5th Metatarsal Fractures: A Special Breed (General Rules)

Fifth Metatarsal Fractures: A Special Breed (by Richard Blake, DPM)

 

    The top 10 initial treatments for 5th metatarsal fractures are:

 

1. X ray evaluation to decide on surgery vs conservative care.
2. If surgery, protocol to be set by surgeon and not the purpose of this writing.
3. If conservative care chosen, some form of immobilization for 8-12 weeks is typically done based on injury (Immobilization Phase). You want to get the pain level between 0-2 with 2 weeks, and maintain that during the entire rehabilitation.
4. During the Immobilization Phase, lower limb strengthening with some cardio should be orchestrated by a physical therapist. Even one legged stationary bike is very beneficial.
5. Bone health is analyzed with dietary calcium and Vit D3, consideration of a bone density screen, and typically healthy diet.
6. Transition period from cast to no cast, with or without surgery, can be very difficult. Custom orthotics with full lateral arch support very helpful. At times, extra big shoes during the transition can be purchased so added padding/accommodation can be used.
7. When not using a permanent cast, 24/7 compression bandages, ice pack 15 minutes twice daily, contrast bathing each evening, as much as possible elevation, 3 times daily 3 minute self massage for desensitization and swelling reduction, and hourly pain free ankle circles are initiated.
8. Weight bearing for bone mineralization, even in casts or boots, is done as early as safe (Good Pain vs Bad Pain)
9. All fifth metatarsal fractures, except a few styloid process avulsion fractures, should have a Exogen Bone Stimulator for 6 months (when insurance allows).
10. Follow up xrays need only be done when symptoms plateau or worsen. As long as the patient makes steady, gradual, progress, it is better to base improvement on function, not x ray or palpable tenderness.

    A. Fifth Metatarsal Fractures: Non Jones Type

 

These images are from a patient of mine that is almost 3 months post injury and her x-rays show a wide gap still. Here are all the thoughts that are meandering through my brain.

Here is the standard Lateral view with quite a large gap noted

 

A Jones Fracture to the Fifth Metatarsal is normally 1 inch closer to the toes. This AP view still shows some displacement.

 

This Oblique view makes the fracture clearer and you can see if the fracture line goes into the joint of the 5th metatarsal/cuboid.

You can see in this post Jones fracture repair xray that the Jones fracture is further forward than a 5th metatarsal avulsion fracture. 

This 5th metatarsal avulsion fractures following some inversion twist of the foot are typically under treated. Because they do not have the stigma of a true Jones fracture (historically more serious), they can be less aggressively treated. Sometimes this is okay, and sometimes not. Again, the goal is to create a pain free environment, which I believe has happened. X-rays for foot fractures, since the healing normally takes place internally first, cannot really reflect the strength of the bone. But, I do not like the gap and I do not like the fact that the joint is involved (possibly future arthritis).

 

    So, what are all the steps we need to make happen?

 

1) Establish a pain free environment if not already occurring

2) Make sure Bone Strength is good (questioning about Vit D3 and Calcium, bone density, healthy diet)

3) Stabilize the fifth metatarsal with orthotic devices, accommodative padding, and kinesiotaping (there are special techniques in orthotic devices for the outside of your foot)

4) Set workout goals that do not over stress this area

5) Avoid anti-inflammatories since they can slow down bone healing

6) Ice Pack 15 minutes twice daily, and contrast baths once daily to reduce inflammation

7) Due to the gap, seek approval for Exogen Bone stimulator

8) Have patient talk to a surgeon to find out what the process of fixing if the above does not work (this keeps the patient well informed)

9) Advise on possible future arthritis

10) Only get future X-rays if treatment has plateaued (there are many cases of pain free non healing) since current healing of the bone is not reflected well on x-rays.

 

5th Metatarsal Fracture: 10 Weeks into the Healing Process

10 weeks ago this military vet rolled her ankle avoiding her dog and that abrupt twist fractured her 5th metatarsal base. She was 6 weeks in a removable boot with crutches when I saw her. To protect the bone, and allow her to get out of her boot and back to activity, I made a rush of some custom orthotic devices and taught her how to use KT tape to circumferentially wrap the area. She took 10 days to painlessly wean from the boot, and has been walking for 3 weeks in athletic shoes, tape, and orthotics. Since she walks without a limp, and is controlling her pain within the 0-2 pain level parameters, I started her on an every other day walk run program. She is to email me when she gets to level 5 and then level 10. If you are uncertain about this program, you can type it into the search bar. 

