• Foot fractures are common due to the high stresses placed on the foot and can occur from trauma, overuse, or repetitive strain. Stress fractures, toe fractures, sesamoid fractures, and fractures in poorly vascularized areas each behave differently and require specific evaluation.
• Stress fractures often develop without a clear injury and present with localized pain, redness, and swelling—especially after increased walking or activity. Metatarsal stress fractures are most common, while navicular and cuboid stress fractures may not appear on X‑ray and often require MRI or CT for diagnosis.
• Toe fractures usually follow direct trauma and cause pain, bruising, and swelling. Contrary to popular belief, treatment is often necessary, typically involving buddy‑splinting to stabilize the toe and prevent non‑union or chronic pain.
• Sesamoid fractures beneath the big toe joint may result from hyperextension injuries and can be difficult to diagnose because small fractures may not show on X‑ray. These fractures often require casting to offload pressure, and persistent pain may require surgical removal of the sesamoid.
• Certain fractures—such as those of the talus neck and the base of the fifth metatarsal (Jones fracture)—heal slowly due to limited blood supply. These may require prolonged immobilization, bone stimulators, or surgical fixation to ensure proper healing.
Fractures of the foot happen quite frequently, primarily due to stresses and strains applied to the foot as well as the simple fact that the foot seems to be a focal point for trauma. The purpose of this page is actually to discuss various types of fractures that occur primarily in the foot.
Since fractures can occur any where in the human body there are plenty of reference sites on the internet that discuss the mechanism and treatment of fractures in general.
The first foot fracture I would like to mention are stress fractures. They are not limited to the foot, but are very common in the foot. Stress fractures of the foot were first identified in 1855 and were known as "march fractures" because they were associated with the pain and swelling that some soldiers experienced while marching.
Metatarsal Stress Fractures The most common site for stress fractures of the foot is the metatarsal bones, but the most common site in the body for a stress fracture is the tibia.
Notice the x-ray below. The fracture line is easily identified.
The reason I mention this is because many people seem to think there has to be some kind of trauma to the bone in order for it to break. This is not always the case. When a patient presents to the office with the cardinal signs of tenderness, redness, and swelling over a localized area of the forefoot, usually on top of the foot, with no history of trauma, one of my first thoughts is stress fracture.
A typical scenario may have been spending a day walking in the city wearing dress shoes, carrying packages that may have added additional weight to your feet or forced you to walk in a more abnormal manner. However, rarely during the day will you remember any kind of trauma to the foot. You get home, one foot may be a little more sore than the other, but when you wake up the next morning the affected foot is very sore, generally red, and usually swollen in the area.
In simple stress fractures where the two broken ends line up next to each other and there is virtually little space between the two ends, a surgical shoe, which is a stiff flat-bottomed shoe will suffice, until the bone heals. The good news is that the lion’s share of stress fractures are of this nature.
Midtarsal Stress Fractures It is important to note that stress fractures of the tarsal bones such as the navicular or cuboid bone can be much more difficult to diagnose. These two bones may be broken and never reveal any radiographic evidence. Usually an MRI will be performed and the diagnosis will come back as increased bone marrow edema, which is swelling of the middle of the bone commonly seen in over-stress of a bone. It is important to note here that increased bone marrow edema may also occur in non-fractured bones.
The thing to do here is to err on the side of caution and correlate the MRI findings with the patient's clinical symptoms and treat the problem as a fracture.
Another option for suspected fractures in this area of the foot is to have a CT scan. Computerized tomography has the ability to better visualize the cortex (outer surface) of bone and may be able to pick up fractures where the MRI failed.
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Treatment of cuboid or navicular stress fractures is non-weightbearing casting usually for six weeks, followed by two weeks or so of limited weightbearing and physical therapy. Because of the stresses placed on these bones in the gait cycle, walking casts as an initial form of treatment has been found to be unsatisfactory.
In cases where non-weightbearing casting fails to heal the stress fracture, surgical intervention may be indicated.
