Working Diagnosis:
Stress fracture of the base of the 5th metatarsal, of the Jones type

Treatment:
The athlete was placed in a walking boot while waiting for MRI evaluation. Conservative vs. operative treatments were discussed at length with the athlete once MRI results confirmed a stress fracture of the Jones type. With conservative treatment, return to play too early could lead to a full fracture. Operative treatment recovery can be between 9-12 weeks.

At the time of diagnosis, the athlete was five days/one game beyond the deadline to redshirt for his sport. Surgery would end his soccer season for the year because of the recovery time. The athlete opted for conservative treatment, with early return to play, and trying to play through any remaining soreness. He was fully aware that it could progress to a full fracture.

He was one week pain-free to palpation at the end of four weeks using the walking boot and requested to play. After again discussing the risk of progression fracture and subsequent need for surgery, the athlete was cleared for progressive return to play. At that time, there were three games remaining in the season.

Several days out of the boot, during the progressive return to play protocol, the athlete made a sudden lateral movement, felt a pop in his left lateral foot, and was immediately unable to bear weight. X-ray revealed acute nondisplaced transverse Jones fracture through both corteces. He subsequently underwent surgical placement of an intramedullary screw.

Outcome:
Post surgery he was non-weight bearing for 1 week, and then transitioned to partial weight bearing with walking boot for 5 weeks. He was then out of the boot for rehabilitation and progression of activities; he was back in his soccer cleats at 8 weeks. He is now 15 weeks post full-clearance and doing well without limitations.

Author's Comments:
Base of 5th Metatarsal Stress Fracture: metatarsal fractures represent 25% of stress fractures, most commonly involving distal 2nd and 3rd metatarsals. The 5th metatarsal is least common, and must be distinguished between Jones type or avulsion type. Because of poor blood supply, these fractures can progress to delayed union or non-union. Stress fractures typically present as insidious onset with increases in activity. This particular case is atypical in that the athlete presented with an acute injury.

X-Ray findings: The “dreaded black line� is more commonly associated with anterior tibial stress fractures, recognized as a tension fracture from repetitive muscle force. In this particular case, its location likely represents repetitive tension stress from the peroneal tendon.

To Play or Not to Play: It must be recognized from this case the importance of discussing all risks, complications, and to set realistic expectations. Had the player presented one week earlier with the first injury, the stress fracture may have been discovered sooner, and he would have been able to use his “red shirt� year.

Because of the high risk of non-union, in some instances surgeons will forego conservative treatment in high level athletes and place an intramedullary screw. In this case the player wanted to take the risk of conservative therapy because of his eligibility, and surgery would equate to him losing the entire soccer season. He ended up requiring surgery and did not play the rest of the season.

Editor's Comments:
Additional consideration of medical causes of stress fractures should also be considered. A medical workup should include CBC, TSH, Basic metabolic panel, calcium, phosphate, alkaline phosphatase, Liver function tests, PTH, Vitamin D level,
Serum and urine electrophoresis, and
Dexa scan.
Nutritional assessment and evaluation of the athlete’s training regimen and equipment should also be done to address the possible factors contributing to the development of the stress fractures.5

References:
1. Roche AJ, Calder JD. "Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review," Knee Surg Sports Traumatol Arthrosc. 2012 Sep 6. [Epub ahead of print]

2. Collins KS, Streitz W. " Bilateral Jones Fractures in a High School Football Player," J Athl Train. 1996 Jul;31(3):253-6.

3. Shindle MK, Endo Y, Warren RF, Lane JM, Helfet DL, Schwartz EN, Ellis SJ. "Stress Fractures About the Tibia, Foot, and Ankle," J Am Acad Orthop Surg. 2012 Mar;20(3):167-76.

4. Boden BP, Osbahr DC. "High-Risk Stress Fractures: Evaluation and Treatment," J Am Acad Orthop Surg. 2000 Nov-Dec;8(6):344-53.
5. Hosey RG, et al. "Evaluation and Management of Stress Fracture of the Pelvis and Sacrum" Orthopaedics. 2008 April;31(4).

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