     She had no pain on examination today. I felt no need to xray since the fracture line never looks great on xray for the first 3-4 months. I find I can rehab the patient based on their symptoms. 

Fractured 5th Metatarsal: Email Advice

Hello Dr. Blake,

My 14-year old daughter just got out of a cast (2 weeks) for a fractured 5th metatarsal (no displacement). Apparently, she's had the fracture for up to 7 mths and has been doing up to 30 hrs of gymnastics on it per week (competitive gymnast). It finally got to the point where she couldn't walk (up until then, it was on and off pain). So, after 2 weeks of a hard cast, her xrays were 'good' (whatever that means). Her doctor (orthopedist) put her in an ankle brace (??), which after wearing for a day, was hurting her foot, as it cuts right into the fractured area. 

Next step was "no jumping/running" for 4 weeks. She says she still has pain when she walks. 

Is there something specific we should be doing?? How should she be taping? I feel like her doctor was in and out--not giving us much to go on. 

Dr. Blake's comment: 

     I am very late in this response, so if you like, please get me up to date. Yes, you are right to question this. Ankle braces do cut right across the area of injury so I do not understand its use at this time. You have to create the 0-2 pain level so walking in pain is not desirable at all. You typically advance from the hard cast to a removable boot while a lab is preparing an orthotic which will protect it out of the cast. 2-3 weeks out the patient can tend wean from the protection of the removable boot to the protection of the orthotic. I use KT tape (or some other similar) circumferentially around the foot once or twice to stabilize even in the removable boot. It takes 3-5 times of doing it yourself to get the right tension, without irritation. I have copied more from my book on this subject below. Sorry for the delay. Hope she is doing better. Rich

This is an excerpt from Secrets to Keep Moving. It is hard to know which of these rules are important for your daughter, but they are definitely at least asking questions about if the treatment is stalled. The fact that every step she takes places full weight on the fifth metatarsal unless she is severely limping makes the progression from cast to full activity a thoughtful process. 

. Fifth Metatarsal Fractures: A Special Breed

    The top 10 initial treatments for 5th metatarsal fractures are:

1. X-ray evaluation to decide on surgery vs conservative care.
2. If surgery, protocol to be set by the surgeon and not purpose of this writing.
3. If conservative care is chosen, some form of immobilization for 8-12 weeks is typically done based on injury (Immobilization Phase).
4. During the Immobilization Phase, lower limb strengthening with some cardio should be orchestrated by a physical therapist. Even one legged stationary bike is very beneficial.
5. Bone health is analyzed with dietary calcium and Vit D3, consideration of a bone density screen, and typically healthy diet.
6. The transition period from cast to no cast, with or without surgery, can be very difficult. Custom orthotics with full lateral arch support very helpful. At times, extra big shoes as a transition can be purchased so added padding/accommodation can be used.
7. When not using a permanent cast, 24/7 compression bandages, ice pack 15 minutes twice daily, contrast bathing each evening, as much as possible elevation, 3 times daily 10-minute self-massage for desensitization and swelling reduction, and hourly pain-free ankle circles are initiated.
8. Weight-bearing for bone mineralization, even in casts or boots, is done as early as safe (Good Pain vs Bad Pain)
9. All fifth metatarsal fractures, except a few styloid process avulsion fractures, should have an Exogen Bone Stimulator for 6 months (when insurance allows).
10. Follow up xrays need only be done when symptoms plateau or worsen. As long as the patient makes steady, gradual, progress, it is better to base improvement on function, not x-ray or palpable tenderness. 

Fifth Metatarsal Fracture: Email Advice

Hello Dr. Blake,

   Thank you in advance for answering me and I will be happy to donate to
your blog.

 At the beginning of May of this year (2017) I rolled my foot and broke my
5th metatarsal. It is a slightly displaced avulsion fracture at the base.
I kept it in a soft cast non weight bearing for 4 weeks. After 4 weeks, I
felt I could walk on it while in the cast with out too much pain. After a
week I took it out of the cast and walked carefully. I wonder if this was
too soon, but I thought it was okay because I really had minimal pain.

