David Beckham in 2002, Lionel Messi in 2006, Gabriel Jesus in 2017 and Neymar in 2018 Have all suffered the dreaded fifth metatarsal fracture. 

Fifth metatarsal (MET) fractures are relatively common since first being described by Sir Robert Jones in 1903. 68% if all MET fractures are on the 5th with the majority of those being proximal (closer to head). Most fractures commonly occur in the 20-60 year old age group with younger males and older females more likely. 

Risk factors include

  • A larger 5th MET
  • Higher medial longitudinal arches
  • An increased 5th MET adduction angle
  • Shoe design
  • Vitamin D deficiency 
  • The non-dominant foot in footballers
  • Harder playing surfaces
  • Increased loading

The anatomy

The proximal base of the 5th MET is attached to the 4th MET and cuboid bone by strong ligaments. The strong ligament attachment directs stress from the mobile head of the MET to the more rigid base. This means that a strong vertical or medial / lateral forces applied to the 5th MET may cause a fracture distally to the rigid base. 

The 1st and 2nd MET absorb the most peak forces during running, followed by the 5th MET. However, the thinness of the 5th MET cause it to be weaker and therefore more prone to fracture. The lateral aspect of the 5th MET gets the greatest tensile and torsional force when running. This can cause the healing ends of a fracture to not connect and leads to high rates of non-union.  

Types of fractures

Zone 1 fractures are very common and account for 93% of all 5th MET fractures. They are usually caused by inversion injuries where traction is caused from the muscles to the tendons attaching to the bone. The traction caused the tendon to be pulled off the bone. Treatment usually would be non-weight bearing in an orthopaedic shoe. However, if the fracture is displaced by more than 2-3mm, is comminuted or involves more than 30% of the cuboid – metatarsal articulation it has a large avulsed fragment then surgery is often recommended. 

Zone 2 fractures are caused by a stepping or cutting movement creating a bending of the plantar aspect of the 5th MET. Treatment is usually surgical due to its poor blood supply. 

Zone 3 are stress fractures which are more prone to delayed union or even non-union. They are typically due to overload of the mid foot and forefoot from running and cutting movements. The most pressure between the base and the head of the 5th MET occurs during acceleration. 

Symptoms include:

  • An episode of acute trauma or repetitive trauma to the foot. 
  • A mechanism of injury that included strong plantarflexion (foot pointing away from you) and/or inversion (foot turned in)
  • A large adduction force applied to the foot in plantarflexion 
  • Pain with walking and running
  • Pain on direct palpation of the 5th MET

An x-ray will detail a Zone 1 or 2 type fracture but a zone 3 will usually require a CT scan, bone scan or MRI. 

Recovery from these injuries depends on the surgical intervention and any radiological testing as well as no symptoms during the rehabilitation phase.