The other very common type of fracture seen in the foot is a fracture of one or more of the toes. There is almost always a history of trauma, usually stubbing your toe against the bedpost when going to the bathroom during the middle of the night (hence the name bed-post fracture). In this case the toe will usually be painful, red, bruised and swollen.
The reason I even bother to mention toe fractures is that there is a general misconception that there is no treatment for toe fractures. That could not be further from the truth. The toe is very similar to the finger and there certainly is treatment for finger fractures.
The severity of the fractured toe determines the treatment. For the vast majority of fractured toes the treatment is simple. The fractured toe has to be taped to the adjacent toe. This is known as "buddy splinting". By doing this you are able to somewhat immobilize the fractured toe so it can heal. If a fracture site is not adequately stabilized the fracture may not heal (some simple fractures will heal on their own).
BUDDY SPLINTING
When a fracture does not adequately heal you are left with scar tissue in the fracture site and what is known as a pseudoarthrosis or more commonly known as a non-union. The significance of this is the fact that the toe may always continue to hurt, thus requiring surgical intervention, or at the very least you will always be the one who can predict when it is about to rain, because the toe will start bothering you, (changes in barometric pressure will irritate the fracture site).
I find that once I demonstrate to the patient how to properly tape the toe they are usually able to get their foot into a wide boxy shoe. Dress shoes are out until the bone is healed, even if the toe does not hurt, the dressier the shoe the more it may force a poor alignment of the broken toe.
The other misconception that patients have is my ability to look at a foot or toe and tell if it is broken. The only way to know is through an x-ray (sometimes small fractures will not show up and a bone scan or MRI need to be performed to find the break.) When I “guess”, to appease the patient, I am wrong in about fifty percent of the cases.
The sesamoid bones are two bones located just below the big toe joint. Their purpose is to act as a lever or fulcrum for the tendons that allow the big toe to bend downward. Fractures of these two bones generally occur when there is a hyperextension (excessive bending up of big toe) injuries. Many times the force of the injury will break the sesamoid bone into multiple fragments. Less frequent to the sesamoids are crush injuries.
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When there is a history of trauma certainly a fracture has to be considered but the harder diagnosis is when there is no history of trauma and there is pain in the sesamoid bones. Many times a fracture in such a small bone(s) will not show up on x-ray and a bone scan or MRI will be needed to actually find the fracture. The diagnosis can be further complicated because some people exhibit what is known as a bipartate sesamoid, meaning instead of having one sesamoid bone there is two separate bones that make up the one sesamoid bone.
A fractured sesamoid can be a very difficult problem to remedy due to its location. A fractured sesamoid is usually casted in such a manner as to keep pressure off the bottom of the foot. Once healed it can still be a few more months before a person can return to their normal activities. In cases where the fracture does not heal and there is constant pain, the sesamoid bone may have to removed. This, however, can have implications in the way the big toe joint functions.
see related article....sesamoiditis
In the foot there are two areas that are prone to taking “forever” to heal even in simple fractures. These are the neck of the talus and the base of the fifth metatarsal bone.
The diagram below shows the two places where fractures can take longer to heal. The top arrow is the neck of the talus, usually the result of a sudden upward jarring of the foot as seen in car accidents, and the bottom arrow points to the fifth metatarsal base foot fracture, more commonly known as a Jones fracture which can be the result of 1. trauma, 2. a forceful twisting motion or 3. the breaking of bone as a result of the tendon that attaches to the base pulling (avulsing) part of the bone off.
As a general rule, if you sprain your ankle and have x-rays of the ankle taken, you should also have x-rays of the fifth metatarsal base taken as well.
The reason for this is that both areas are poorly vascularized meaning the blood supply to these areas is less than the other surrounding bones. Since blood is the vehicle that carries healing nutrients to an area, any site that has diminished blood flow will have longer healing tendencies.
I mention this so that if you happen to be suffering from a fracture in one of these sites you should not be alarmed if it takes longer than usual. Many times in addition to the standard treatment of immobilization for a broken bone, these two sites may require a bone stimulator to heal the foot fracture or even surgery to fix the break. You should by all means discuss this with your doctor.
