Dr. Yi-Cheng Wu
中文

Lateral Foot Pain Warning Signs: Causes and Treatment Strategies for Fifth Metatarsal Fractures

By Dr. Yi-Cheng Wu · Reviewed June 21, 2026

Proximal fifth metatarsal fractures fall into three types by location, with widely differing causes and prognosis; poor management can lead to chronic pain and foot instability.

Proximal fifth metatarsal fractures are classified by the Lawrence & Botte system into three types: avulsion fracture, Jones fracture, and diaphyseal stress fracture, with widely differing causes and prognosis. Research shows the latter two have a higher risk of delayed union and nonunion because of poorer blood supply. Avulsion fractures can often be managed conservatively with a hard-soled shoe or walking boot; Jones fractures frequently require a non-weight-bearing cast, and cases with significant displacement or nonunion may need surgery. Management depends on your condition and a physician's assessment.

Three phases of rehabilitation after a fifth metatarsal fracture

  1. Phase I (0-2 weeks): protection and swelling control

    Protect the foot with a walking boot (Cam Walker Boot) and use axillary crutches to control weight-bearing on the injured side. Perform metatarsophalangeal, pain-free ankle, knee, and hip range-of-motion exercises, activate the lower-limb and core stabilizing muscles, and maintain whole-body fitness on a stationary bicycle. Use cold, compression, and elevation of the limb to reduce swelling and help prevent thrombosis.

  2. Phase II (2-6 weeks): weight-bearing and strengthening

    Progress gradually to full lower-limb weight-bearing in a walking boot or hard-soled shoe. Continue range-of-motion exercises and add active and resistance-band foot and ankle training, lower-limb and trunk strengthening, and rolling and stretching for the plantar fascia and calf. An anti-gravity treadmill can be used for gait re-education, along with sensorimotor, stability, and coordination training.

  3. Phase III (6-10 weeks): advanced training and return to sport

    Restore full ankle and foot range of motion, continue active and resistance exercises, and perform progressive strength training for the trunk, lower limbs, and upper limbs. Advance sensorimotor and stability training, use an anti-gravity treadmill for whole-body conditioning such as running, and finally add return-to-sport training tailored to the sport and player position, including power, multidirectional movement, coordination ladders and cones, shuttle runs, and rapid-reaction drills.

Proximal fractures of the fifth metatarsal can occur at different locations, with widely varying causes, prognosis, and treatment. Managed poorly, they can lead to chronic pain and foot instability.

They usually present with lateral foot pain and acute onset, with or without pain in the affected region. The most commonly used classification today is the Lawrence & Botte system. Under this system, a Zone I fracture is an avulsion fracture of the tuberosity, a Zone II fracture (also called a Jones fracture) is an acute fracture at the metaphyseal-diaphyseal junction, and a Zone III fracture is a stress fracture of the proximal diaphysis. Zone II and III fractures share a similarly tenuous blood supply, which can negatively affect healing. Distal diaphyseal fractures are known as dancer’s fractures because of their frequency in high-level dancers.

For Zone I injuries, the injury usually occurs when the foot is inverted and plantarflexed, causing the lateral band of the plantar fascia to pull on the tuberosity. Zone II injuries usually occur when the forefoot is flexed. Zone III injuries are usually due to repetitive trauma, such as running and jumping.

Fracture Classification

Based on the location relative to the joint between the fourth and fifth metatarsal bases, proximal fifth metatarsal fractures are classified into three types:

  1. Avulsion fracture:
    • Occurs in the region where the peroneus brevis tendon attaches, within 0.5 cm of the proximal tip of the fifth metatarsal
    • Is an extra-articular fracture that does not extend into the joint between the fourth and fifth metatarsals
    • The fracture line intersects the cuboid joint
  2. Jones fracture
    • The fracture line extends to or toward the joint between the fourth and fifth metatarsal bases
    • Usually located between 0.5 and 1.5 cm from the proximal tip of the fifth metatarsal
    • Because of the poorer blood supply and the greater stress across the intermetatarsal ligament and the fracture site, healing is slower, with a tendency toward delayed union and nonunion
  3. Diaphyseal stress fracture
  • Most often occurs between the mid-shaft and distal portion of the fourth and fifth metatarsals
  • Caused by chronic, repetitive microtrauma, especially common in young athletes
  • Has the slowest healing, and the highest risk of delayed union, nonunion, and refracture

