March 2013

Bad breaks: Fifth met fractures can curtail NFL careers

In the moment: Sports medicine #64522222 #64522222

By Emily Delzell

Jones and proximal diaphyseal fifth meta­tarsal fractures are common among football players and may shorten their athletic careers, according to a February study that found players with fractures were significantly more likely than players without the injuries to have played in fewer than 10 National Football League (NFL) games.

A poor blood supply in the proximal fifth metatarsal means microscopic damage from stress heals slowly, increasing risk for fractures, which also present healing challenges, said Dominic S. Carreira, MD, lead author of the study, an orthopedic surgeon in private practice in south Florida, and a team physician for professional sports teams including the Miami Dolphins.

To determine bone union and extent of healing the researchers retrospectively reviewed data collected between 2004 and 2009 at the NFL Combines, where college players are questioned about current and past injuries as well as previous surgeries and undergo medical examination, including imaging studies.

The investigators identified 74 fifth metatarsal fractures in 68 players and paired them with a control group with other types of injuries. The control group was matched based on medical orthopedic grade, player position, body mass index, and whether the player was drafted.  Researchers determined foot alignment and type of operative fixation used and grouped player positions to determine differences in injury patterns and outcomes. For players who went to the NFL, they collected data on the number of games and years played. The findings were e-published in February by Foot and Ankle International.

DJO Global Bone Healing - CMFDuring the period studied, the incidence of proximal fifth metatarsal fractures in players’ medical history was 3.42%, and offensive linemen were injured most often (28% of injuries across all positions). Radiographic review showed 61% of the injuries were Jones fractures, 20% were proximal diaphyseal, and 19% were indeterminate.

Fifty-six (76%) fractures were treated with surgical fixation and 18 (24%) were treated nonoperatively; at the time of the NFL Combines, nine (12.2%) were nonunions. Operatively treated players had a union rate of 89% versus 83% in nonoperatively managed athletes.

Investigators found no statistically significant differences in body mass index, draft status, medical grade, or screw type or size. In addition, they found that injury location (Jones vs proximal diaphyseal) had no influence on treatment or outcomes.

They found a trend toward fewer total NFL games played, but it was not statistically significant, a finding Carriera said may be due to the study’s sample size and injuries among controls.

Sagittal plane foot alignment did not differ significantly between groups, but coronal plane alignment did, with varus alignment linked to higher fracture rates.

“In my practice I recommend bilateral over-the-counter or custom orthotics for correction of cavovarus alignment in players who have been injured on one side,” Carriera said.

He also noted that operative fixation, which is traditionally offered to athletes, may also be the best course for nonathletes with these fractures, as nonoperative treatment requires strict nonweightbearing and casting for six weeks, while the operative approach allows patients to bear weight one to two weeks after screw insertion.

David Thordarson, MD, professor of surgery at Cedars-Sinai Medical Center in Los Angeles, agreed.

“Inserting a screw stabilizes the bone, significantly increases the union rate, and decreases the disability period,” said Thordarson, who is editor in chief of Foot and Ankle International. “If I had one of these fractures I would absolutely have it fixed surgically because I could start walking on it a week or so later.”

He added that one in three patients don’t heal with nonoperative management and go on to need operative fixation.

“Occasionally I see older patients who may be osteoporotic and have one of these fractures and I explain the options,” he said. “Most say, yes, put the screw in because I don’t want to have all that nonweightbearing time. With athletes you want to get them back on the field as soon as possible, but the rest of us are playing the game of life, and you don’t want to be out of that game any longer than you have to.”


Carreira DS, Sandilands SM. Radiographic factors and effect of fifth metatarsal jones and diaphyseal stress fractures on participation in the NFL. Foot Ankle Int 2013 Feb 15. [Epub ahead of print]

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