Keywords: fractures, Metatarsal V, Passive ROM, Rehabilitation, Physiotherapy, Special tests, Differential Diagnosis, execises.
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Clinically relevant Anatomy
Metatarsals are the long bones in the forefoot. There are five in each foot, one leading up to each toe and forming the metatarso-phalangeal joints otherwise known as the MTP joints. Metatarsal fractures can be either an acute fracture or a stress fracture. A stress fracture is a more gradual onset of pain caused by overuse.
An acute metatarsal fracture is caused by a direct impact such as having the foot trodden on by a football stud or similar. Often something is dropped on the foot or the foot might be stamped on. Alternatively, an inversion and/or plantar flexion violent twisting or turning motion at the ankle may cause a fracture in the 5th metatarsal in particular.
Specific types of metatarsal fracture include an avulsion fracture, where the tendon of the peroneus brevis muscle pulls a piece of the bone away. Or a Jones fracture which occurs at the base of the 5th metatarsal. This area typically has a poor blood supply and so healing may be affected. It is important that the clinician differentiate an avulsion fracture from fractures of the metatarsal shaft within 1.5 cm of the tuberosity because management will differ.
- Pain on the lateral aspect of the foot on the base of the 5th metatarsal.
- Bruising/swelling lateral aspect of foot.
- Click here to see a full ankle and foot assessment.
- Radiographs should include three views of the foot—anteroposterior, lateral and oblique. (Strayer et al, 1999)
- Accessory Ossicles.
- Neuropathic Foot
- Failure of supporting anatomy
- Abnormal bony anatomy
- Entrapment neuropathies
Non displaced tuberosity fractures
Conservative. Options include elastic wrapping, ankle splints and low-profile walking boots or casts. Weight bearing is allowed as tolerated. Treatment should be continued until symptoms abate—usually within three to six weeks.
Orthopedic referral is indicated for fractures that are
- Fractures that involve more than 30 percent of the cubo-metatarsal articulation surface
- Fractures with delayed union.
- Acute fracture (Jones fracture) and stress fracture of the fifth metatarsal within 1.5 cm of the tuberosity depend on the type of fracture, based on Torg’s classification.
Type I fractures
Usually treated conservatively with a nonweight-bearing short leg cast for six to eight weeks.
Type II fractures
- Some treated conservatively or
- surgically, depending on patient preference and other factors.
Displaced fractures and type III fractures
- Managed surgically.
Although most fractures of the proximal portion of the fifth metatarsal respond well to appropriate management, delayed union, muscle atrophy and chronic pain may be long-term complications.
(Strayer et al, 1999)
- Optimise bone healing.
- Removed causative factors.
- Reduce pain.
- Return to full function.
- Maintain good movement/load absorption through the forefoot.
- Advice on good nutrition, smoking cessation and optimal bone healing.
- Deep transverse frictions for tendons.
- Muscle stretches to maintain good ROM
- Graded return to exercise based on healing times/ WB status.
- Joint mobilisations.
- Low intensity pulsed ultrasound to aid fracture healing
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