Do you have a sharp, aching pain on the top of your foot when
you run? If so, it might be a metatarsal stress fracture. The metatarsals are
perhaps the most elegant bones in your lower body.
The five long, slender bones extend from your midfoot to your toe joints, and despite their small size, must handle a tremendous amount of stress when you run. As a result, the metatarsal bones are a common location for stress fracture in runners.
The five long, slender bones extend from your midfoot to your toe joints, and despite their small size, must handle a tremendous amount of stress when you run. As a result, the metatarsal bones are a common location for stress fracture in runners.
If you have pain on the top of your foot or pain in your
forefoot, you’ll want to read on. We’ll dig into the scientific research on who
gets metatarsal stress fractures, why they happen, how to prevent them, and how
you can return to running as quickly as possible.
The basics: Metatarsal anatomy and symptoms of stress fracture
You have five metatarsal bones in your foot. Each one corresponds
to a toe, and they are numbered, by convention, starting from the inside. So
your first metatarsal corresponds to your big toe, and your fifth metatarsal
corresponds to your pinky toe.
When you run, the metatarsals act like a lever, helping you to catapult your body forward by using your forefoot as a base of support. They’re a critical part of allowing your body to use your calf muscles and Achilles tendon to store and generate power when you run. This is why the metatarsals are longer and thicker than their upper-body analogy, the metacarpals on the hand.
When you run, the metatarsals act like a lever, helping you to catapult your body forward by using your forefoot as a base of support. They’re a critical part of allowing your body to use your calf muscles and Achilles tendon to store and generate power when you run. This is why the metatarsals are longer and thicker than their upper-body analogy, the metacarpals on the hand.
Each metatarsal bone has a “base” further up your foot, while
its “head” is the rounded part that makes up half of each toe joint. The
junction between each metatarsal bone and its corresponding toe is called the
metatarsal-phalangeal joint, or MTPJ for short.
Metatarsal stress fractures cause a sharp, localized pain on
the top of your foot. Weightbearing, especially in unsupportive shoes or
barefoot, will often make the pain worse, and pushing on the top of your foot
is usually very painful.
You might get aching or throbbing even when you aren’t putting weight on your foot. Swelling and bruising usually do not occur (if they do, see a doctor ASAP—chances are you have a full-on fracture of a bone in your foot!).
You might get aching or throbbing even when you aren’t putting weight on your foot. Swelling and bruising usually do not occur (if they do, see a doctor ASAP—chances are you have a full-on fracture of a bone in your foot!).
Diagnosis: Is your top of foot pain a stress fracture or tendonitis?
If you are a runner with pain on the top of your foot, the
cause is usually one of two things: either a metatarsal stress fracture or
tendonitis in one of the extensor tendons that runs along the top of your foot.
Fortunately, differentiating between extensor tendonitis and a stress fracture
is fairly straightforward.
![]() |
The extensor tendons of the foot, circled in red. Tendonitis here can be mistaken for metatarsal stress fracture. |
Extensor tendonitis, either of the extensor digitorum longus
(EDL) or the extensor hallucis longus (EHL) tendons, causes pain along the
length of the top of your foot that will be most painful with resisted toe
extension and running downhill.
Running uphill or on a soft surface will be less painful, as will running barefoot or in minimalist shoes. This is because these tendons are stressed the greatest just after heel strike, as your entire foot comes into contact with the ground.
Anything that accelerates or accentuates a heel strike, like running shoes with a large heel to toe drop, running downhill, or running on a hard surface, will cause greater pain in the extensor tendons. Even though extensor tendonitis can be painful, it usually does not hurt to push on the top of your foot.
Running uphill or on a soft surface will be less painful, as will running barefoot or in minimalist shoes. This is because these tendons are stressed the greatest just after heel strike, as your entire foot comes into contact with the ground.
Anything that accelerates or accentuates a heel strike, like running shoes with a large heel to toe drop, running downhill, or running on a hard surface, will cause greater pain in the extensor tendons. Even though extensor tendonitis can be painful, it usually does not hurt to push on the top of your foot.
![]() |
"Lydiard Lacing" can sometimes keep extensor tendonitis at bay |
The extensor tendons can also be aggravated simply by lacing up
your shoes too tightly. Tying your shoes looser and using a “Lydiard lacing” or
“ladder lacing” strategy is occasionally enough to tame mild cases of extensor
tendonitis.
The symptoms of metatarsal stress fracture differ markedly from
extensor tendonitis. Metatarsal stress fracture often feels worse if you try to run barefoot or in
minimalist shoes, and if you push directly on the area that’s sore, you will
get a lot of pain.
This isn’t the case with tendonitis. Extensor tendonitis is associated with diffuse pain along the length of the affected tendon, while a metatarsal stress fracture causes localized pain. A stress fracture also has the tendency to ache and throb, even when you aren’t putting weight on it. Tendonitis often feels better as you get warmed up; a stress fracture will feel progressively worse over the course of a run.
This isn’t the case with tendonitis. Extensor tendonitis is associated with diffuse pain along the length of the affected tendon, while a metatarsal stress fracture causes localized pain. A stress fracture also has the tendency to ache and throb, even when you aren’t putting weight on it. Tendonitis often feels better as you get warmed up; a stress fracture will feel progressively worse over the course of a run.
