There are five metatarsal bones in a normal foot, numbered 1 through 5, from the one attached to the big toe to the outside of the foot respectively. They are straight in shape with a slightly widened base and a knob-like section (the head) at the end that connects to the toe bones. They start about the midway point of the foot and end just before the webs of the toes. For the first through third metatarsals, the closer ends of the metatarsal bones (near the middle of the foot) create joints with other bones of the midfoot, but these joints do not move much. However, at the other end of the bones near your toes, the joints made from metatarsals and the toe bones do move a lot. This movement and location is what dictates the chosen treatment for each particular injury of the foot.
Mechanism and Epidemiology
Metatarsal bones usually break from a crush injury, from a falling heavy object, a twisting injury, or getting your foot caught in something while the body continues to move. Occasionally the bone can break from a stress injury due to overuse, such as suddenly increasing running distance while training for a marathon.
If your metatarsal fracture is the result of a crush or twisting injury, the pain will likely be great enough to make you seek immediate medical attention. You may decide to go to an emergency room or to your primary care doctor. The diagnosis is usually made by taking x-rays. If the bone did not poke through the skin, the emergency room provider will typically put you in a splint (half cast), place you on crutches, prescribe medications to help you deal with your pain, and advise you to follow up with either your primary care provider or an orthopaedic surgeon. You should also elevate your foot as much as possible for the first 2-3 days, and apply ice to help decrease the swelling as well as your pain.
Most metatarsal fractures can be treated without surgery. A stiff soled shoe, walking boot, or even a cast may be used. The amount of pressure you are able to put on your foot will depend on which bones are broken. Your treating physician will decide this. As your broken bone(s) heal over 8-12 weeks, your pain will decrease. You may be able to place more pressure on your foot over time.
If you are diagnosed with a stress fracture of the metatarsal, you will be advised to stop the activity that caused it. You will likely be advised to stay off the foot for 4-6 weeks or even longer until the pain subsides. After a period of healing, you may begin a slow return to activity.
There are some metatarsal fractures that benefit from surgery. These include fractures that have poked through the skin, and any fractures that are so separated that they do not line up well enough to heal or work properly afterwards. This is especially true for fractures involving the first metatarsal. If surgery is needed, the bones can often be realigned and held in place with temporary pins. These pins may then be removed in the office in about 6-10 weeks. Sometimes, a cut will need to be made on the top of your foot to realign your bones, and the bone will be stabilized with metal plates and screws.
There is a particular fracture that happens near the base of your fifth metatarsal (the bump on the outside of your foot halfway along your foot) that warrants special attention. It is called a Jones fracture. This fracture occurs where the fifth metatarsal bone decreases in size from its wide base to the narrower shaft. This fracture can be caused by a twisting injury. Some foot shapes may increase the likelihood of this fracture. Surgery is usually recommended for athletes or those who need to return to demanding physical activities in a short amount of time. Non-surgical treatment can also heal a majority of these fractures. You should discuss the advantages and disadvantages of operative vs. non-operative treatment for this specific fracture with your treating physician or surgeon. There are several other types of fractures to the 5th metatarsal that are not Jones fractures, and these heal well without surgery. This is a discussion for you and your physician.
If surgery is needed, you will typically need to stay off your foot for at least 6-8 weeks to allow your fracture to heal. You may also be placed in a cast or hard boot. If pins are placed, they will typically be removed in the office after about 6-8 weeks. Plates and screws may or may not need to be removed. You will see your physician every few weeks or months to make sure the break and wounds are healing well.
Because your foot absorbs all of your weight when you walk or run, it needs to be able to withstand a lot of stress. Fortunately, metatarsal fractures usually heal completely and patients are typically able to resume their pre-injury activities without problems. Sometimes they do not heal and may require surgery, bracing, or modification of activity. Some patients develop painful feet after metatarsal fractures even if the fracture heals completely.
- American Academy of Orthopedic Surgeons
- American Orthopedic Foot and Ankle Society
Alan T. Kawaguchi, MD
Edited by the OTA Patient Education Committee and David Sanders, MD (section lead)
All x-rays and pictures taken from the personal collection of Dr. Kawaguchi