SLR - December 2021 - Jacob Harder
Reference: Stone JA, Miranda AD, Gerhardt MB, Mandelbaum BR, Giza E. Outcomes of Surgically Treated Fifth Metatarsal Fractures in Major League Soccer Athletes. Am J Sports Med. 2021 Sep;49(11):3014-3020.Level of Evidence: Level IV
Scientific Literature Review
Reviewed By: Jacob Harder, DPM
Residency Program: Ascension Wisconsin Hospital – Milwaukee, WI
Podiatric Relevance: Fifth metatarsal fractures are a very common injury in professional sports. This injury is also very common in collegiate athletes and results in the second longest time loss from sport. Due to the biomechanical factors that can place excessive loading at the metadiaphyseal junction and poor vascular supply, sports related fifth metatarsal is prone to delayed union or nonunion. Many studies have shown that surgical correction of fifth metatarsal fractures, especially in athletes, provides more predictable healing with lower rates of delayed union and nonunion with quicker return to sport. The purpose of this study was to quantify the burden of operative fifth metatarsal fractures in Major League Soccer (MLS) players, compare outcomes as well as refracture and complication rates with other professional sports, analyze factors that may contribute treatment failure, and return to play characteristics for affected players.
Methods: This level four case series looked at all operative fifth metatarsal fractures in the Heal the Athlete database for MLS from 2013-2017. Following the search, 21 fifth metatarsal fractures were treated operatively in 18 athletes. Information was then collected from these cases including demographics, treatment, post-operative course, and return to play statistics.
Results: Of the 21 fifth metatarsal fractures, 17 were zone 2 and four were zone 3 injuries, according to Lawrence and Botte classification. The mechanism of injury was reported as chronic with progressive worsening of pain in eight athletes (38.1 percent), rolled foot or ankle in five (23.8 percent), direct trauma in five (23.8 percent), and quick pivot or cut in three (14.3 percent). Eleven athletes underwent surgical fixation with a solid screw, three with a cannulated screw and one was fixated with a plate. Five out of twenty-one athletes had either platelet rich plasma, bone marrow aspirate, calcaneal bone autograft, or recombinant platelet derived growth factor bone graft used during their procedure. Post op protocol generally followed the guidelines of two to four weeks of non-weightbearing followed by progressive weightbearing in a boot to full weightbearing and practice when healed. Mean time to healing was 8.5 weeks in 17 injuries where the data was available. Refractures were reported in 4/18 players (22.2 percent) with a mean time to refracture of 390 days. Mean return to play was 11.1 weeks. It was also reported that player performance showed small detrimental effects in the first year after injury but seemed to improve to pre-injury level by the second year.
Conclusions: Following a fifth metatarsal fracture treated operatively, MLS players can expect quicker return to sport with little performance deterioration that appears to improve over time. The time to healing, return to play and refracture risk are consistent with other professional sports. Given the refracture risk, even with surgical intervention, athletes should be counseled on this prior to undergoing surgical fixation. However, due to the repetitive stresses placed on the athletes daily either through games or training, providing them with more predictable healing by surgical fixation should be considered.