A 38-year-old male semi-professional player presented with an acute onset of right foot pain. This started suddenly when he pushed off to change direction. There was not major trauma or twisting mechanism. Further questioning revealed that he had dramatically increased his running volume during a COVID19 related lock-down. For approximately three months prior to developing pain he had been averaging 50km per week more running than normal.
On examination he was very reluctant to weight bear, had swelling of the dorsum of his midfoot and had localised tenderness over the third metatarsal shaft.
X-ray images of the right foot show an undisplaced fracture of the third metatarsal. The fracture involves the shaft and is not associated with any periosteal reaction or evidence of healing (suggesting that it is of acute onset). Soft tissue swelling can be seen on the lateral view in the region of the fracture. A number of incidental findings should be noted. On the lateral view an os trigonum and calcaneal spur can be seen. On the oblique view and os peroneum can be seen. Given that the diagnosis seems clear on the basis of the clinic and x-ray findings no further imaging was felt necessary.
Give the absence of any significant trauma, and innocuous injury mechanism, it is likely that this injury reflects bone stress. It is probable that the recent change in training volume was a major contributor in the development of this injury. Third metatarsal stress fractures are considered to be “low risk” and generally heal without complication. The plan is for this player to spend a period of 1-2 weeks in a walking boot until he is pain-free. During this time, he will be encouraged to do pool-based activities (as long as this does not exacerbate his symptoms) and to continue upper body conditioning. From this point he will be encouraged to progressively increase his training volume with a goal of him returning to play approximately six weeks after diagnosis.
Metatarsal bone stress injuries are relatively common among athletes and in new military recruits (hence the term March fractures). These most commonly involve the second and third metatarsals and account for approximately 25% of all stress fractures. It is thought that a major factor in the development of these injuries is that osteoblastic activity lags behind osteoclastic activity during initial increases of exercise. In general terms, fractures occur secondary to bone fatigue, bone insufficiency or due to a combination of both of these factors. Bone fatigue occurs when normal bone is unable to resist the loads that are applied to it. Bone insufficiency occurs when normal stress occurs on abnormal bone. In this case there were no identifiable intrinsic risk factors for low bone density or energy deficit. It is likely that extrinsic risk factors, training load and potentially shoe selection, were more important causative factors.
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