This elite referee presented with an semi-acute injury to his foot six weeks prior to a major international competition.
On examination he walked with no distress. He was however unable to toe walk or hop. He had localised tenderenss over the second metatarsal.
An x-ray image of foot and ankle was normal. MRI images show an abnormality at the base of the second metatarsal with T2 hyperintensity and T1 low signal as well as cortical thickening posteriorly. This is affecting the plantar aspect of the tarsometatarsal articulation and is typical of subacute incomplete fracture. There is no completed low signal band traversing the metatarsal shaft.
The referee was manged with a short period in a walking boot. When he was able to walk comfortably (about ten days) he started an aqua jogging programme and cross trained for a four week period. During this time he ran on an underwater treadmill, did intervals on a bike and trained in the gym. He did not run. At a little under six weeks post-initial presentation he was able to return to training and complete the required pre-tournament training camp with the other officials. He was also able to officiate during the tournament with minimal discomfort.
Stress fractures involving the metatarsals are the second most common stress fracture (after the tibia). The most common metatarsal stress fracture involves the neck of the second metatarsal. Injuries involving the proximal second metatarsal, especially when the tarso-metatarsal joint is involved) can take longer to heal and are generally best managed with a period of non-weight bearing.
Patients generally complain of forefoot pain that is aggravated by activity. Focal tenderness suggests a stress fracture. The injury can general be diagnosed on the basis of the clinical findings however imaging can be helpful.
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