Recurrent

Metatarsal Stress Fractures in a College Football Lineman

Jamie L. Moul, EdD, ATC Andrew N. Massey, MA, ATC

Abstract: Stressfractures are common

overuse injuries of bone attributed to repetitive trauma, training errors, and/or structural abnornalities. A 21-year-old, 252-lb football lineman participating in spring conditioning drills complained of right foot pain following a plantar flexion, inversion injury that occurred while cutting. Pain was concentrated over the dorsum of the foot in both weight bearing and at rest. X-ray evaluation indicated an acute stress fracture of the fourth metatarsal and two nonunions of the second and third metatarsals. Additionally, x-rays revealed metatarsus adductus, a congenital anatomic deformity. The athlete demonstrated compensatory hyperpronation in the right hind foot during a follow-up biomechanical evaluation. He was removed from weightbearing activities, treated symptomatically for pain and swelling, and placed in a rigid orthotic. He has returned to full activity withoutfurther incident. This case report emphasizes the important role that biomechanical factors may have in osseous stress injuries.
tress fractures are common overuse injuries of bone attributed to repetitive trauma, training errors, and/or structural abnormalities. Stress fractures are not only among the most common overuse injuries suffered by athletes, but are also among the more potentially serious injuries.2 Despite the
Jamie L Moul is the Athletic Training Curriculum Director at Appalachian State University in Boone, NC 28606. Andrew N. Massey is the Head Athletic Trainer at Appalachian State University.

frequency with which stress fractures are seen in orthopedic, sports medicine, and military clinics, their actual incidence is not well documented. Approximately 85% of 44 reported stress fractures occurred in the lower extremity.7'9 The tibia was the most common site reported (52%), followed by the metatarsals (19%), and the fibula (16%).7 9 The second (39%) and third (41%) metatarsals revealed the highest concentration. The skewed distribution toward second and third metatarsal stress fractures suggests the presence of underlying factors. The second metatarsal is the least resistant to bending stresses but is asked to absorb the greatest load during running.4 This structural deficiency and excess load bearing4 combined with sudden changes in training patterns1 or foot pathology '5'6 predispose an athlete toward metatarsal stress fractures. This case study presents an example of metatarsus adductus and its relationship to metatarsal stress fractures. Cases such as this reinforce the need to consider foot pathology as an important component in the evaluation of metatarsal stress fractures.

ullary screw fixation (Fig 1). The second was an episode of foot pain for which the athlete did not seek medical attention. While participating in spring conditioning drills during his sophomore year, the athlete incurred his third injury. At that time, x-rays revealed a stress fracture of the third metatarsal, a nonunion of the second, and a retained intramedullary lag screw in the fifth metatarsal. The third metatarsal fracture was treated nonoperatively (Fig 2). Physical examination of the current injury revealed tenderness along the shaft of the fourth metatarsal. Extension and flexion of the toes increased the tenderness. Swelling was present over the dorsum of the foot. Weight bearing revealed mild metatarsus adductus, more significant on the right than the left (Fig 3), calcaneal valgus, and mild hind foot pronation (Fig 4). X-rays revealed an acute stress fracture of the fourth metatarsal, nonunions of the second and third metatarsals, and metatarsus adductus (Fig 5). The athlete was removed from weight-bearing activities for 6 weeks, placed in a rigid orthotic, and treated symptomatically for pain and swelling with cold whirlpool and Sof-Roll compression dressing (Johnson & Johnson, New Brunswick, NJ). Additionally, longitudinal arch and ankle exercises were prescribed along with a functional progression for return to activity. Criteria for return included pain-free weightbearing activity and equal strength bilaterally. He completed the 1993 football season and the 1994 spring drills without further incident, although he continues to have periodic pain and swelling associated with repeated cutting activities. Further evaluation is being conducted to as-

Presentation of the Case

A 21-year-old black, 252-lb football lineman participating in spring conditioning drills during his junior year complained of dorsal right foot pain following a plantar flexion inversion injury. He had no previous history of ankle injuries; however, he had reported three previous incidents of foot pain following similar mechanisms of injury. Two incidents occurred before entering our institution. The first was diagnosed as a fifth metatarsal stress fracture treated by intramed-

Fig l.-AP radiograph showing intramedullary screw fixation of a fifth metatarsal stress fracture and mild
metatarsus adductus.

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a prominent fifth metatarsal base, a concave medial border, and a convex lateral border giving the foot the appearance of being "C"-shaped.6 As compensation occurs, hyperpronation, soft tissue ankle equinus, and collapse of the medial lon-

Fig 4.-Posterior view of the right foot depicting calcaneal valgus indicative of pronation.
tural demand and most frequent metatarsal stress fracture. According to Gross and Bunch,4 the second and third metatarsals incur the greatest strain during running activites but are the least resistant to strain structurally. In addition to the normal strain on the foot presented by running, abnormal structural alignment resulting in pathomechanical difficulties can produce a stress fracture in an unusual location. Metatarsus adductus is an abnormal foot condition that may create compensatory action in the foot sufficient enough to cause osseous injuries..6 It is an "osseous deformity consisting of a medial deviation of all of the metatarsals in the transverse plane."6 The etiology is unknown; the incidence is 1:1000 with no gender predilection.6 Clinically, there is

Fig 2.-A) Nonunion of a stress fracture in the second metatarsal (see arrow); B) acute stress fracture of the third metatarsal (see arrow).
certain the biomechanical efficiency of this athlete's feet.