Epidemiology

  • Fifth metatarsal fractures account for 47 to 50 percent of all metatarsal fractures
  • Avulsion fractures are the most common type among them, accounting for 57 to 90 percent
  • Diaphyseal stress fractures are the least common type, accounting for 3 to 15 percent

Etiology

  • Avulsion fractures are usually caused by an inversion injury of the foot and ankle
  • Jones fractures may be caused by a forefoot twisting injury, a vertical load acting on the lateral forefoot while the foot is plantarflexed, or direct trauma to that area
  • Stress fractures are related to repetitive impact on the lateral aspect of the foot

Risk Factors

  • A prior history of proximal fifth metatarsal fracture
  • Lateral ankle instability
  • Static forefoot adduction

Physical Examination

  • Marked tenderness over the lateral foot, especially at the base of the fifth metatarsal
  • Local swelling and bruising are usually associated with the fracture
  • Sensory examination of the foot, particularly checking for reduced sensation within the distribution of the lateral dorsal cutaneous nerve
  • Resisted eversion or external rotation may provoke pain at the fifth metatarsal fracture site and tests the integrity of the peroneus brevis

Diagnostic Tools

  • Imaging

    • Radiographs (anteroposterior, lateral, and oblique views): can identify obvious or avulsion fractures; subtle bone cracks can sometimes be hard to diagnose
    • When the initial radiograph shows no abnormality but a stress fracture is suspected, a repeat examination is recommended 10 to 14 days later

  • Ultrasound: useful for diagnosing surrounding soft-tissue involvement and subtle bone cracks

  • Whether a fracture has delayed union can be further assessed by CT or MRI

  • CT is better suited to precisely assessing joint incongruity in intra-articular fractures

  • MRI is highly sensitive for early stress fractures and soft-tissue injury

Initial Treatment

  • Analgesia

    • Ice and elevation of the foot to reduce swelling and pain

  • Immobilization

    • Patients with an avulsion fracture can wear a hard-soled shoe or walking boot to keep the area stable for 3 to 4 weeks
    • For a Jones fracture (acute and non-displaced), a short-leg cast with complete non-weight-bearing for 6 to 8 weeks can be used; for delayed-union cases, this may be extended to 16 weeks

  • Referral recommendations

  • Situations requiring surgical management include significantly displaced fractures or those with associated neurovascular injury

Short-Term Medication

  • Anti-inflammatory pain relievers (NSAIDs)
    • As a first-line analgesic, especially in the first 48 hours
    • Options include ibuprofen (600 mg orally every 8 hours) or naproxen (250 to 500 mg orally twice daily)
  • Acetaminophen: suitable for mild to moderate pain
  • Patients with severe pain may need oral low- to moderate-potency opioid medication

Additional Treatment

  • Bone stimulation
    • Electromagnetic field therapy or ultrasound bone stimulation may offer some help for delayed-union and nonunion cases, but the evidence is not yet conclusive
  • Physical therapy and exercise training
    • Begin range-of-motion exercises for foot eversion and supination, gradually strengthening the peroneus brevis
    • Continue strengthening and proprioception training to restore normal movement function

Surgery

  • Avulsion fractures

    • Usually do not require surgery, but displaced fractures or those involving the cuboid and fifth metatarsal joint may need it

  • Jones fractures and diaphyseal stress fractures

  • Type I (acute fracture with rotational displacement): open reduction and internal fixation may be considered to speed up an athlete’s recovery

  • Type II (delayed union) and Type III (nonunion): surgical fixation is usually necessary

