While conflicting data as to the effect of hard surfaces call into question the assumption that surface density is directly related to metatarsal problems (Laker, Saint-Phard, Tyburski, et al., 2007), the insufficient cushioning properties of athletic footwear likely increases the overall risk nevertheless. Proper fitting, particularly in the lateral dimension (i.e. width) is directly related to increased susceptibility to metatarsal problems because it further (artificially) contracts the overall surface areas available to dissipate and absorb dynamic forces by squeezing the metatarsals closer to each other as well (Cullen & Hadded, 2004). Finally, excessive roominess in athletic footwear can also contribute to stress fractures and other debilitating foot problems by allowing the foot to develop momentum within the shoe and resulting in momentarily high loads when the foot rapidly decelerates against the walls of the shoe

(Logan, 2009).

Injury Treatment in the Acute Phase:

R.I.C.E

As always, the primary treatment for athletic injuries involving inflammation or trauma begins with rest, ice, compression, and elevation (RICE), all designed to minimize the accumulation of blood and synovial fluid that retards healing by inhibiting the supply of oxygenated blood to the injured tissue and by requiring the its gradual breakdown and re-absorption. Metatarsal stress fractures are associated with significant bone marrow edema (Frankel & DiFiori, 2007) and therefore benefit tremendously from rest and icing in particular.

Crutches/walking boot

As in all injuries involving stress fractures to bone, rest and the elimination of weight bearing is crucial (Howe, 2007). Metatarsal fractures heal well provided the athlete suspends participation in any activity that subjects the metatarsals to continued stress of the kind that precipitated the trauma in the first place. Crutches and walking boots are generally sufficient and the patient may continue to ambulate during the healing process. Generally, pain is an appropriately accurate indication in this regard and should be heeded as evidence that the region has been exposed to continual stress capable of delaying or interfering with proper healing (Iazetti & Rigutti, 2007).

Rehabilitation stages:

Short-Term Goals

During the first phase of rehabilitation, the immediate goals include reduction of the stresses responsible for the development of stress fractures, minimization and reduction of swelling, and pain control. For that purpose, crutches in conjunction with a walking boot are often used for the first week. Usually, the athlete may continue self ambulating provided it does not cause pain. As with athletic injuries in general, continued (or recurring) pain is treated as an indication that the previous phase of rehabilitation has not been sufficient for recovery; therefore continued pain in subsequent phases necessitates a return to this phase of treatment. Generally, a walking boot is used for the first two to three weeks, followed by several weeks of light non-weight-bearing training. The absence of continued or recurring pain in this phase allows a gradual return to athletic activity although not at a strenuous level and only with deliberate limitation of any plyometric stresses (Frankel & Difiori, 2007).

Long-Term Goals

The second phase of rehabilitation consists of a gradual return to light plyometric loading at about six weeks, subject to any discomfort. Provided the patient experiences no discomfort or swelling, exercises are begun to restore neuromuscular control, range of motion, and muscular strength, all of which deteriorate very quickly during any period of immobilization such as associated with the walking cast (Vu, McDiarmid, Brown, et al.,

2006). One of the most productive rehabilitation exercises in this phase consists of reverse (i.e. backwards) stair climbing, because the motion of raising the front of the foot targets the muscles on the front of the shins and also increases flexibility of the ankle joint lost during immobilization in the walking boot (Frankel & Difiori, 2007).

Criteria for Full Return to Athletic Competition

The final phase of rehabilitation transitions to the evaluation phase in which the athlete is evaluated for stability and balance while simultaneously building up cardiovascular and respiratory conditioning to pre-injury levels. At this stage, resumption of training is limited only by recurrence of symptoms, which...

Generally, once the athlete can perform a balance test on a narrow block and when vigorous plyometric action produces no discomfort, the athlete is cleared for competition. During this period, the area of injury should no longer produce any pain, even through manual palpitation of the area. Any tenderness in that regard indicates the need to dial back rehabilitation until such tenderness resolves completely. Because of anatomical location of the metatarsal bones, external bracing or taping is not helpful in the manner that it is in connection with toe or ankle injuries.
Potential Complications:

If the athlete ignores the symptoms associated with metatarsal stress fracture and continues subjecting the injured bones to the stresses associated with high-level athletic activity of the type responsible for the development of the stress fractures, the consequences can be devastating. Instead of a relatively simple period of reduced activity followed by low-level rehabilitation and the likely return to competition with eight or nine weeks, the athlete who ignores the pain associated with stress fractures of the metatarsals (or masks it with analgesics) risks the progression of many micro-

fractures into a complete fracture of the bone necessitating surgical repair, a much longer period of immobilization, and prolonged recovery and rehabilitation. Certain complete

fractures of the fifth metatarsal do not necessarily require surgery, but others do, depending on the precise location of the break and the available blood supply to that area because natural healing without surgical intervention can be much more lengthy (Vu,

McDiarmid, Brown, et al., 2006).

Conclusion:

Metatarsal stress fractures are an easily manageable athletic injury that usually require little more than RICE intervention. However, failure to reduce activity and allow healing can result in the development of a complete fracture, often requiring surgical repair and prolonged healing. Therefore, one of the sports trainer's responsibilities is to monitor athletes who report metatarsal pain and to provide appropriate medical guidance throughout the entire cycle of the injury from initial diagnosis through each phase of immobilization, rehabilitation, post-injury assessment, and return to competition.