Unique Perspectives on Fifth Metatarsal Stress Fractures

When it comes to fifth metatarsal stress fractures, surgery is often considered the gold standard—but emerging evidence may be shifting that perspective. In this episode, Dr. Patrick DeHeer explores new data on shockwave therapy and what it means for clinical decision-making.

Key Takeaways

1. Shockwave therapy may rival surgery in select patients.
RCT data suggest similar healing rates, outcomes, and complication profiles between shockwave therapy and surgical fixation—with a potentially faster return to activity.

2. Patient selection remains critical.
While many fractures can be managed nonoperatively, surgery may still be appropriate for elite or highly active individuals where faster, more reliable healing is essential.

3. Long-term management should focus on preventing recurrence.
Offloading the lateral column—such as with valgus wedging—can play a key role in reducing refracture risk after healing, regardless of treatment approach.

Transcript

Please note: This content is a direct transcript, capturing the authentic conversation without edits. Some language may reflect the flow of live discussion rather than polished text. 

Jennifer Spector, DPM: When it comes to fifth metatarsal stress fractures, has surgery quietly become the default? In this episode, we'll revisit a longstanding clinical debate, but with a new and thought provoking twist. While operative fixation may be favored by some, especially in certain patient populations, research is still challenging whether that approach is always necessary or even optimal. We're thrilled to welcome back with us today, Dr. Patrick DeHeer. He's the current president of the APMA. He's double board certified by the American Board of Foot and Ankle Surgeons, and he's the residency director at St. Vincent's Hospital in Indianapolis. He is going to help us extend our conversation on this, break down what some of the literature is showing us, and hopefully helping us reexamine some assumptions and explore where the evidence may be leading us next. Dr. DeHeer, welcome back to the podcast.

Patrick DeHeer, DPM: Thanks for having me.

Jennifer Spector, DPM: So this is not really a new discussion as far as surgical versus non-surgical intervention for fifth met stress fractures. However, it's still a lively debate. I happen to see a LinkedIn post of yours on this very topic a while back, but I found it really interesting because it brought up a dimension I really hadn't seen yet before. You pointed out a level 2 pilot RCT from 2023 that went in a completely different direction beyond fixation, beyond immobilization. Can you tell us a little more about this?

Patrick DeHeer, DPM: Yeah, it was an article published in Foot and Ankle International where they were comparing shockwave to surgery in soccer players and competitive soccer players.1 And it was a prospective randomized RCT and the surgery was just IM screw fixation. And then the shockwave was high energy 2000 pulses with three sessions that were done weekly. And then they had identical protocols for both groups for the rehab portion of it.

Jennifer Spector, DPM: So what's your take on this study? What do you feel that something like this might mean for clinical practice?

Patrick DeHeer, DPM: Well, shockwave has been used for non-unions in Europe for a while. I don't know why it hasn't really become more popular in the United States. I am a huge fan of shockwave and I've used it for a long time. Although I have an older machine that just kind of conked out on me recently, so I'm trying to deal with that. But it doesn't surprise me that this article came out. They were looking at VAS pain scales and they looked at AOFAS, PROMIS measures, and then radiographic healing, obviously, and then returned to play. Like I said, these were all soccer players and then any complications. And essentially what they found was a little bit of both groups had VAS of 0 by three months and they had 100% union rate by five months. And the return to play was a little bit quicker on the shockwave patients than the surgery patients about three weeks sooner.

And the functional PROMIS scores were similar. They both ended up at a hundred in both groups and neither group really had any complications. So essentially the outcomes were the same. And I just think the shockwave, I think some of it is access in the United States. Not that many people have the shockwave machines and it has to be high energy, not lower energy. So making sure it's the correct therapy. We tend to default to surgery because I think we don't have a $20,000 or $30,000 shockwave machine available. But I do a lot of reconstructive surgery and I do a lot of fusions and non-unions are very frustrating and it's kind of similar here. I wish we were using this more just from a bone healing standpoint in general.

Jennifer Spector, DPM: Absolutely. And are there any future questions or considerations that we may want to start to take a look at as we move forward, perhaps some things in the literature or even some things internally in our practices that we need to look at more closely?

Patrick DeHeer, DPM: Yeah, I mean, you have to take this in context. For this article from interpretation, it was a small sample size. So it was a pilot study was slightly underpowered and it was mixed fractures and there was no pure conservative immobilization arm. So there wasn't like just put them in a walking boot and see how they do. And the AOFAS scores are not formally validated, so they weren't using a formally validated measure. And these were elite soccer players, not the general population. Just today, I had a patient who was an older female patient. She's in her 70s and she had a stress fracture of her fifth met and it's been five or so month, four maybe months, and I had to do a percutaneous IM screw on her. And she's three weeks out today and I'm already seeing healing. So the screw definitely changed the fracture healing pattern.

Patrick DeHeer, DPM: The other problem too is sometimes in a patient like her where she's not showing progress, access to bone stimulators is really difficult from an insurance standpoint. Then the whole other problem with the shockwave therapy, which I'm a big fan of, like I mentioned earlier, is it's not covered by insurance. So then you have that sort of hurdled across for can patients afford it or not as an out- of-pocket expense.

Jennifer Spector, DPM: Is there anything else that you feel that this audience should take away from this article or from this discussion today that they might be able to apply in their practices tomorrow?

Patrick DeHeer, DPM: Well, I lecture frequently around the country and I hear colleagues who I speak with talk a lot about fifth metatarsal fractures and so many of them talk about not operating on them very much anymore. I would agree with that. I don't really operate on them frequently. I have worked with professional athletes and this study was on soccer players and I think in an elite athlete and I've become a big pickleball player. And so if you have a 60—I have a friend who's one of the top pickleball players in the country and he's in his 60s, he's not a professional athlete, but he's a professional pickleball player in the master's class. So he is an elite athlete, even though he is in his 60s and that's a big part of his life. So if he did have a Jones fracture, I might be more inclined to go ahead and put a screw in there to help get him healed and make sure he doesn't refracture because there is a high refracture rate and people who are very active with Jones fractures.

I will say one thing that I've learned from working with professional athletes and some of the literature on this with professional athletes, once you do get a Jones fracture healed or a fifth metatarsal stress fracture healed, it is often important to unload the lateral calm of the foot and to take pressure off of it. So particularly there was an article on professional football players where once they were healed and they went back to play, they put a valgus wedge on the orthotic that extended from the heel to the fifth metatarsal base. I've done that for years since that article came out and I use that frequently for any kind of lateral problem like peroneal tendonitis, like at the fifth metatarsal base. I definitely do it if I've had a Jones fracture patient and whether I have surgery on them or not, I think we need to think long-term on how to then protect that and prevent recurrence and that's where deloading the lateral column of the foot without valgus heel wedge can really be beneficial.

Jennifer Spector, DPM: Well, thank you so much, Dr. DeHeer, for sharing your insights with us today.

Patrick DeHeer, DPM: You're welcome. Thanks for having me.

Jennifer Spector, DPM: Of course. And this discussion is a great reminder that even well-established treatment pathways deserve ongoing scrutiny. If you're interested in staying current with evolving evidence and clinical debates like this one, be sure to follow the podcast on any of your favorite podcast platforms and share the episode with colleagues who may also be rethinking their approach to stress fracture management. We appreciate you listening and we will catch you in the next episode.

Reference

1. Ramon S, Lucenteforte G, Alentorn-Geli E, et al. Shockwave treatment vs surgery for proximal fifth metatarsal stress fractures in soccer players: a pilot study. Foot Ankle Int. 2023;44(12):1256-1265. doi:10.1177/10711007231199094