Where do metatarsal stress fractures occur?
Metatarsal stress fractures usually occur around the middle of
the metatarsal bones, not at the base or at the head. If you do get pain at the
head of a metatarsal, it’s more likely an injury to the metatarsal-phalangeal
joint.
In terms of their distribution among the five metatarsals of the foot, stress fractures are most common in the second and third metatarsals—these two bones account for 71%of all metatarsal stress fractures.
In terms of their distribution among the five metatarsals of the foot, stress fractures are most common in the second and third metatarsals—these two bones account for 71%of all metatarsal stress fractures.
Fourth metatarsal stress fractures are somewhat common, but in
contrast, first metatarsal stress fractures are almost unheard of in distance
runners.
While it’s possible to get a stress fracture in your fifth metatarsal, these are often associated with an acute rolling or jostling of your ankle—a sharp turn or cutting motion puts tension on the peroneus brevis tendon, which in turn pulls on the base of the fifth metatarsal, causing a fracture, so stress fractures to the fifth metatarsals are more often seen in activities like soccer, basketball, and ballet dancing.
While it’s possible to get a stress fracture in your fifth metatarsal, these are often associated with an acute rolling or jostling of your ankle—a sharp turn or cutting motion puts tension on the peroneus brevis tendon, which in turn pulls on the base of the fifth metatarsal, causing a fracture, so stress fractures to the fifth metatarsals are more often seen in activities like soccer, basketball, and ballet dancing.
I should emphasize that all the
information in this article does not apply for these kinds of fifth metatarsal stress fractures,
sometimes called avulsion fractures or “Jones fractures.” These are deemed high-risk stress fractures because this
area has a tendency to heal poorly, so you should be under the close
supervision of a doctor when recovering from a fifth metatarsal stress
fracture.6
The risk factors and causes of metatarsal stress fracture
Metatarsal stress fractures are the second-most-common type of
stress fracture in runners, next to tibial stress fractures.7 They only account
for about one percent of all running injuries, but because of their fairly long
recovery time (measured on the order of weeks) they can be a pretty devastating
injury.
Aside from runners, metatarsal stress fractures are also common
among basketball players, ballet dancers, and military recruits. I haven’t
encountered direct evidence that women are at higher risk of metatarsal stress
fracture, but given that women are 1.5-2 times more likely for any type of stress fracture, it’s highly
likely they are at higher risk for metatarsal stress fractures specifically.8
There are very few studies that directly examine risk factors
for metatarsal stress fractures in runners; those that do exist are
extraordinarily small (sample sizes of 10 people or fewer!) and have
contradictory findings. As such, we’ll have to look at circumstantial evidence
and use biomechanical analysis to uncover the likely causes of metatarsal
stress fracture.
Some indirect experimental evidence does suggest that
minimalist shoes increase your risk for a metatarsal stress fracture. A 2013
study conducted out of Brigham Young University followed two groups of runners
for 10 weeks.9
One of the groups transitioned carefully to a minimalist shoe (Vibram FiveFingers) while the other group remained in their usual running shoes. The researchers used an MRI machine to capture any evidence of the early stages of stress fractures or top of foot pain in the feet of the runners in the study. They found that 10 of the 19 runners in the Vibram FiveFingers group displayed evidence of bone marrow edema during the study, while zero of the 17 subjects in the control group developed bone marrow edema.
One of the groups transitioned carefully to a minimalist shoe (Vibram FiveFingers) while the other group remained in their usual running shoes. The researchers used an MRI machine to capture any evidence of the early stages of stress fractures or top of foot pain in the feet of the runners in the study. They found that 10 of the 19 runners in the Vibram FiveFingers group displayed evidence of bone marrow edema during the study, while zero of the 17 subjects in the control group developed bone marrow edema.
One valid counterargument to this finding is that bone marrow
edema on an MRI does not necessarily mean injury is imminent—a different study
on Stanford University cross country runners found that 43% of the team had
bone marrow edema in their tibia at some point during the season, but none
developed any shin pain that season or in the following year.10
However, additional evidence may support a minimalist
shoe/metatarsal stress fracture connection. Baseline findings from a cohort
study on over 1,200 ultramarathoners found a lower rate of stress fractures in
the tibia but a higher rate of stress fractures in the foot among
ultramarathoners compared to previous research on road runners.11
The more minimalist design of ultramarathon shoes is one possible explanation for this observation, although the rough terrain and hill climbs involved in ultra running may also play a role.
The more minimalist design of ultramarathon shoes is one possible explanation for this observation, although the rough terrain and hill climbs involved in ultra running may also play a role.
A shift to forefoot striking is the obvious explanation for why
a minimalist shoe would increase your risk of a metatarsal stress fracture.
However, the evidence for this hypothesis is similarly circumstantial. Forefoot
runners must sustain greater forces underneath their metatarsal heads, so we
might expect them to be at greater risk for metatarsal injury.
![]() |
During forefoot-strike running, there is more force under the forefoot for a greater period during the stance phase, and peak ground reaction forces are higher.12 |

This suggests that middle distance runners and sprinters would be at particularly high risk because they run fast with a forefoot strike (in minimalist shoes, no less!), but this has yet to be examined in any epidemiological studies that I’ve seen.