Follow-Up

  • Radiographs are taken weekly to ensure correct fracture alignment and assess the response to treatment
  • Once radiographic and clinical healing is confirmed, weight-bearing training can be gradually resumed
  • If a patient recovers poorly, referral to a specialist for evaluation should be considered

Post-Operative Training and Prognosis

  • The prognosis depends on the fracture type and treatment method:

    • Avulsion fractures usually have a shorter healing time, and patients can return to normal activity within 3 to 4 weeks
    • Jones fractures need a longer healing time (8 to 16 weeks) and carry a higher risk of nonunion or delayed union

  • With an appropriate treatment approach, most patients can return fully to their pre-injury activity level

  • Phase I (0-2 weeks)

    • Foot protection: use a walking boot (Cam Walker Boot)
    • Walking: use axillary crutches to support weight-bearing on the injured limb
    • Range-of-motion exercises (ROM): including the metatarsophalangeal joint and pain-free ankle, knee, and hip
    • Activation exercises for the lower-limb and core stabilizing muscles
    • Whole-body fitness exercise: such as riding a stationary bicycle
    • Anti-thrombosis and swelling-control measures: such as cold, compression therapy (e.g. NormaTec), and elevation of the limb

    Phase II (2-6 weeks)

    • Full lower-limb weight-bearing: in a walking boot or hard-soled shoe
    • Manual therapy: including scar-tissue massage and mobilization of the foot and calf soft tissue
    • Continue ROM exercises
    • Active and resistance foot and ankle exercises: using tools such as resistance bands
    • Muscle strengthening: strengthening the lower-limb, trunk, and upper-limb muscles
    • Gait re-education: using an anti-gravity treadmill
    • Exercises to improve sensorimotor function, stability, and coordination
    • Rolling and stretching: targeting the plantar fascia, calf muscles, and other areas
    • Edema prevention measures

    Phase III (6-10 weeks)

    • Full restoration of ankle and foot range of motion
    • Continue active and resistance exercises for the foot and ankle
    • Progressive strength training: for the trunk, lower-limb, and upper-limb muscles
    • Advancement of sensorimotor and stability training
    • Whole-body conditioning: such as running on an anti-gravity treadmill
    • Advanced training: considering the specific demands of soccer and the player’s position
      • Improving soccer players’ athletic skills and coordination
      • Power training
      • Multidirectional movement based on rotational patterns
      • Drills using coordination ladders and cones
      • Shuttle run training
      • Running training at varying intensities
      • Rapid-reaction drills

References

Further Reading

Frequently asked questions

How are proximal fifth metatarsal fractures classified?

They are classified by the Lawrence & Botte system into three types. Zone I is an avulsion fracture within 0.5 cm of the proximal tip. Zone II is a Jones fracture, where the fracture line runs toward the joint between the fourth and fifth metatarsal bases. Zone III is a diaphyseal stress fracture.

Are fifth metatarsal fractures common?

Fifth metatarsal fractures account for about 47 to 50 percent of all metatarsal fractures. Among them, avulsion fractures are the most common (57 to 90 percent), and diaphyseal stress fractures are the least common (3 to 15 percent).

What causes a fifth metatarsal fracture?

Avulsion fractures are usually caused by an inversion injury of the foot and ankle. Jones fractures may result from a forefoot twisting injury, a vertical load applied while the foot is plantarflexed, or direct trauma. Stress fractures are related to repetitive impact on the lateral aspect of the foot.

Who is more likely to have a proximal fifth metatarsal fracture?

Research shows a higher risk in people with a prior history of proximal fifth metatarsal fracture, lateral ankle instability, and static forefoot adduction.

What does the physical examination check for?

The physician checks the lateral foot, especially the base of the fifth metatarsal, for tenderness, swelling, and bruising, and assesses sensation in the lateral dorsal cutaneous nerve distribution, as well as whether resisted eversion or external rotation provokes pain, to test the integrity of the peroneus brevis.

This article is also available in the original Chinese, with the full reference list.

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