Stress fractures in any population occur most commonly in the metatarsals, with the second and third metatarsals as the most common site. It has been suggested that fatigue and poor train ing play a role in the development of metatarsal stress fractures, and athletes involved in repetitive impact sports are at the most risk.10-13 High arches, forefoot varus, and metatarsal adduction are risk factors. Stress fractures may occur in healthy players, but those with unusual or multiple injuries should be evaluated for structural or metabolic abnormalities. The most common metabolic abnormality associated with these fractures in female athletes is amenorrhea.11
The clinical presentation is usually one of an insidious onset of pain and swelling on the dorsum of the foot. Patients report more pain with increased activity that improves with rest. They will have a varied amount of swelling over the metatarsals but will be reproducibly tender over the affected bone.
In the first few weeks of symptoms, radiographs are commonly negative. An experienced clinician will proceed with treatment based on history and clinical examination. In questionable cases, a three-phase bone scan or magnetic resonance imaging may be performed.
In general, metatarsal stress fractures may be treated conservatively with a supportive shoe and rest. Rarely, a cast or frac ture boot may be needed for more symptomatic injuries. Athletes should be encouraged to participate in nonimpact exercise to maintain condition while resting. Return to prior activity may proceed when clinically healed. Radiographic union may lag behind clinical healing. A nonunion is rare and should be treated with fixation and bone grafting.
In ballet dancers, an unusual stress fracture of the base of the second metatarsal has been reported. It occurs at the metaphy-seal-diaphyseal junction and may generally be treated conservatively, although several reinjuries have been reported.13
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