Given the massive complexity (and elegance) of the
human foot, computational models of the metatarsals during running are still in
their infancy.
Nevertheless, models like this one (left), published in 2010, show some agreement with what we empirically observe—substantially greater stress in the second metatarsal compared to the first metatarsal.14
Nevertheless, models like this one (left), published in 2010, show some agreement with what we empirically observe—substantially greater stress in the second metatarsal compared to the first metatarsal.14
The biomechanical causes of metatarsal stress fracture
The most straightforward cause of metatarsal stress fracture is
excessive loading on the metatarsal bones. People in sports that don’t involve
heavy loading of the metatarsals—like swimming—don’t get metatarsal stress
fractures.
But what’s “excessive”? Plenty of people run 100 miles a week or more, yet don’t suffer stress fracture. Clearly, there’s an interaction between how much you run, the way you run, and the internal structure of your body that determines whether or not you suffer a metatarsal stress fracture.
But what’s “excessive”? Plenty of people run 100 miles a week or more, yet don’t suffer stress fracture. Clearly, there’s an interaction between how much you run, the way you run, and the internal structure of your body that determines whether or not you suffer a metatarsal stress fracture.
If you’ve read my articles on tibial stress fracture and medial tibial stress syndrome in runners—the
two primary causes of running-related shin-pain—you know that bone geometry
plays a major role in determining who suffers a shin injury. This makes sense:
thicker, stronger bones are less likely to break, because they can spread out
the same force over a greater area.
The distribution of metatarsal stress fractures within the foot
gives a clue as to how bone geometry in the foot affects your risk for
metatarsal stress fracture. The fact that metatarsal stress fractures are
extremely rare in the first metatarsal—by far the largest, strongest, and
shortest of the five—strongly suggests that bone geometry plays a significant
role in determining injury risk.
Data on the relative bone strength of each of the five
metatarsals supports this theory. A study on the metatarsal bones of 40 human
skeletons by researchers at George Washington University found that the first
and fifth metatarsals are the most resistant to bending forces, while the
second and the third metatarsals are the least resistant.15 This lines up
quite nicely with the observed distribution of metatarsal stress fractures in
athletes that we saw in the pie chart earlier.
The correspondence between bone geometry and metatarsal stress
fracture rates suggest another potential risk factor—a “Morton’s toe,” the
colloquial name for a natural variation in human foot shape where the second
metatarsal is significantly longer than the first, which puts the second toe
further forward than the rest of the toes.
Because this foot variant is fundamentally rooted in metatarsal length, it suggests that people with a Morton’s toe (also known as a Greek foot) may be more likely to get a second metatarsal stress fracture.
Because this foot variant is fundamentally rooted in metatarsal length, it suggests that people with a Morton’s toe (also known as a Greek foot) may be more likely to get a second metatarsal stress fracture.
However, bone geometry isn’t the whole story. It doesn’t
explain why the fourth metatarsal experiences such a low rate of metatarsal
stress fracture compared to the second and third. It’s just as long and slender
as the second and third metatarsals, but experiences one third the rate of
stress fractures.
We might be able to explain this mystery by looking at the
distribution of force underneath the foot. While it makes sense that a skinnier
bone would be more susceptible to damage than a thicker bone, that's only true if
the applied force is the same.
Studies looking at the distribution of pressure underneath the
foot in walking and running find that most of the force weight passes right
under the head of the second metatarsal.
The fact that there is less pressure under the fourth metatarsal than the second and third (in most people, at least) might explain why it’s less likely to sustain a stress fracture. Further, it suggests that people who do have a laterally-deviated center of pressure while pushing off the ground (so-called "late supinators") might be at a higher risk for fourth metatarsal stress fractures.
The fact that there is less pressure under the fourth metatarsal than the second and third (in most people, at least) might explain why it’s less likely to sustain a stress fracture. Further, it suggests that people who do have a laterally-deviated center of pressure while pushing off the ground (so-called "late supinators") might be at a higher risk for fourth metatarsal stress fractures.
Why toes play a role in preventing metatarsal stress fracture
Compared to the rest of your foot, your toes—and the muscles
that control them—are stubby and small. The calf muscles, for example, which
plantarflex the ankle, are vastly more powerful than the toe flexor muscles.
Still, it appears that the toes play an important role when it comes to
reducing stress on the metatarsal bones and offloading force from underneath
the metatarsal heads during running.
Initial evidence on this front came from studies on metatarsal
bone strain in military recruits. Using some creative (albeit painful) methods,
researchers in Israel mounted a tiny strain sensor inside a surgical-grade
staple, then stapled it into the top side of the second metatarsal bone of a
group of Israeli soldiers before a long training march.
Since the strain sensor was fixed to the metatarsal bone in two places, it could accurately measure the amount of deformation the bone sustained throughout the march. The researcher found, perhaps not surprisingly, that metatarsal strain had increased by the end of the march.16 This has implications for runners, too—it indicates that long, fatiguing runs, like those done in preparation for a marathon, are likely to put more stress on your metatarsals.
Since the strain sensor was fixed to the metatarsal bone in two places, it could accurately measure the amount of deformation the bone sustained throughout the march. The researcher found, perhaps not surprisingly, that metatarsal strain had increased by the end of the march.16 This has implications for runners, too—it indicates that long, fatiguing runs, like those done in preparation for a marathon, are likely to put more stress on your metatarsals.