Dr Blake's comment: This is considered appropriate as you want to stimulate mineralization and the fracture should be knitting well by then. And, you are creating and maintaining the 0-2 pain level. 

When I had a follow up xray 6 weeks after the initial xray, I was actually
surprised that there was no sign of healing and that it was still broken.
Somehow, maybe because of inflammation, I wasn't feeling the break at that
time. Over the course of the summer, I felt weakness in my ligaments and
like I had a 'dumb foot'. I have been trying to strengthen with a tensor
band and balancing. September 27th xray showed no healing in the bone.

Dr Blake's comment: Xrays reflect the amount of calcium in an individual area. Since the fracture area has high metabolism, typically there is alot of water in the area, giving the impression of poor healing. The Golden Rule is that xrays reflect the healing 2 months late, so they are poor indicators of what is happening right now. 

Now, almost 8 months later, I feel the break (tender), and the whole foot
feels sore and achy after walking on it for a half hour to an hour. It
feels great with no pain when I wake up in morning. I just had a CT scan
yesterday to see if there is any sign of healing. Will see surgeon about
results on January 8th. My questions....

Dr Blake's comment: The base of the 5th metatarsal typically bears all of our weight as we lift our heal off the ground. The fracture area can be healed, but sensitive, for 6 months after the injury. Things that help reduce the sensitivity are taping to stabilize the area, inserts with off weight bearing padding to float the broken area, icing and contrasts bathes to daily reduce inflammation, and pain free massage to move the sensitive tissue out of the area and de-sensitize the local skin nerves. I am always afraid, unless you are doing these things, an agressive surgeon will look at the CT scan and do surgery. But, of course, there is no guarantee you will need it, but these are options. Also, if we feel that he bone is slow, get a Exogen bone stimulator for twice daily home use. 
How long before I have to worry about Avascular Necrosis?

Dr Blake's comment: Were there signs of demineralization of the fragment? Since there is such good blood supply, I have never seen it in this area. 

Should I consider putting it back in the boot, or even using crutches
again? Will it make any difference at this point?

Dr Blake's comment: You have to create the 0-2 pain level environment. Some docs and PTs are good designing the padding, experimenting with taping, using PT treatments, perhaps stiff soled hiking boots, hike and bike shoes, etc. Can you send me a photo of the xray, honing down on the fracture? I personnally would not go back in a boot, unless off weight padding or inserts are not helpful. 
I received an Exogen in the mail today. I've heard it's never too late to
use it and can help 'non unions'.

Dr Blake's comment: Great!!!

Should I be concerned about ligaments that are not healing?

Dr Blake's comment: An MRI is needed to check. Definitely with a bad sprain in this area with ligament tears, orthotics and taping for one year in normal. Golden Rule it is normally better to break a bone than sprain a ligament. I know too little to really comment. 

I know surgery is an option if I am still not pain free in a few months
but I have doubts that it will heal from surgery. If such a simple break
doesn't heal naturally doesn't it seem likely that it would also have
difficulty healing from surgery?

Dr Blake's comment: If you do need surgery, it will be depend on what they do. Typically, they rebreak the bone, and put a screw across the fracture. They heal wonderfully unless you have some overall problem with healing: diabetes, smoking, obesity, vascular disease, etc. If you smoke, stop now. There are good studies showing the positive effect that has on surgery healing even if only 3 months have elapsed from stopping. If you have any question on bone health, get a Vit D3 level and bone density. 

 I have done everything I can think of to heal this...supplementation
(calcium, vit D, vitamin C, trace minerals, collagen), acupuncture,
osteopathy, physio.

Dr Blake's comment: Have not heard anything about taping (specifically for the fracture and surrounding ligaments, orthotics of some sort to off weight the bone at heel lift, icing and contrasts for anti-inflammatory, and of course, an MRI to look closer at the soft tissue. 

My main question is...can I be optimistic that I can still fully heal the
bone and ligaments 8 months after the accident?

Dr Blake's comment: I can only say from this far away that it is very rare that surgery is needed, although not impossible. Therefore, with those odds, try to work with my suggestions above, and see if they help. Good luck, and Merry Christmas. Rich

Thank you very much and Merry Christmas!

