A 23-year-old female player presented with an insidious onset of right foot pain. This was initially only present during training but progressed to become sore while walking and at rest. She was found to have localised tenderness over her fifth metatarsal shaft, pain with compression of the forefoot and pain hopping.
The player’s past medical history included prior stress fractures of both the tibia and fibula. She had been amenorrhoeic for five years, since starting an elite training programme at her current club.
An x-ray series, taken about three weeks after the onset of pain, is normal with no fracture or periosteal reaction seen. The MRI sequences show that there is a transverse low signal fracture line through the distal diaphysis of the right 5th metatarsal. There is surrounding, low signal periosteal mineralisation, consistent with a subacute stress fracture. There is extensive bone marrow oedema throughout the distal metaphysis and the entire diaphysis of the 5th metatarsal. Bone marrow signal elsewhere is preserved.
After some discussion about the treatment options, this player was managed with a six week period of immobilisation followed by a return to football over a further six weeks. At this point she hadachieved both clinical and radiological union. Given the history of amenorrhoea and that this was her third stress fracture, a DEXA scan was conducted. She was noted to have bone marrow density that was low for age. She was seen by a dietician and has ongoing follow-up with an inter-disciplinary team to monitor her energy availability.
In general terms fractures of the fifth metatarsal can occur at three sites. These are the tuberosity, the junction of the metaphysis and diaphysis (what is generally referred to as a Jones fracture) or the diaphysis. Fractures of the tuberosity are generally benign and tend to heal predictably. They are caused by an avulsion injury from the pull of the lateral band of the plantar fascia or of the peroneus brevis tendon during plantarflexion and inversion of the foot. These injuries are generally treated with a short period of immobilisation and a progressive return to activity. A Jones fracture occurs at the junction of the metaphysis and diaphysis, approximately 1.5cm from the proximal end of the bone. These injuries are classically the result of an acute inversion and plantarflexion injury. There is a high incidence of non-union and they generally require either 6-8 weeks of non-weight bearing cast immobilisation or early fixation. Most stress fractures, as illustrated in this case, generally involve the diaphysis. This usually occurs distal to the 4th/5th intermetatarsal joint. Surgical stabilisation may be required as these can be difficult to heal with conservative management.
FIFA does not bear any responsibility for the accuracy and completeness of any information provided in the “Radiology Review” features and cannot be held liable with regard to the information provided or any acts or omissions occurring on the basis of this information.