What is a metatarsal fracture? How long does it take to recover?

In a continuing series, The Athletic breaks down some of the most common football injuries (no pun intended), giving you the lowdown on what exactly it is and what happens after a player picks it up…

Here, Mark Davies, a leading expert in foot and ankle surgery and founder of the London Foot and Ankle Centre, who has been the foot and ankle surgeon to teams including Chelsea, Arsenal and Tottenham Hotspur, offers a guide to metatarsal fractures. This could be incredibly timely for Manchester United's Lisandro Martinez, who suffered such an injury against Sevilla on Thursday evening…

What is it?

The metatarsal bones are a group of five long bones in the foot, found between the bones of the toes and the tarsal bones (a group of seven bones situated towards the back of the foot). The outside of the metatarsal bone – the hard bit – is called a cortex. Any break in the cortex of a metatarsal bone is a fracture.

The analogy I use is, if you've got a teacup and it's got a crack in it, it's technically a broken teacup. If you've got a teacup that you've just driven over with a steamroller, you've still got a broken teacup, but you've got a completely different problem to deal with. So basically, a metatarsal fracture is any break of a metatarsal, and there's lots of different types.

What terminology will I hear?

Aside from a reference to David Beckham (who famously fractured his second metatarsal in the run up to the 2002 World Cup), you're only really likely to hear 'they've got a fractured metatarsal', but that's a bit like saying 'there's a flower growing in your garden'. Yeah, but which one?

The terms you're likely to hear are avulsion fracture, which is when a little piece of bone pulls off a stress fracture or a Lisfranc injury to the foot. A Lisfranc injury is usually a ligament injury in the mid-foot with small avulsion fractures, which are little bits of bone that pull off the metatarsals. These can be devastating injuries and often require surgery.

But the most common football injury I have seen over the years in terms of metatarsal fractures is a stress fracture of the fifth metatarsal – also known as a Jones fracture. The fifth metatarsal is the sticky-out bit on the outside of your foot, halfway between your ankle and your toes. These also often need an operation because it has a nasty habit of not joining up (if left to heal).

Beckham's 2002 injury sent the English press into a frenzy (Photo: Getty)

How does it happen?

Stress fractures are cracks in the bone caused by repetitive strain or overuse, as opposed to acute fractures which are caused by direct impact or trauma. Stress fractures rarely happen to the second, third and fourth metatarsals and rarely need surgery when they do. And stress fractures of the first metatarsal don't happen as a general rule, especially in football. But as mentioned above, they are relatively common with the fifth metatarsal. Overuse in flimsy shoes is probably the best way to give yourself a fifth metatarsal stress fracture.

It's actually very rare for someone to be stamped on and fracture a metatarsal, but it can happen. The other injuries tend to occur as a result of twisting injuries or a very heavy fall on the foot. And that's when you get Lisfranc injuries.

How painful is it?

You're not going to fracture your foot and not know about it. But for example, with a Lisfranc injury when you pop the ligament and pull off a little piece of bone, often, people will go, 'Oh, I think something's happening to my foot'. But they won't collapse to the ground, they just can't run around.

With a Jones fracture, they may get some symptoms for a few days or even weeks beforehand, thinking, there's something wrong with my foot, but I don't know what it is. And suddenly it goes crack, and it hurts. It's not pain like getting crushed by a bus, but it is the moderate-to-severe pain associated with any significant fracture.

How long are you out of action?

When Wayne Rooney had his fracture before the 2006 World Cup, he got back and played within seven weeks. But that wasn't a conventional metatarsal fracture; I think he pulled off a tiny flake of bone.

Very few people will be back within three months. And if you end up having surgery, it's more likely to be six months, especially if you have a Lisfranc injury that's unstable. In these cases you have to put metalwork in and then take it all out, so the recovery from all of that is at least six months.

What's the recovery process?

It all depends on what you have done, but whether there's an operation or not, they're usually going to be in a boot with crutches. And obviously, if they have surgery, then you've got to wait for wounds to heal before you can start the rehabilitation process.

I remember John Terry having multiple little avulsion fractures in his foot. We just treated him in a boot and he was back after about nine or 10 weeks, but he had physio all day every day for about that length of time.

So, you're likely to see a player in a boot with crutches, which enables them to get from A to B without too much pain. When you've first broken it, the physio is simply trying to keep the swelling down, and as the healing progresses, the physios are going to put them through their paces, get some strength back and get the range of motion back in any joints that are stiff. And finally work on getting them back to full fitness before they're allowed to get back to playing football.

Most common setbacks/secondary injuries?

If they're managed well, they don't usually have setback injuries. The one thing that can happen with elite sportspeople is that they try to get back too quickly and that can lead to a recurrent injury to the foot.

Is that part of your body vulnerable going forward?

It is until you've recovered. With a Jones fracture, if you put a screw up the middle of the bone and it heals up, I've never seen a re-fracture after that. We tend not to take the screws out because it confers more strength on the bone. So no, we're talking about very fit, athletic people who once they've had an injury, which they've recovered from, they're not going to fall to pieces as a result.