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• W4243896595 abstract "Introduction A 20-year-old male college basketball player presented with a 2-month history of left foot pain. There was no acute trauma. The pain was of gradual onset and localized to the lateral aspect of the left forefoot. The pain was provoked with running; however, there was no pain with walking or daily activities. The patient denied swelling, bruising, numbness, or tingling, or previous injuries of the left foot. He related the onset of pain to the use of new basketball footwear. On physical examination, the patient was 6 feet 5 inches tall and weighed 213 lb. The gait appeared normal, the stance demonstrated a mild pes planus deformity, and bunionettes were noted bilaterally. There was mild soft tissue swelling in the area of the left fifth metatarsophalangeal joint, as well as tenderness to palpation. No crepitus was noted. The patient had normal lower extremity strength with normal sensation and pulses distally. Radiographs of the left foot were obtained and were unremarkable. An MRI of the left foot was then obtained that demonstrated marrow edema involving the head of the fifth metatarsal (Fig. 1). No fracture line was present, consistent with a stress reaction. A small effusion was present at the fifth metatarsophalangeal joint. No soft tissue masses were seen. The collateral ligaments were intact and the flexor and extensor tendons were normal. The remainder of the forefoot was unremarkable.Figure 1: Coronal (A) and axial (B) T2-weighted MRI of the left foot showing edema of the head of the fifth metatarsal (arrows).Based upon the patient's physical examination and corresponding findings on MRI, he was diagnosed with a stress reaction of the left fifth metatarsal head. He was placed in a walking boot with the use of crutches and advised to avoid impact activity. He was weaned from the crutches after the first week. Tenderness to palpation resolved after 2 weeks, and the swelling was improved although not completely resolved. Non–weight-bearing aquatic conditioning was initiated. He was weaned from the walking boot after 3 weeks. New footwear with a wider toebox was obtained and foam donuts were fabricated to reduce pressure over the bunionette. At 4 weeks, there was no pain with daily activities and only slight swelling over the fifth metatarsophalangeal joint. Use of a stationary bike was initiated. Swelling was resolved at 5 weeks and activity was increased to elliptical training, free throw shooting, and limited spot shooting. Impact activities, beginning with running, were gradually added at 6 weeks, with no pain occurring with increased training. Over the next 2 weeks, running, jumping, and plyometric training were performed without pain. The athlete returned to full, unrestricted activity at 9 weeks and completed the entire basketball season without recurrent symptoms. Discussion This case describes the diagnosis and management of a metatarsal stress reaction at an unusual anatomic location. Among athletes who have stress injuries (stress fractures or stress reactions), the metatarsals are involved in 9% to 19% of cases, with the second and third metatarsal shafts accounting for 80% of these injuries [1–3]. The fifth metatarsal is the least common site of metatarsal stress fractures [4,5]. The majority of fifth metatarsal stress injuries occur in the proximal third of the bone and may be difficult to treat [6]. Management of these injuries has been discussed extensively in the literature [7–11]. Stress injuries of other segments of the fifth metatarsal are much less common. One report recently described a stress fracture of the fifth metatarsal shaft, also in a basketball player [12]. Stress injuries involving the head of the metatarsals have not been widely reported and are very rare in athletes. Lechevalier et al. [13] reported 16 cases of stress fracture of the metatarsal heads in 11 patients who ranged in age from 21 to 81 years (mean, 63.5 years). Eight of these patients had underlying conditions predisposing to insufficiency fractures and three patients had fatigue fractures secondary to overuse after periods of using a walking or non–weight-bearing plaster boot. The second metatarsal head was affected most commonly (n = 7), followed by the fourth metatarsal (n = 4), third metatarsal (n = 3), first metatarsal (n = 1), and fifth metatarsal (n = 1). In 1998, Chowchuen and Resnick [14] reported on 12 cases of stress fractures of the metatarsal heads in eight patients who ranged in age from 31 to 72 years (mean, 52.3 years). Three of the patients were active in sports. Three other patients had underlying conditions predisposing to insufficiency fracture, and one patient had a bunionectomy on the affected foot 5 years previously. The three middle metatarsal heads were affected uniformly; the third metatarsal head was involved most commonly (n = 6), followed by the second metatarsal head (n = 4), and the fourth metatarsal head (n = 2). Bone stress injury development is multifactorial. The anatomy of the fifth metatarsal makes it particularly prone to stress injury when subjected to the loads that occur during commonly performed basketball maneuvers. Muscular forces, whether acting directly or indirectly on the metatarsal, may also be important in the pathogenesis of fifth metatarsal stress injuries. Other factors, such as foot shape and type of footwear, are also likely involved [15]. Both ground-reactive forces, as well as the dynamic muscular forces exerted during activity, are postulated to play a role in development of fifth metatarsal stress injuries. Basketball players repeatedly pivot, shuttle, and jump-land during play, subjecting themselves to significant ground-reactive and dynamic muscular forces. For instance, a basketball player who lands after a jump can experience a force more than five times his or her body weight [16]. The shape of the foot may predispose to bone stress injury development. A flat foot absorbs stress, which may lead to a higher incidence of stress fractures in flat-footed people [17]. Patients with metatarsus adductus may be at increased risk for stress injuries involving the lateral metatarsal bones, likely related to altered biomechanics placing greater loads across the lateral aspect of the foot [18]. Footwear can have an impact on bone stress injury development [19], and appears to have played a role in this case report, in which a stress reaction of the fifth metatarsal head occurred. Because foot loading, structure, and stability all have a role in development of stress fractures, footwear may play an important role in development (and prevention) of fifth metatarsal stress fractures [15]. MRI has been used to detect stress changes by showing prominent bone marrow signal alterations, allowing early identification and treatment of bone stress injuries. MRI of bone stress injuries reveals a spectrum of abnormalities that accompany pain on physical examination. These range from a marked increase in signal intensity in the medullary portion of the bone on a T2-weighted marrow-sensitive sequence to the more specific finding of a transverse, low-signal-intensity medullary line or periosteal reaction [20]. Signal alterations in the medullary space or bone marrow edema can result from altered biomechanics of the foot [21,22]. Because it is an excellent modality for examining bone marrow edema, MRI is effective for identifying bone stress injuries of the metatarsals [23]. Conclusions This case report describes the diagnosis and management of a stress reaction of the fifth metatarsal head in a college basketball player. The diagnosis was made by combining the physical examination with the MRI findings of marrow edema involving the head of the fifth metatarsal. Contributing factors to the development of this injury likely included footwear and foot shape, combined with the loading forces produced in this sport. Protected weight-bearing, modification of the footwear, and gradual return to activity proved successful in returning this athlete to full activity without recurrent symptoms." @default.
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• W4243896595 title "Stress Reaction of the Fifth Metatarsal Head in a College Basketball Player" @default.
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