The really interesting question is why long, tough training sessions increase strain in the metatarsal
bones. The best explanation is, believe it or not, toe flexor fatigue. A number of studies support this conclusion:
First, a rather grisly but insightful experiment by Seth
Donahue and Neil Sharkey at UC-Davis involved using a mechanical contraption
hooked up to a human cadaver foot to simulate the effects of toe flexor fatigue
on metatarsal bone strain.17
Like the Israeli researchers, Donohue and Sharkey mounted a sensor to the bone of the cadaver foot so they could measure how much the metatarsal bone deformed under the applied load. When force in the toe flexor tendons was reduced, strain in the second metatarsal increased, and vice versa.
Like the Israeli researchers, Donohue and Sharkey mounted a sensor to the bone of the cadaver foot so they could measure how much the metatarsal bone deformed under the applied load. When force in the toe flexor tendons was reduced, strain in the second metatarsal increased, and vice versa.
![]() |
Toe flexor strength can offload the metatarsal heads |
Long, fatiguing runs also appear to decrease your ability to
use your toes to push off the ground. Research across multiple studies shows
that, at the end of a long, difficult run (such as a military training march, a
marathon, or even a 240-mile ultramarathon), you put more pressure under your
forefoot and less pressure under your toes compared with how you run or walk when
you’re fresh.18,19,20
A close examination of how the toes and the metatarsal heads
interact provides evidence for how toe flexor strength could reduce the load on
the metatarsal.
The figure to the left shows how: the toe flexor tendons and muscles push the toe into the ground, creating a reaction force to catapult the body forward.
The figure to the left shows how: the toe flexor tendons and muscles push the toe into the ground, creating a reaction force to catapult the body forward.
The tension from this muscular activity is transferred to the
insertion point of the toe flexor muscles, which is on the backside of your
fibula. All of this means that less force
needs to be applied to the metatarsal head to achieve the same overall force
acting on the body.
However, during a long run or a fatiguing workout, the toe
flexor muscles become less able to produce force. Hence, your body shifts force
from the toes onto the metatarsal heads, leading to an increase in metatarsal
stress.
How strengthening your toes could prevent metatarsal stress fracture
All of the research above implies that strength exercises that
target the toe flexor muscles should be included in the rehabilitation program
of anyone with a metatarsal stress fracture, and might be worth considering if
you know you’re at risk for one.
We’re far from having any clinical trials or
scientifically-endorsed exercise programs to increase toe flexor strength, so
barring that, we’ll have to do what we always do when faced with scientific
uncertainty—revert to what coaches have discovered over many years of working
in the real world.
I’ve developed a set of foot strengthening exercises based
largely on a set of “foot drills” introduced by chiropractor Russ Ebbets. These
exercises are done barefoot on grass or astroturf, ideally, and strengthen the
foot muscles in a variety of ways. This is a great place to start if you want
to strengthen your toe muscles for preventative reasons.
Barefoot drills for foot strength:
Done barefoot on grass or astroturf. Unless otherwise noted, do 2 sets of each exercise for 20 meters.
*Walking with toes in
*Walking with toes out
*Walking with toes up
*Walking with heels up / Walking with heels up backward
*Walking on inside edge of feet
*Walking on outside edge of feet
*Side shuffle to left and right
*Double-leg hops (30 reps)
*Single leg calf raises (start with 10, progress over time to
30 or more)
Once the weather
improves, I’ll be making a video on the foot drill routine—stay tuned for that!
I have found that doing this routine 2-3 times per week is
adequate if your goal is to improve your overall foot strength.
All of these exercises are weight-bearing and some of them involve high impact, which makes them great for building bone strength, too, but also makes them a terrible idea if you’ve already got a metatarsal stress fracture that’s causing pain! Instead, you’re better off working on toe flexor strength with more traditional physical therapy-style exercises, like the ones below:
All of these exercises are weight-bearing and some of them involve high impact, which makes them great for building bone strength, too, but also makes them a terrible idea if you’ve already got a metatarsal stress fracture that’s causing pain! Instead, you’re better off working on toe flexor strength with more traditional physical therapy-style exercises, like the ones below:
Rehab exercises to increase toe flexor strength:
*Towel crunches with
weight on end of towel
Using your toes, curl up a towel with a weight on the opposite
end.
*Toe flexion with
Thera-band and wooden plank
Using a Thera-Band and a wooden plank, flex your toes against
the resistance of the band.
*Standing isometric
“arch lift”
While balancing on one foot, use the muscles in your feet to
"flex" your arch and flex your toes.
These exercises are all from standard physical therapy programs for increasing toe flexor strength—though I've yet to see any programs specifically for metatarsal stress fracture.
While there are no set prescriptions on number of repetitions
and sets, a good place to start for the toe flexion and towel crunch exercises might
be two to three sets of 10-15 repetitions each, progressing in difficulty or
number of repetitions over time.
As you might guess, if you are recovering from injury, you shouldn’t do these if they cause pain. Since they are less stressful on the foot, you can do these exercises every day.
As you might guess, if you are recovering from injury, you shouldn’t do these if they cause pain. Since they are less stressful on the foot, you can do these exercises every day.