Discussion
The uniqueness of this case is due to the location of the stress fracture and the athlete's predisposition to abnormal foot biomechanics. Orava and Hulkka7 and Sullivan et a19 reported that 37 (19%) of 199 recorded stress fractures were located in the metatarsals. Further breakdown of the metatarsal fractures revealed a high concentration in the second (77 (39%)) and third (81 (41%)) metatarsal shafts. The fourth and fifth metatarsals (22 (11%) and 13 (7%), respectively) accounted for all but one of the remaining fractures. These data indicate a relationship between location of greatest struc-

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gitudinal arch appear.6 The compensated deformity is the cause of much morbidity in the adult.6 The inability or failure of a hyperpronated foot to go into inversion produces large vertical and mediolateral forces in the fifth metatarsal that may lead to an injury.5 An adduction stress to the forefoot, with the foot in a plantar flexed, inverted position may also predispose an athlete to an injury.' Both of these conditions, adducted forefoot and compensated hyperpronation, are present in metatarsus adductus. In the case presented, the athlete had incurred a previous fifth metatarsal fracture that was treated surgically with an intramedullary screw, followed by stress fractures of the second and third metatarsal, and, finally, a fourth metatarsal fracture. The work of several researchers2'3'5'10 indicates that the fifth metatarsal stress fracture may have occurred due to the hyperpronated, adducted foot of the football player. A confounding factor associated with the second and third metatarsal fractures may include the athlete's weight (252 lb). The stress fracture located in the fourth metatarsal may be attributed to intramedullary screw fixation of the fifth metatarsal. DeLee, Evans, and Julian3 have noted alterations in metatarsal stiffness and alignment following intramedullary screw fixation. Additionally, the fourth metatarsal is ligamentously bound to the fifth.' The increased stiffness in the fifth metatarsal transmits more stress to the fourth, thereby placing an overload on this metatarsal, resulting in osseous damage. Further, the fourth metatarsal stress fracture occurred during spring conditioning drills. Byrd's' research demonstrated that bones are most vulnerable to stress reactions during intense training because the strength of the bone lags behind the increase in muscle power.

Fig 3.-Weightbearing positions of the right foot depicting metatarsus adductus deviation of the metatarsals in the transverse plane.

Fig 5.-A) Nonunion second metatarsal stress fracture; B) nonunion third metatarsal stress fracture; C) acute fourth metatarsal stress fracture.

Although stress injuries are commonly associated with military training and vigorous sports, we only have a vague idea of their true incidence.8 Also,
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while there is still debate regarding the exact etiology of stress injuries of bone, there is evidence that training errors, repetitive trauma, and structural abnormalities all play a role. This case study presents an athlete who repeatedly stressed the bones of a biomechanically unsound foot, the result being multiple metatarsal stress fractures. The recurrent nature of these injuries, under similar training conditions, emphasizes the important etiological role that structural deviations may play in stress injuries to bone. Athletic trainers evaluate many foot and ankle injuries in which an inversion, plantar flexion mechanism is described. The differential diagnoses for this mechanism may include a sprain of the anterior talofibular ligament and/or calcaneofibular ligament at the ankle, a lateral longitudinal arch sprain, a metatarsal stress fracture, a dorsal intermetatarsal ligament sprain, or an extensor digitorum longus strain. Appropriate diagnostic tools such as x-ray, special stress tests, and manual muscle strength assessments should be included to differentiate between osseous and soft tissue pathology. Foot biomechanics and pathomechanics should also be assessed.

Acknowledgments
We would like to thank Ted J. Waller, MD, and Robert B. Anderson, MD, for their assistance with this case study.

References
1. Byrd T. Jones fractures: relearning an old injury. South Med J. 1992;85:748-750. 2. Daffner RH. Stress fractures: current concepts.

Skeletal Radiol. 1978;2:221-229. 3. DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med. 1983;1 1: 349-353. 4. Gross TS, Bunch RP. A mechanical model of metatarsal stress fracture during distance running. Am J Sports Med. 1989; 17:669-674. 5. Kavanaugh JH, Browe TD, Mann RV. The Jones fracture revisited. J Bone Joint Surg [Am]. 1978;

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:_>imm

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6. Marcinko DE, Hetico HR. Structural metatarsus adductus deformity: surgical case report. J Foot Surg. 1992;31:607-610. 7. Orava S, Hulkko A. Delayed unions and nonunions of stress fractures in athletes. Am J Sports Med. 1988;16:378-382. 8. Scully TJ, Griffith JC, Jones B, Moreno AJ. Bone scans yield a high incidence of false positive diagnoses of stress fractures. Presented at the 60th Annual Meeting of the American Academy of Orthopedic Surgeons; February 19, 1993; San Fran-

sico, CA. 9. Sullivan D, Warren RF, Pavlov H, et al. Stress fractures in 51 runners. Clin Orthop. 1984;187: 188-192. 10. Torg JS, Pavlov H, Torg E. Overuse injuries in sport: the foot. Clin Sports Med. 1987;6:291-320.

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