024) concluded that second–fourth metatarsal stress fractures have a high propensity to heal with activity modification and protected weight-bearing, reserving surgery for non-union or deformity.
Warden, Edwards, and Willy (2021) describe an “optimal loading” approach for low-risk tibial and metatarsal bone stress injuries that avoids both over-rest and over-load, using graded exposure to loading to support bone adaptation.
High-Risk Fifth Metatarsal Fractures
For proximal fifth metatarsal fractures, especially in athletes, contemporary reviews and meta-analyses suggest that operative management often yields:
- Faster time to union
- Lower non-union and refracture rates
- Quicker return to sport
(Wang et al., 2020; Mallee et al., 2015; Chloros et al., 2022).
Mallee et al.’s (2015) systematic review of high-risk stress fractures (anterior tibia, navicular, proximal fifth metatarsal) reported shorter return-to-sport times and fewer complications after surgery compared with conservative care, although overall evidence quality was low.
Rehabilitation and Return to Sport
Bone stress injury research increasingly supports criteria-based, rather than purely time-based, return-to-sport decisions. Hoenig et al. (2023) showed that more than 90% of athletes with bone stress injuries ultimately returned to sport, but timelines and complication rates vary by injury site and risk category.
For metatarsal fractures, a practical progression typically includes:
- Protection phase
- Boot or stiff-soled shoe; load management guided by pain.
- Cross-training (bike, pool, upper-body work) to maintain fitness.
- Reloading phase
- Gradual reduction of boot time.
- Foot intrinsic, calf, and peroneal strengthening plus balance training.
- Low-impact cardio before impact (Paavana et al., 2024; Warden et al., 2014).
- Impact and performance phase
- Walk–jog intervals → continuous running.
- Progression to change-of-direction drills, hopping, and sport-specific skills.
- Full training, then competition, once pain-free hopping, near-symmetrical strength, and tolerance of sport-like loads are demonstrated (Hoenig et al., 2023; Warden et al., 2021).
A physiotherapist can individualize this framework to the athlete’s sport, schedule, and risk profile.
Prevention and Clinical Implications
Systematic and narrative reviews highlight several strategies to lower the risk of metatarsal and other bone stress injuries (Beck & Drysdale, 2021; Warden et al., 2014; Paavana et al., 2024).
For athletes and patients, key points include:
- Progress training loads gradually, especially when adding hills, speed work, or extra sessions.
- Prioritise recovery: sleep, rest days, and planned deload weeks.
- Maintain adequate energy intake and bone-supportive nutrition (calcium, vitamin D, overall energy).
- Choose appropriate footwear and consider gait/footwear assessment if injuries recur.
- Include strength training for calves, foot muscles, and hips to improve load distribution.
For clinicians, high-quality reviews recommend:
- Screening for prior stress fractures, RED-S, and high training loads (Beck & Drysdale, 2021).
- Identifying high-risk fracture locations early and involving sports medicine/orthopaedic specialists when needed (Paavana et al., 2024; Chloros et al., 2022; Mallee et al., 2015).
- Using a multidisciplinary approach (physio, sports physician, dietitian, podiatrist, coach) for recurrent or complex cases.
Conclusion
Metatarsal fractures sit at the intersection of local mechanics and whole-body load tolerance. Contemporary systematic reviews show that most low-risk metatarsal fractures respond well to conservative treatment with well-structured load management and rehabilitation, whereas high-risk fifth metatarsal fractures in athletes often benefit from early surgical fixation (Chloros et al., 2022; Mallee et al., 2015; Wang et al., 2020; Sun et al., 2024).
For both clinicians and patients, the key is to combine good diagnosis, appropriate protection, progressive loading, and attention to systemic risk factors, so that athletes can return to sport confidently and reduce the chance of another fracture.
Abe Ofosu
Physiotherapist (APAM)
References
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Chloros, G. D., Kakos, C. D., Tastsidis, I. K., Giannoudis, V. P., Panteli, M., & Giannoudis, P. V. (2022). Fifth metatarsal fractures: An update on management, complications, and outcomes. EFORT Open Reviews, 7(1), 13–25. https://doi.org/10.1302/2058-5241.7.210012 PMC+2PubMed+2
Hoenig, T., Eissele, J., Strahl, A., Popp, K. L., Ackerman, K. E., Hollander, K., & Tenforde, A. S. (2023). Return to sport following low-risk and high-risk bone stress injuries: A systematic review and meta-analysis. British Journal of Sports Medicine, 57(7), 427–432. https://doi.org/10.1136/bjsports-2022-106328 PubMed+2British Journal of Sports Medicine+2
Mallee, W. H., Weel, H., van Dijk, C. N., van Tulder, M. W., Kerkhoffs, G. M., & Lin, C.-W. C. (2015). Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): A systematic review. British Journal of Sports Medicine, 49(6), 370–376. https://doi.org/10.1136/bjsports-2013-093246 PubMed+2British Journal of Sports Medicine+2
Paavana, T., Rammohan, R., & Hariharan, K. (2024). Stress fractures of the foot – Current evidence on management. Journal of Clinical Orthopaedics and Trauma, 50, 102381. https://doi.org/10.1016/j.jcot.2024.102381[PMC+2PubMed+2](https://pmc.ncbi.nlm.nih.gov/articles/PMC10904895/?utm_source=chatgpt.com)
Sun, J., Feng, C., Liu, Y., Shan, M., Wang, Z., & Fu, W. (2024). Risk factors of metatarsal stress fracture associated with repetitive sports activities: A systematic review. Frontiers in Bioengineering and Biotechnology, 12, 1435807. https://doi.org/10.3389/fbioe.2024.1435807 uptodate.com+3PubMed+3Frontiers+3
Wang, Y., Gan, X., Li, K., Ma, T., & Zhang, Y. (2020). Comparison of operative and non-operative management of fifth metatarsal base fracture: A meta-analysis. PLOS ONE, 15(8), e0237151. https://doi.org/10.1371/journal.pone.0237151[PLOS+1](https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0237151&utm_source=chatgpt.com)
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