How to prevent a metatarsal stress fracture
As with all bone-related injuries, using “down weeks” every 3
to 4 weeks is a scientifically-supported way to allow bone to adapt and
strengthen to a new stress. After exposure to a new stress, the body initiates
the bone remodeling process. This is a fantastic capability—it’s what allows
you to strengthen your bones over time.
However, the first step of this
remodeling process involves your body eating away at old bone tissue to make
room for new bone cells.
One consequence of this is that your bones are actually weaker for about 3-4 weeks following introduction of a new stress.21 After that, new bone cells start to mature and your bones strengthen again. This is borne out in observations of military recruits at boot camp—most stress fractures don’t occur right away; they occur about a month into the new training program.
One consequence of this is that your bones are actually weaker for about 3-4 weeks following introduction of a new stress.21 After that, new bone cells start to mature and your bones strengthen again. This is borne out in observations of military recruits at boot camp—most stress fractures don’t occur right away; they occur about a month into the new training program.
In the case of metatarsal stress fractures, it’s especially
important to recognize that a “new stress” on the bone is not limited just to increased mileage. Transitioning from doing
mileage on the roads to doing intervals on the track in racing flats or spikes
is another new stress on your metatarsal bones, for two reasons.
The obvious one is that spikes and racing flats tend to make you run with more of a forefoot strike, hence increasing the stress on your metatarsal bones.
The obvious one is that spikes and racing flats tend to make you run with more of a forefoot strike, hence increasing the stress on your metatarsal bones.
Perhaps less obvious is simply the effect of speed. Even
independent of footwear, high speed workouts also result in most people transitioning to more of a forefoot
striking style, hence increasing metatarsal stress. So, even if your mileage
stays the same, consider taking a “down week” from using spikes and flats every
3-4 weeks when ramping up track work.

Doing the foot drill routine 3 times per week is a good place to start (assuming you don't currently have a metatarsal stress fracture!).
Some evidence suggests that training in a flexible shoe, like Nike Frees, might increase toe flexor
strength.22 However, keep in
mind that what we saw earlier—long, challenging workouts in this type of
footwear will cause toe flexor fatigue, which will increase stress on the
metatarsal bones.
Using highly flexible footwear is best thought of as a training tool to be introduced gradually and used occasionally, rather than a cure-all solution. Too much training in minimalist shoes appears more likely to cause a metatarsal stress fracture than prevent one.
Using highly flexible footwear is best thought of as a training tool to be introduced gradually and used occasionally, rather than a cure-all solution. Too much training in minimalist shoes appears more likely to cause a metatarsal stress fracture than prevent one.
How to treat a metatarsal stress fracture
None of this prevention does a whole lot of good for you right
now if you’ve already got a metatarsal stress fracture. The good news is that
metatarsal stress fractures tend to heal somewhat faster than other stress
fractures, and in most cases, are “low risk”—they heal quite well, excepting
the rare case of fifth metatarsal stress fractures.
One review of 320 cases of
stress fracture found that metatarsal stress fractures take an average of 7.9
weeks to heal, compared to 11.7 weeks for tibial stress fractures.23 In this study,
"recovery" was defined as the time from diagnosis to return to
pre-injury activity level (not the amount of time off from any running).
The best method for returning to running following a metatarsal
fracture is the same strategy you’d use for other low-risk stress fractures. I
outlined this in detail in this article on returning to running after a stress fracture,
but it’s worth going over again here.
The first rule is this: if
you are having pain when you are walking, you need to be on crutches or in a boot. Pain with walking means
that the loading on your body during walking is too great for your bone’s
current condition, so you need to take some time off from full weight-bearing.
![]() |
An Aircast (left) is the best option, but United Surgical makes a lower-cost cam walker that also works. |
The least intrusive way to offload your foot is using a full-sized walking cast,
also known as a cam walker, or more colloquially, a "boot." When worn
properly, these transfer load from the ground directly to your lower leg,
bypassing your foot. This allows you to be fairly mobile without pain.
“Half sized” cam walkers that only go halfway up your leg are
not as desirable because there’s less surface area to offload force onto your
leg—they really only prevent your ankle from moving.
When I was a coach at Edina High School, we bought a stockpile of full-size United Surgical cam walkers in a range of sizes. For what it’s worth, I (when I was unfortunate enough to need one!) wore a size Medium—I’m 5’10, 140 pounds, and wear a 9.5 D men’s shoe.
When I was a coach at Edina High School, we bought a stockpile of full-size United Surgical cam walkers in a range of sizes. For what it’s worth, I (when I was unfortunate enough to need one!) wore a size Medium—I’m 5’10, 140 pounds, and wear a 9.5 D men’s shoe.
We found that the “boots” from United Surgical were the best
balance between efficacy and affordability—since we bought something like ten
or twelve total, we couldn't’ splurge on the best walking cast for stress fractures.
If you do have the funds, I definitely recommend the Aircast FP cam walker. These use a pneumatic air bladder to increase the amount of off-loading and spread out the load more easily on your lower body, so you get better off-loading and better comfort.
If you do have the funds, I definitely recommend the Aircast FP cam walker. These use a pneumatic air bladder to increase the amount of off-loading and spread out the load more easily on your lower body, so you get better off-loading and better comfort.