As an added note, recently some doctors have begun using ESWT or Extracorporeal Shock Wave Therapy in fractures resistant to healing. ESWT has been used primarily in orthopedic medicine to treat painful ligaments and tendons but in small studies has also been shown to stimulate bone growth in a fracture site, thus increasing the healing process.
REFERENCES
Cleveland Clinic
see related article....talar dome fracture
Q: Ten years ago, I fractured my ankle and chipped the bone, but I was initially told it was just a bad sprain. It was never reset or put in a cast. Now, I have periods where the pain is so bad I can hardly walk, especially after running. It feels like there is no support in the ankle. Can this be fixed after all this time?
A: Because your ankle was not properly immobilized when the injury first occurred, there are several mechanical issues that could be causing your current chronic pain.
Recommendation: This is a quality-of-life issue. I suggest getting a fresh set of X-rays and an MRI to evaluate the bone and soft tissue. Many of these issues can be addressed surgically to prevent the problem from worsening as you age.
— Marc Mitnick, DPM
I have recently been told that I have fractured both sesamoid bones in both feet 8 years ago. As I had pain in my feet as well I was diagnosed with CRPS and can hardly walk without using 2 crutches. I have had every treatment possible but nothing has helped and I have to take lots of medication just to get through the day.
I have had surgery to remove a large lump on the bottom of my foot and have had numerous xrays over the years. I was sent to an orthotics clinic when my ankles began to collapse and the doctor there got out my old xrays and began to show me the fractures, assuming that I knew about them. When he took impressions of my feet he told me that due to the fractures my right leg was out of alignment and would need correcting.
The 2 bones on my left foot are still together but are cracked down the centre. On my right foot 1 is still together but the other is open. When he realised that I didn't know he quickly began to back peddle and told me to talk to my GP. Is it too late to solve this problem? No one wants to take responsibility for this and it is not recorded anywhere because the orthotic doctor says its not up to him to record it.
Hi Tracy, I realize I am only getting your side of the story and obviously I do not have access to your records and more importantly your x-rays, but your narrative does not make sense to me. I am not sure how you could have fractured both sesamoid bones in both feet. Unless you fell from a high position and landed on both feet the wrong way, it is virtually impossible to fracture all four sesamoids.
Yes, with Complex Regional Pain Syndrome, over time your bones will become osteoporotic and so they will be demineralized and therefore weakened which would subject them to a higher incidence of fracture, but that would also pertain to all the bones of your feet and possibly your legs as well. You do not mention having had fractures any where else. So strictly on a percentage basis, the odds of fracturing four sesamoid bones, with no history of trauma and from simply walking seem far fetched to me.
Why did the doctor tell you all four bones were fractured? Maybe he is reading the x-ray wrong. What I mean by that is there is a condition known as bipartate sesamoids. In this condition when the sesamoid bones are formed, instead of each one forming one bone, they form two instead. To the uninitiated they will appear as fractures when in reality they are actually two bones. That would be the only logical reason why you were never told you had fractured these bones, simply because they are not fractured.
The other problem is that in most cases, but not all, it is very difficult to see fractured sesamoids on x-ray, unless again, there was severe trauma and you really crushed them. In many instances, a bone scan or even an MRI is necessary to determine if there is really a fracture or not.
I think the best advice I could give you is to have your x-rays reviewed by a podiatrist or an orthopedist for a more accurate reading. Your GP is not the person to resolve this. If on the chance you actually have four fractured sesamoid bones, there is probably nothing you can do to get them to heal at this point as they would be considered a non-union of eight years duration and I cannot think of anything you could possibly do other than have an orthotic made to take pressure off of the bones, in the same manner that we treat sesamoiditis.
I was having sciatic pain on my left side that went from my back to my big toe. I babied that side and put most weight on my right side. I stepped over a baby gate and came down on my right foot wrong. It twisted and I heard it break. It was immediately swollen and bruised. This happened on March 15th.
