›Avoid circumferential casting during swelling phase
›Reassess fit as swelling changes
›Neurovascular check after immobilization
›Pulses and cap refill
›Sensation in key distributions
Reduction
›Not applicable
›Stress fractures typically nondisplaced
›If displaced fracture on imaging, manage as acute fracture pattern
Open fracture medications and timing
›Not applicable unless open injury
›If open injury present, open fracture pathway
›Cefazolin IV dosing per local protocol
›Add gram negative coverage for severe contamination per local protocol
›Tetanus prophylaxis per immunization status
DVT prophylaxis when relevant
›Usually not indicated
›Consider only if prolonged non weight bearing with additional VTE risk
›Prior VTE history
›Active malignancy
›Major thrombophilia
Pain control and bone health support
›Analgesia ladder
›Non opioid first line
›Acetaminophen
›Adult 650 mg to 1000 mg PO every 6 to 8 hours
›Maximum 4000 mg per 24 hours
›NSAID selective use
›Ibuprofen
›Adult 400 mg to 600 mg PO every 6 to 8 hours with food
›Avoid if renal disease or GI bleeding risk
›COX 2 selective alternative when GI risk
›Celecoxib
›Adult 100 mg to 200 mg PO twice daily
›Avoid if sulfa allergy or high CV risk
›If severe pain despite above
›Short course opioid
›Hydromorphone
›Adult 1 mg PO every 4 to 6 hours as needed
›Avoid with concurrent sedatives
›Bone health measures
›Calcium intake optimization
›Dietary sources prioritized
›Vitamin D supplementation if deficient
›Dosing per local guideline and baseline 25 hydroxyvitamin D
›Activity modification and rehab
›Impact activity cessation until pain free walking
›Cross training
›Swimming
›Cycling
›Return to run progression only after symptom free
›Incremental load increase
›No more than 10 percent weekly volume increase
›Footwear evaluation
›Replace worn shoes
›Consider orthotics if biomechanical risk
09Special Populations/sp28
Pregnancy
›Pregnancy considerations
›Imaging preference
›Radiographs acceptable with shielding when needed
›MRI without gadolinium preferred for confirmation
›Analgesia
›Acetaminophen preferred
›Avoid routine NSAIDs especially after 20 weeks gestation
›Bone health context
›Nutritional assessment if low intake
Geriatric
›Older adult considerations
›Lower threshold for metabolic bone workup
›Osteoporosis assessment referral
›Fall risk and balance review
›Mobility aids for safe offloading
›Medication safety
›Opioid delirium risk
›NSAID renal and GI risk
Pediatrics
›Pediatric considerations
›Growth plate and apophyseal pain mimics
›Apophysitis patterns
›Imaging
›Radiographs first line
›MRI if persistent symptoms with negative x ray
›Weight based analgesia
›Acetaminophen 15 mg per kg PO every 6 hours
›Ibuprofen 10 mg per kg PO every 6 to 8 hours
›Safeguarding
›Consider non accidental trauma if history inconsistent
10Background/b28
Epidemiology
›Population patterns
›Overuse injury common in runners and military recruits
›Second and third metatarsals most common march fracture sites
›Risk higher with rapid training increases
›Sudden changes in volume, intensity, surface, or footwear
Pathophysiology
›Bone stress mechanism
›Repetitive submaximal loading
›Microdamage exceeds remodeling capacity
›Continuum of injury
›Stress reaction
›Edema without fracture line
›Stress fracture
›Cortical break or fracture line
›Fifth metatarsal base biology
›Relative watershed blood supply region
›Higher delayed union and nonunion risk
Therapeutic Considerations
›Treatment rationale
›Offloading reduces microdamage accumulation
›Allows remodeling and callus formation
›Low risk metatarsal shaft injuries
›Typically heal with relative rest and boot or stiff shoe
›High risk locations
›Require stricter immobilization and earlier specialist involvement
›Return to sport pacing
›Premature return increases refracture risk
›Evidence and recommendation framing
›Class I recommendation from expert consensus for activity cessation and protected weight bearing in symptomatic bone stress injury
›Class IIa recommendation from expert consensus for MRI when radiographs negative with high clinical suspicion or high risk site
11Patient Discharge Instructions/pdi24
Copy discharge instructions
›Discharge instructions
›Diagnosis
›Possible metatarsal stress fracture from overuse
›Protection
›Walking boot or stiff shoe as directed
›Crutches and reduced weight bearing if painful
›Activity
›No running, jumping, or marching until cleared
›Low impact exercise only if pain free
›Swelling care
›Elevation above heart when resting
›Ice 10 to 15 minutes up to 4 times daily
›Pain medicines
›Acetaminophen as directed on label
›Ibuprofen only if safe for you
›Follow up
›Sports medicine or primary care in 7 to 14 days
›Earlier follow up in 3 to 7 days if fifth metatarsal base pain
›Return to ED now if
›Worsening pain despite rest and immobilization
›New numbness or weakness in the foot
›Toes cold, pale, or blue
›Increasing swelling with tight boot or shoe
›Fever or spreading redness
12References/r10
Guidelines and evidence sources
›Core references
›American College of Radiology Appropriateness Criteria for suspected stress fracture imaging
›Radiographs first line
›MRI preferred for early diagnosis when radiographs negative
›Sports medicine consensus statements on bone stress injuries and return to sport progression
›Low risk versus high risk location framework
›Orthopedic and sports medicine references on fifth metatarsal base stress fractures
›Higher nonunion risk than central metatarsal march fractures
›Clinical resources on female athlete triad and relative energy deficiency in sport
›Screening in recurrent stress fractures
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
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