I should emphasize again that the cam walker should be used only until you can walk pain-free
again. After that, it's actually harmful
to be in a cast—you need to return to normal, pain-free loading so you can
stimulate your body to keep repairing bone mass.24
For all cases of stress fracture, it’s wise to review your
calcium intake and your vitamin D status. These nutrients are tremendously
important when it comes to improving your bone strength, and deficiencies in
both are known to contribute to stress fracture risk.
Given the amount of time
most people spend indoors (myself included), it’s virtually impossible to
maintain a healthy vitamin D status during the winter months, unless you live
somewhere like California or Florida.
![]() |
Nutrigold Vitamin D3 is my top pick for Vitamin D. |
I’m not generally a supplements person, but one of the few
things I do recommend to the vast majority of runners is a high-quality vitamin D supplement that provides at least 2000 IU per day. At a minimum, you
should take this during the fall, winter, and spring, when it’s too cold to run
outside without a shirt on.
I’m currently taking Nutrigold
Vitamin D3—one bottle will last you an entire year. If you are a strict vegetarian or vegan, you
can opt for DoVitamins Daily D—it’s
plant-derived and made with a cellulose capsule instead of a gelatin capsule.
Calcium is an obvious contributor to bone strength, given
that’s what bones are made out of. One
study in female Navy recruits suggested that a calcium supplement with 400% of
your recommended daily intake can decrease the risk of a stress fracture by
25%,25 and research on
adolescent girls further supports the importance of calcium intake for bone
health.26
It’s not too difficult to get adequate calcium intake through
your diet (barring conditions like lactose intolerance, which I happen to have!), but if you are
looking for a supplement, the one I recommend is Bluebonnet Calcium Citrate. Note that, while this and other calcium
supplements include vitamin D for bone health, the amount is insufficient to get the health and
performance benefits of high vitamin D levels.
How long do you need to
be in a walking cast for a metatarsal stress fracture?
Here’s the good news: the days of “six weeks in a cast and call
me in the morning” are over. If walking causes pain, the scientific evidence
says you should be in a cast—but for the
minimum amount of time.
As soon as you can walk without pain, you should be
doing so. The reason, as described in a 2014 article by some of the leading
researchers on stress fractures, is that your bone adapts to the load it
experiences. So, if you are on crutches or in a boot for too long, you’re actually delaying your healing!26
Usual protocol calls for a week or so in a walking cast,
followed by some tentative attempts at normal walking. If these still cause
pain, you probably need to be in the boot for another week or two. But the
sooner you can work back into walking without pain—which you should do
gradually, of course, just like anything else—the better.
You may find that walking in a cam walker or “boot” still
causes pain—if this is the case, you need to be on crutches until you’re able
to transition to a cam walker. The same principle applies: the sooner you can
use a cam walker without pain, the better.
Of course, the above is only the current scientific consensus.
These are guidelines, not hard and fast rules. Severe cases of metatarsal
stress fracture, or people with poor bone healing, may need much longer in a
cast or a boot, so if you have any doubts, ask
your doctor (and make sure you’ve found a good doctor).
Returning to running after a metatarsal stress fracture
The same loading principles apply to transitioning from walking
(without a boot) to running. Warden et al. recommend that you have five to seven full days of pain-free daily
activity—i.e. walking to class, going up staircases, etc.—before you try
running again. Your first run back isn’t supposed to be a hard ten-miler
either. After a week of no pain is when you can start a return-to-running program.
This first “run” is probably going to be a pretty humble
walk/jog routine (see here for some sample programs on returning to running after injury). If things go well, you can return to some
semblance of “regular” running within a few weeks of your initial walk-jog
bouts.
In the meantime, if you want to maintain your fitness, you
should definitely take up a cross-training routine. If possible, I recommend aqua jogging, since it’s the most
mechanically similar cross-training you can do while not loading your foot.
As
I've detailed over at RunnersConnect, aquajogging
can maintain running fitness for at least six weeks. However, even with
aqua jogging, you may find the mere resistance from moving your foot back and
forth causes pain if you have a more serious case of metatarsal stress
fracture. If so, you’ll need to lay off even from the pool until you have no
pain.
Research shows that aquajogging with a flotation belt is more
mechanically similar to running, so I always recommend runners wear a flotation
belt (albeit the smallest one they can get away with) when they aquajog.
I'm still not in love with any flotation belt
brands—the Water Gear Aqua Trim in size small is the
perfect amount of flotation for runners, but the belt is too short for many
people, and it feels cheaply made.
The Aqua Jogger Pro Plus is very well made, but provides a little too much flotation for skinnier runners. You could always get an Aqua Jogger Pro and lop off some of the foam with a utility knife. Drop me a line if you've got aquajogging belt suggestions!
The Aqua Jogger Pro Plus is very well made, but provides a little too much flotation for skinnier runners. You could always get an Aqua Jogger Pro and lop off some of the foam with a utility knife. Drop me a line if you've got aquajogging belt suggestions!
If you are truly lucky, you may have access to an AlterG Antigravity Treadmill. In my coaching
tenure at Edina, we used an AlterG with great success to facilitate a rapid
return to running after stress fractures (and even avoided a few by putting
runners with early stage bone pain on the AlterG for a week or two).