I went to an orthopedic surgeon the next week. He x-rayed it and said that it was broken and that I could wear any shoes and put as much weight on it as I could stand. I had surgery on my back on March 31st. Below are the notes that I have received from the doctor:
The ortho said it was healed and I shouldn't have any more problems. I told him that it still hurt a lot and he said he didn't know why. I went to a new ortho who wanted a CAT scan and an MRI. The MRI showed the bone wasn't completely fused. I go back on December 9th to discuss my options. I just wanted to get an idea of what to expect or what to ask.
Hi Sherri, The bottom line is that you have an unhealed fracture after approximately 26 weeks. That can be classified as a non-union. Normal nondisplaced fractures take on average six to eight weeks to heal; you are well beyond that. Your initial report described it as a mildly displaced fracture meaning there was a little separation of the fracture site.
The advice you received to walk on it with any shoe was probably not the best advice you could have received. Midshaft fractures in long bones have a higher propensity not to heal and a part of your fracture was midshaft. That is all water under the bridge right now and so your question becomes one of what to do next.
Since the fracture is partially healed, that tells me the fracture has the potential to fully heal. If you were my patient, my next step would be to order a bone stimulator for you. This is a device that creates a "current" across the fracture site and helps the fracture heal. It would also require wearing a cam walker for immobilization of the fifth metatarsal bone.
You are probably looking at a minimum of four to six weeks with this, but if it works, you are done with very little fanfare. It is probably worth mentioning that things like smoking can delay fracture healing so if that is part of the equation, it should be eliminated.
Hi! I was diagnosed with 3rd metatarsal foot stress fracture 3-4 weeks ago after an MRI.
What is of concern to me is my symptoms haven't diminished at all. I have an aching pain that comes and goes depending on what I am doing (sitting/getting around). I have been in a boot walker and using crutches the whole time.
The WORST seems to be when I stand up and stay standing for a minute. Seems the blood is flowing towards my injury and it becomes very painful after a few minutes. One example would be standing at an elevator waiting on crutches (without even weight baring) and the pain can be difficult to handle. Moving about isn't as bad.
IS this normal? Is this something different going than the stress fracture? Perhaps I need to stay patient and all my pain will diminish in time? Just seems that I would notice at least some progress after almost 4 weeks. — Paul
Hi Paul,
I am at an obvious disadvantage because I do not have the luxury of examining you or even seeing your MRI. Generally speaking, if the stress fracture was picked up on MRI and not an x-ray, that tells me at the very least, that it must be a small "crack" in the bone, otherwise some evidence of the fracture would have been seen on the x-ray.
Also, in general terms, when a patient goes from normal walking to wearing a cast boot and using crutches there should be almost an immediate reduction in pain for the simple reason that you are no longer putting as much pressure on the third metatarsal bone as you were prior to immobilization. Taking this point further, even if there is an accompanying soft tissue injury of some sort, wearing the cast boot and crutches should have reduced that pain as well.
I do not know how old you are, nor do I know your weight, but those factors may also come into play. If you are an older individual or are overweight that may account for why you have had no reduction in pain. If you are diabetic or have some metabolic disease that may slow down the healing process, that too, may account for why you are still having so much pain.
May I also assume you are wearing a plastic cast boot with velcro straps? If you had an actual fiberglass cast applied to your foot, then there is always the possibility that the cast was applied too tight.
If you were my patient and called me 3-4 weeks after wearing a cast and using crutches, I would be somewhat concerned if you were still having the same amount of pain that you originally experienced. Even though the fracture may not yet be healed, it certainly should be well on its way and therefore should be less painful.
The smart move here would be to call your doctor's office and run this by them. They obviously are more familiar with your case and are in a better position to decide whether or not there is an issue here.
Marc Mitnick DPMVisitor Name: Juli
Location: Not Specified
Question: Broken Fused Toe
I broke the tip of my 2nd toe. My concern is that it is a previously fused toe of about 4 years. I know not much can be done for a broken toe but is this serious?
I live an hour from a podiatrist so trying to decide if I am being overly concerned. Thanks.
RESPONSE
Hi Juli,
I am making the assumption that the fusion you had four years ago was at the proximal joint, the joint that is closer to the foot than the end of the toe. Even if it happens to be at the distal joint, the one closer to the tip of the toe, I assume the fracture does not extend into the fusion.