Metatarsal Fractures: Email Advice

I broke my feet (age 54 female with a great diet raw and grass fed only) and walked on them for four months orginaly at Christmas building fence using my feet in a way I should not have.  (lever)

 Upon x-ray last week after resting weight free for three weeks it showed the breaks and white line on my fifth where it was said to have started healing.    Broken: 5th and 4th metatarsals on left and 4th on my right foot.  My  Chiropractor  took the xrays and put me on a vibation machine for a bit but it was a killer.  I think I re-injured them with that or at least it felt like it.   Then I got the great idea to swim just the next day.  Not moving them but a bit. Then the next morning did a stretch a couple of times touching my toes and it felt like my tendons were going to pop out of my feet. 

My feet were in cam boots but that squished them too much. The pain is right at the tendon attachment on both feet. Right where the  Peroneus Brevis tendon inserts into the 5th matatarsal bone on the outside of the foot.  So i ordered the flat shoe you wear next and that is far more agreeable.  I have no insurance and live in a small town with no podiatrist I trust. I was just wondering since I walked on them so long after they were broken could i have also damaged this tendon on both feet?

Dr Blake's comment: Possible yes, probably no. Usually only with a severe fall. When the tendon is injured, it hurts back to the ankle, and sometimes, up the leg. Usually no localized. 

 I probably only had stress fractures as I only had pain on the right the lesser break but I did not know until it got to the point I could not walk then I gave in and figured they must be broken...Then the x-ray after three weeks with them up.  I have been doing the hot and cold baths and have a used Exogen on they way.  How long should i stay non weight bearing.  

Dr Blake's comment: You want to create the 0-2 pain level, but gradually weight bear to build bone strength. Inside the shoe you can take 1/8th adhesive felt (like from mooremedical.com) and build a base that has a float for the fractures. Need alittle experimentation, but important for weight shifting and gets you walking faster. 

A second hand exogen dealer gave me your blog and I have read about the hot cold stretching.  How soon can I do that?

Dr Blake's comment: You can use ice pack for 10 minutes twice daily now, and begin each evening with one minute hot one minute cold alternating for 20 minutes. It is not stretching, but range of motion in the hot water with your foot. You can start that now. 

   Also the good pain bad pain I am so unsure at this point.  can you please help with some advice?  It has been six days  since the x-rays and vibrator machine.  a couple since stretching. 

Dr Blake's comment: Bad pain is pain that is above level 3 that you ignore and push through. An occasional sharp pain that last 10-30 seconds is nothing. If you start doing something that starts to hurt, you have to listen to your body and stop. If you do something that does not hurt until later or the next day, you have to wait to the pain subsides for a day, before you can do the same activity. Since this is a bone problem, at some point consider a Vit D blood test, and a Bone Density Screening Test. Hope this helps some. Rich

5th Metatarsal Fractures: General Treatment Thoughts

  The top 10 initial treatments for 5th metatarsal fractures are:

1. X ray evaluation to decide on surgery vs conservative care.
2. If surgery, protocol to be set by surgeon and not purpose of this writing.
3. If conservative care chosen, some form of immobilization for 8-12 weeks is typically done based on injury (Immobilization Phase).
4. During the Immobilization Phase, lower limb strengthening with some cardio should be orchestrated by a physical therapist. Even one legged stationary bike is very beneficial.
5. Bone health is analyzed with dietary calcium and Vit D3, consideration of a bone density screen, and typically healthy diet.
6. Transition period from cast to no cast, with or without surgery, can be very difficult. Custom orthotics with full lateral arch support very helpful. At times, extra big shoes as a transition can be purchased so added padding/accommodation can be used.
7. When not using a permanent cast, 24/7 compression bandages, ice pack 15 minutes twice daily, contrast bathing each evening, as much as possible elevation, 3 times daily 10 minute self massage for desensitization and swelling reduction, and hourly pain free ankle circles are initiated.
8. Weight bearing for bone mineralization, even in casts or boots, is done as early as safe (Good Pain vs Bad Pain)
9. All fifth metatarsal fractures, except a few styloid process avulsion fractures, should have a Exogen Bone Stimulator for 6 months (when insurance allows).
10. Follow up xrays need only be done when symptoms plateau or worsen. As long as the patient makes steady, gradual, progress, it is better to base improvement on function, not x ray or palpable tenderness.