As you might guess, you'll want to start at a low relative
weight (usually we started at 60%) and, over the course of a few weeks, progressively
increase your relative weight, always staying below the threshold that causes
pain. Once you reach 90 or 95% of body weight, you are ready to move to running
outdoors again.
When you do return to running, especially if this isn’t your
first metatarsal stress fracture, you might consider a change in footwear. The
scientific evidence reviewed above suggests that two types of shoes might be
helpful: First, a more traditionally-cushioned shoe seems to cause less stress
in the metatarsal bones compared to a minimalist shoe, at least based off the
BYU study on minimalist shoes.
Second, because the role of the metatarsals is to act like a
fulcrum to catapult your body forward, outsourcing some of this fulcrum
behavior to your shoe could take some stress off your metatarsals. Nike’s Zoom Fly incorporates a
spring-like plate made of, which runs the length of the sole, so it could work
as an ideal shoe for people prone to metatarsal stress fractures.
A Hoka One One shoe, with its thick midsole, may also provide a similar function. It remains to be seen whether other shoe companies follow suit with full-length rigid plates in the soles of their shoe.
A Hoka One One shoe, with its thick midsole, may also provide a similar function. It remains to be seen whether other shoe companies follow suit with full-length rigid plates in the soles of their shoe.
Conclusion: Preventing, treating, and recovering from metatarsal stress fracture
If you’ve developed an aching pain or soreness on the top of
your foot, you might have a metatarsal stress fracture. This injury can be easily distinguished from
extensor tendonitis—the other main cause of top of foot pain—thanks to a few
key symptoms.
Metatarsal stress fractures hurt (usually a lot) when you apply direct pressure to the injured area with your thumb. They tend to get worse as a run progresses, and they will be more painful on uphills and during barefoot walking or running. None of this is true for extensor tendonitis.
Metatarsal stress fractures hurt (usually a lot) when you apply direct pressure to the injured area with your thumb. They tend to get worse as a run progresses, and they will be more painful on uphills and during barefoot walking or running. None of this is true for extensor tendonitis.
Whether you’ve suffered a metatarsal stress fracture or are
looking to prevent one, the main risk factor that you can control is the level
of stress in the metatarsal bones. Strong circumstantial evidence suggests that
strengthening your toe flexor muscles
is an excellent place to start, because toe flexor fatigue increases stress on
the metatarsals.
Keeping your vitamin D and calcium intake high may reduce your risk as well by helping your body improve bone strength.
Keeping your vitamin D and calcium intake high may reduce your risk as well by helping your body improve bone strength.
Some evidence suggests that a limited amount of training in a flexible shoe could increase your
toe flexor strength, but full-time training in minimalist shoes—even when
introduced gradually—seems to put you at risk for a metatarsal stress fracture,
likely because of the shift to a midfoot or forefoot strike.
A more rigid running shoe that outsources some of the bending stress to your shoe's midsole might reduce stress on your metatarsals.
A more rigid running shoe that outsources some of the bending stress to your shoe's midsole might reduce stress on your metatarsals.
Biomechanical analysis of metatarsal bone stress suggests that
people who are naturally midfoot or
forefoot strikers could be at higher risk, as well as people who do faster
training. This means sprint and middle-distance runners are particularly at
risk. On the other hand, marathon and
ultramarathon training may be a problem too, since long, fatiguing runs tend to increase stress on the metatarsals.
As with all bone injuries, taking down weeks every 3-4 weeks is a good idea. Decreasing stress on the metatarsal doesn’t necessarily mean decreasing mileage—it could be a reduction in high-speed training in flats and spikes, for example, or taking more recovery days after a long, hard marathon workout.
If you do suffer a metatarsal stress fracture, you should be in
a cam walker or walking cast (i.e. a “boot”) until you can walk pain-free. Once
you’ve been able to walk pain-free for a
week or so, you’re ready to start a gradual return-to-running program.
While getting a metatarsal stress fracture can be a major setback, the good news is that they do tend to heal more quickly than other stress fractures, meaning you’ll be back on the roads or out on the trails before you know it.
While getting a metatarsal stress fracture can be a major setback, the good news is that they do tend to heal more quickly than other stress fractures, meaning you’ll be back on the roads or out on the trails before you know it.
References
1. Arendt, E.; Agel, J.;
Heikes, C.; Griffiths, H., Stress injuries to bone in college athletes: a
retrospective review of experience at a single institution. American Journal of Sports Medicine 2003, 31 (6), 959-968.
2. Niva,
M. H.; Sormaala, M. J.; Kiuru, M. J.; Haataja, R.; Ahovuo, J. A.; Pihlajamaki,
H. K., Bone stress injuries of the ankle and foot. The American Journal of Sports Medicine 2007, 35 (4), 643-649.
3. Orava,
S.; Puranen, J.; Ala-Ketola, L., Stress fractures caused by physical exercise. Acta Orthopaedica Scandinavica 1978, 49 (1), 19-27.
4. Hulkko,
A.; Orava, S., Stress fractures in athletes. International Journal of Sports Medicine 1987, 8 (03), 221-226.
5. Barrow,
G. W.; Saha, S., Menstrual irregularity and stress fractures in collegiate
female distance runners. American Journal
of Sports Medicine 1988, 16 (3), 209-216.