My second assumption is that the fracture you sustained is what is known as a non-displaced fracture, meaning there is essentially a "crack" in the bone and the fractured piece of bone is still attached to the main bone, and the gap—the size of the space between both pieces of bone—is small.
Key Observation: If you are reasonably young with good circulation and are not a smoker, your fracture should heal uneventfully. My only recommendation is that you buddy splint the second toe to the third toe to stabilize the fracture site so that it can heal.
Just wrap the two toes together, including the end of the toes, with hypoallergenic cloth tape. You will need to do this for upwards of six weeks, possibly longer. Change the tape regularly.
Just remember I do not have the luxury of actually examining you and seeing your x-rays, so if you have any concerns beyond what I have discussed, you may have to bite the bullet and make that hour drive to the podiatrist.
Marc Mitnick DPM
I fell down the stairs, landing on my right foot twisted, and was diagnosed with a displaced comminuted 5th metatarsal fracture in late February 2018. I was put in a non–weight‑bearing cast for 1 week, and then an aircast boot. The doctor said I could start to walk with the boot as much as pain was tolerated.
After 1 month, I went back for an X‑ray, but it looked exactly the same as before. The doctor had previously told me that my bone would be able to heal in proper alignment, but obviously it wasn’t going to happen without reinforcement. When I asked about options to re‑align the bone, he said surgery was the only way, but he didn’t recommend it due to possible complications and the need to remove whatever callus had formed. He told me to continue wearing the boot and let the bone heal in its misaligned position.
Concerned about long‑term problems, I sought a second opinion. This doctor recommended surgery to put in implants so the bone could heal in proper alignment. However, due to some reasons, I could not do the surgery immediately, and now my X‑ray shows a malunion (about 4 months after the injury).
I am off the aircast boot now and walking in normal shoes with good support. The doctor says to put off surgery and continue walking to let the bone rebuild. I have occasional aches at the side of my foot, and once had a sharp pain followed by a week of tingling. Since then I’ve been afraid to flex my foot too much.
I am not sure if continuing to walk is the right direction, or whether the bone will regain enough strength for me to return to sports like running, considering it is not in proper alignment.
I am female, 28 years old, don’t smoke or drink, and have lost about 2 kg since the injury (now 51 kg at 1.7 m height). It seems I’m losing bone density, and the doctor said I can slowly recover it by putting weight on my foot.
Hi Sally,
I do not want to sound like a Monday morning quarterback, but had you walked into my office with the first X‑ray, I would have explained that you had a very slim chance of that fracture healing.
You had less than 50% bone‑to‑bone approximation, and the distal end of the bone had displaced downward onto the proximal end. Even if the bone had healed, your fifth metatarsal would have ended up excessively short, which could have created additional foot problems due to malalignment of the metatarsal parabola.
At 28 years of age and in good health, you were a perfect candidate for surgery. The potential for success far outweighed the potential complications. The main complication of this type of repair is non‑union — and you have that anyway.
If you decided not to have surgery, you should have been totally non‑weight‑bearing on crutches and given a bone stimulator. This combination should have been used for at least six weeks, possibly longer depending on progress.
That said, broken bones can heal in an abnormal position and people can function — depending on what your definition of “function” is.
If you never fall again, never trip, never stub your foot, and never participate in sports or workouts, the bone might not re‑fracture. In other words, if you change your lifestyle to accommodate this problem, you might get by for the next 60 years. But I doubt it.
This does not even take into account the potential problems that can occur from the new position of your fifth toe and the resulting metatarsal alignment.
My opinion is that you should consider having the surgery. It will probably require a bone graft and a fair amount of hardware. You will need to be off the foot for a period of time, but once you commit to fixing the problem and put in the necessary recovery time, you should be able to resume your life.
Good luck.
Marc Mitnick DPM
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DISCLAIMER: The purpose of this site is purely informational in nature. It is not intended to diagnose, treat or cure any medical condition. This information is not a substitute for advice from a medical professional. Please consult your healthcare provider for accurate diagnosis and treatment. The information presented here may be subject to errors and omissions.
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