Metatarsal stress fractures can be classified as either high risk or low risk, which has an impact on the healing time. This article discusses the difference between the two types, as well as what causes metatarsal stress fractures, how to recognise the symptoms, and how to treat them. We also provide some tips on when you can get back to running and other load-bearing sports. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call.
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High-risk vs. low-risk metatarsal stress fractures
The metatarsal bones connect your toes to your mid-foot – one for each toe. For each metatarsal bone, the part closest to your ankle is known as the base; then we have the shaft, which is the long middle bit, and then the head, which is closest to the toe.
You can get a stress fracture in any part of any of the five metatarsal bones, and depending on where it is, it may be classified as low risk or high risk.
Low-risk stress fractures heal pretty easily, whereas the high-risk ones don’t heal well if you don’t take care of them properly.
Metatarsal stress fractures that are seen as low risk occur in the shaft of any of the middle three bones.
A stress fracture anywhere in the fifth metatarsal (the one on the outside of the foot) struggles to heal well, and if you don't treat them quickly and take the load off them, you may end up needing surgery.
Another area that is seen as high risk is the base of any of the five metatarsal bone.
Causes of metatarsal stress fractures
Overload is the number one cause of metatarsal stress fractures. Some people blame biomechanics – the way you walk or run – but more often than not it is overload. (There’s a bit more about biomechanics at the end of this article.)
What is overload?
Your body has a base strength at any given time. So, your bones, your muscles, your tendons, your ligaments, everything has a certain strength to them at that point.
That strength is determined by what you've done in the last few weeks and last few months up until that point. If you lie on the couch for four weeks, you lose some of that strength, because you're not using your body. If you exercise, you build some strength.
Every time we do an exercise session or any activity that loads an area, we get micro-damage in that area, and that's absolutely normal; that's what we want, because it's that micro-damage that signals to the body that, “Uh-uh, you've got to rebuild me stronger, because this person wants to do this activity.”
Thinking of bones specifically: When we do impact activities, the bones get the micro- damage. As you rest, the bones recover and the micro-damage is repaired, and then they’re stronger than before. However, if you consistently train again before the bones have fully recovered, the micro-damage actually accumulates, and then that's when you get overload injuries like stress reactions in the bone or stress fractures.
There are certain other factors that can predispose you to metatarsal stress fractures or that can amplify the overload effect.
A sudden increase in training volume and/or intensity.
A sudden change from cushioned running shoes to minimalist shoes or barefoot running, which will increase the impact on your metatarsals
A sudden change to a shoe that makes your feet supinate more (roll to the outside as you run) will increase the load on those high-risk fifth metatarsals, which can lead to a stress fracture there.
Poor nutrition, which makes it more difficult for your body to repair the micro-damage.
A Vitamin D deficiency. Your body needs calcium to repair and maintain your bones, and to absorb calcium, it needs Vitamin D. Here’s our article about sport and Vitamin D.
Poor sleep patterns.
There are certain illnesses and conditions, such as osteoporosis, which can cause bone mineral deficiencies, which can increase the risk of a stress fracture.
Metatarsal stress fracture symptoms
Usually the pain builds up over a period of time.
At first, you might feel a bit of achiness while you're running and be a bit sore after you've run, but then it will settle down and be fine until the next run. However, as your metatarsal gets more irritated, you may even have pain with normal activities like walking or standing, and sometimes even when you’re off your feet.
This is because a stress fracture is preceded by a bone stress reaction. On an MRI scan, a bone stress reaction shows up as a bit of swelling in the bone. Once it has progressed to a stress fracture, you will start seeing a fracture line. With some severe stress fractures, the scan will show that the bone is actually displaced.
You can't see the initial stages of a stress fracture on an X-ray; only an MRI scan can show it.
But you don't necessarily need an MRI scan. If your doctor or physio is skilled enough to listen to what you're telling them, take into consideration how much training you've done, and do a proper examination, they should be able to diagnose this. If a bone is tender or sore when they press on it, it is usually a sign of a stress reaction or stress fracture.
What other injuries may feel like a metatarsal stress fracture?
There are other things that can feel like a stress fracture of the metatarsal.
Metatarsalgia is an overuse injury where you get irritation of the soft tissue as well as the bones in the ball of your foot (metatarsal heads).
Morton's neuroma is where the nerves between the metatarsals get irritated.