6. Ding,
B. C.; Weatherall, J. M.; Mroczek, K. J.; Sheskier, S. C., Fractures of the
proximal fifth metatarsal: keeping up with the Joneses. Bulletin of the NYU hospital for joint diseases 2012, 70 (1), 49.
7. Taunton,
J.; Ryan, M.; Clement, D.; McKenzie, D.; Lloyd-Smith, D.; Zumbo, B., A
retrospective case-control analysis of 2002 running injuries. British Journal of Sports Medicine 2002, 36, 95-101.
8. Wentz,
L.; Liu, P.-Y.; Haymes, E. M.; Ilich, J. Z., Females have a greater incidence
of stress fractures than males in both military and athletic populations: a systemic
review. Military Medicine 2011, 176 (4), 420.
9. Ridge,
S.; Johnson, A.; Mitchell, U.; Hunter, I.; Robinson, E.; Rich, B., Foot Bone
Marrow Edema after a 10-wk Transition to Minimalist Running Shoes. Medicine & Science in Sports &
Exercise 2013, 45 (7), 1363-1368.
10. Bergman,
A. G.; Fredericson, M.; Ho, C.; Matheson, G. O., Asymptomatic Tibial Stress
Reactions: MRI Detection and Clinical Follow-up in Distance Runners. American Journal of Roentgenology 2004, 183 (3), 635-638.
11. Hoffman,
M. D.; Krishnan, E., Health and exercise-related medical issues among 1,212
ultramarathon runners: baseline findings from the Ultrarunners Longitudinal
TRAcking (ULTRA) Study. PLoS ONE 2014, 9 (1), e83867.
12. Cavanagh,
P. R.; Lafortune, M. A., Ground reaction forces in distance running. Journal of Biomechanics 1980, 13 (5), 397-406.
13. Li, S.;
Zhang, Y.; Gu, Y.; Ren, J., Stress distribution of metatarsals during forefoot
strike versus rearfoot strike: A finite element study. Computers in Biology and Medicine 2017, 91, 38-46.
14. Gu, Y.;
Ren, X.; Li, J.; Lake, M.; Zhang, Q.; Zeng, Y., Computer simulation of stress
distribution in the metatarsals at different inversion landing angles using the
finite element method. International
Orthopaedics 2010, 34 (5), 669-676.
15. Griffin,
N. L.; Richmond, B. G., Cross-sectional geometry of the human forefoot. Bone 2005, 37 (2), 253-260.
16. Arndt,
A.; Ekenman, I.; Westblad, P.; Lundberg, A., Effects of fatigue and load
variation on metatarsal deformation measured in vivo during barefoot walking. Journal of Biomechanics 2002, 35 (5), 621-628.
17. Donahue,
S. W.; Sharkey, N. A., Strains in the metatarsals during the stance phase of
gait: implications for stress fractures. JBJS
1999, 81 (9), 1236-44.
18. Nagel,
A.; Fernholz, F.; Kibele, C.; Rosenbaum, D., Long distance running increases
plantar pressures beneath the metatarsal heads: a barefoot walking
investigation of 200 marathon runners. Gait
& Posture 2008, 27 (1), 152-155.
19. Rosenbaum,
D.; Engl, T.; Nagel, A., Effects of a fatiguing long-distance run on plantar
loading during barefoot walking and shod running. Footwear Science 2016, 8 (3), 129-137.
20. Karagounis,
P.; Prionas, G.; Armenis, E.; Tsiganos, G.; Baltopoulos, P., The impact of the
Spartathlon ultramarathon race on athletes' plantar pressure patterns. Foot & Ankle Specialist 2009, 2 (4), 173-178.
21. Beck,
B. R., Tibial Stress Injuries-An Aetiological Review for the Purposes of
Guiding Management. Sports Medicine 1998, 26 (4), 265-279.
22. Miller,
E. E.; Whitcome, K. K.; Lieberman, D. E.; Norton, H. L.; Dyer, R. E., The
effect of minimal shoes on arch structure and intrinsic foot muscle strength. Journal of Sport and Health Science 2014, 3 (2), 74-85.
23. Matheson,
G.; Clement, D.; McKenzie, D.; Taunton, J.; Lloyd-Smith, D.; MacIntyre, J.,
Stress fractures in athletes: a study of 320 cases. The American Journal of Sports Medicine 1987, 15 (1), 46-58.
24. Warden,
S. J.; Davis, I. S.; Fredericson, M., Management and Prevention of Bone Stress
Injuries in Long-Distance Runners. Journal
of Orthopaedic & Sports Physical Therapy 2014, 44 (10), 749-765.
25. Lappe,
J.; Cullen, D.; Haynatzki, G.; Recker, R.; Ahlf, R.; Thompson, K., Calcium and
vitamin d supplementation decreases incidence of stress fractures in female
navy recruits. Journal of Bone and
Mineral Research 2008, 23 (5), 741-749.
26. Ilich,
J. Z.; Kerstetter, J. E., Nutrition in bone health revisited: a story beyond
calcium. Journal of the American College
of Nutrition 2000, 19 (6), 715-737.
No comments:
Post a Comment
Note: Only a member of this blog may post a comment.