Your peroneal tendon is attached to your fifth metatarsal, so if you have peroneal tendonitis, it can cause a very similar pain.
You can get an acute fracture of a metatarsal bone, for instance if you twist your ankle.
Treatment of metatarsal stress fractures
Treatment will very much depend on what type of stress fracture you have, in what area it is, and how far it has advanced.
Load reduction / immobilisation
If it's just a stress reaction, where there's no proper fracture line yet, you may just need to reduce the load on that foot. This may mean that you try to limit how much you stand and walk, you don’t run, and maybe you use crutches for walking if it’s a severe stress reaction.
If it is a proper stress fracture, especially in one of the high-risk areas I mentioned above, you'll likely get your foot put in an orthopaedic boot, because you want to immobilise that area as well as you can to allow the bone to heal. Top tip: Use a shoe leveller and a running shoe with a thick sole on your other foot when you walk. It will help you hobble less when you walk and reduce the strain on the rest of your body. Get the shoe leveller here on Amazon.
Metatarsal stress fracture rehab
When the pain from your stress reaction has calmed down or when your foot comes out of the boot, it’s not the end of the story. Your bones are weaker than usual now, because they have been inactive for some time and are still recovering from the injury. You need to strengthen them back up so they can deal with your sport and everyday activities once again.
How do you strengthen a bone?
When you come out of that boot or the pain settles enough so that you can start placing weight on the foot, your physio will usually guide you with a progressive rehab programme. This will involve gradually increasing the time you spend on your feet and strength exercises that load that area (this is referred to as a progressive loading programme).
It's best just to make peace with the fact that it will likely take you about three months to get back to doing load-bearing sports such as running (more about that further down). If you rush it, you'll likely end up overloading the bone again and having to start the rehab process from scratch.
This doesn't mean that you can’t do sports at all; you can do anything that doesn't place too much load on the affected area.
Swimming is a good option for cardiovascular exercise. Later on, as your injured metatarsal gets better, you can do some running in the water.
You may be able to go cycling, depending on what stage you're in and how much pressure goes through the affected part of your foot. Sometimes, you just need to adjust how your foot is placed on the pedal to reduce the load.
Rowing could be another option for cardiovascular exercise.
Also, there's nothing to prevent you from doing strength training for your upper body and core.
As your metatarsal bone grows stronger, you can gradually start to introduce activities that place a more direct load on it; your physio should be able to guide you on when to start with these and how to ramp it up responsibly.
When can I start running again after a metatarsal stress fracture?
When you run, forces of between three and six times your body weight go through your foot.
When I decide whether a patient is ready to get back to running, I look at what their activities were like in the past week or two.
For instance, if you've not been able to manage a brisk walk yet, there's no way you can run.
So, we've got to build up your walking and your walking speed before we can get to sessions that combine running and walking.
We want to look at your calf muscle strength and endurance when doing heel or calf raise exercise, for instance. If you can't go up on your toes – up-and-down with a bit of extra weight in your back – without irritating your foot, you’re not ready to run.
So, you want to be able to tick those boxes, that you can do certain exercises without aggravating your metatarsal, before you transition back to running.
Running style and metatarsal stress fractures
Sometimes, people feel that there must be something wrong with how they move when they run, and that's the reason they got the metatarsal stress fracture.
For a very small proportion of people there may be some biomechanical factors that could help if they changed it. However, there is no perfect running form. There is no, “You have to run like this if you want to be injury-free.”
Our bodies can adapt and grow strong in many running positions, as long as you don't load it too quickly and as long as you allow it time to adapt to it. So, biomechanics is not the first thing to try and change. Especially if you've run for years and years without problems, it's not biomechanics that's your issue.
Before you start worrying about biomechanics, focus on getting yourself strong, top-to-bottom, in your normal positions and movement patterns. Also, look at things like your training load so that your body has enough time to recover between sessions, and look at your nutrition.
If these things have been sorted and the problem persists, then you could start looking at biomechanics.
If you supinate really severely, you may benefit from seeing a podiatrist. The solution could be as simple as switching to running shoes that don't allow that much supination or getting an orthotic with a little bit of a wedge on the outside that prevents your foot from rolling quite so much. Get it on Amazon: Running shoes; orthotics.
How we can help
Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.
About the Author
Mallee, W. H. et al. (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