March Fracture

Lower Limb

Overview

March fracture is a stress fracture commonly affecting the second or third metatarsal, typically occurring in military personnel, athletes, or individuals with sudden increases in weight-bearing activity. It results from repetitive microtrauma exceeding the bone's capacity to repair, causing incomplete fracture lines without displacement. Early recognition and appropriate load management are essential to prevent progression to complete fracture and chronic complications.

Pathophysiology

March fracture develops through cumulative microtrauma to metatarsal bones during repetitive high-impact activities. Osteoclastic activity exceeds osteoblastic repair capacity, creating stress-induced bone resorption. The second metatarsal is most commonly affected due to its length and reduced mobility at the tarsometatarsal joint. Progressive microfractures can propagate through the cortex if loading continues unchecked.

Patient Education

Stress fractures heal best with early identification and activity modification—complete rest is often unnecessary, but you must avoid high-impact activities while maintaining gentle, pain-free movement to promote bone remodeling and prevent muscle deconditioning.

Typical Presentation

Site

Dorsal midfoot over the second or third metatarsal shaft; pain typically well-localized and point-tender

Quality

Dull, aching pain with sharp exacerbations on weight-bearing; described as 'gnawing' or 'throbbing'

Intensity

Mild to moderate (3-6/10) at onset, increasing progressively with activity; morning pain common

Aggravating

Marching, running, jumping, prolonged standing, high-impact activities, sudden increases in training intensity, wearing tight footwear

Relieving

Rest, ice application, elevation, reduced weight-bearing, soft shoes with appropriate arch support, gentle activities like swimming or cycling

Associated

Swelling over the metatarsal head, warmth, erythema, limp, antalgic gait, foot stiffness in morning, possible generalized foot pain

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

No accuracy study

Plain X-ray

Procedure

Arranged through the GP or a sports doctor.

Positive Finding

A fracture line or new bone formation (callus) on the metatarsal shaft.

Interpretation

Early X-rays are often normal; changes may only appear after two to three weeks. A normal early X-ray does not exclude a stress fracture if the clinical picture fits.

Sources

No accuracy study

MRI

Procedure

Arranged by the treating doctor when X-rays are normal but a stress fracture is suspected, or when early confirmation matters.

Positive Finding

Bone marrow oedema, with or without a fracture line.

Interpretation

Shows bone stress injury early and grades it, which guides the offloading period.

Sources

No accuracy study

Bone Scan

Procedure

A nuclear medicine scan arranged by the treating doctor, now used mainly when MRI is not available.

Positive Finding

Increased uptake at the affected metatarsal.

Interpretation

Detects bone stress early but is less specific than MRI and involves radiation.

Sources

No accuracy study

Percussion Test (Axial Loading)

Procedure

Tap gently along the length of the affected toe towards the metatarsal, or tap over the metatarsal shaft away from the painful spot.

Positive Finding

Pain at a point on the metatarsal shaft.

Interpretation

Supports a stress fracture but is not reliable on its own. Suspicion rests on the history (recent increase in walking, running or marching) and focal bone tenderness.

Further reading

No accuracy study

Palpation for Bony Tenderness

Procedure

Palpate each metatarsal shaft from the top of the foot, looking for a single tender spot, often with swelling.

Positive Finding

Focal tenderness on one metatarsal shaft, most often the second or third, with swelling on the top of the foot.

Interpretation

Focal bony tenderness after increased load strongly raises concern for a metatarsal stress fracture; offload and refer for imaging. Stress fractures of the base of the second metatarsal or the proximal fifth metatarsal are higher risk and need prompt referral.

Sources

Performance measure

Hop Test / Single-Leg Stance

Procedure

Ask the patient to stand on the affected leg, then hop gently if standing is painless. Stop if painful.

Positive Finding

Focal forefoot pain on standing or hopping.

Interpretation

Pain with hopping supports a stress fracture. Do not insist on hopping if the patient has focal bone pain.

Sources

⚠ Red Flags

  • •Severe, unrelenting pain unresponsive to activity modification over 6+ weeks
  • •Signs of systemic infection (fever, chills, night sweats) suggesting osteomyelitis
  • •History of pathological fractures or multiple stress fractures suggesting underlying metabolic bone disease
  • •Acute onset with direct trauma suggesting displaced fracture requiring imaging
  • •Severe soft tissue compromise, compartment syndrome signs (severe swelling, pain out of proportion, paresthesia)
  • •Non-healing fracture after 3+ months of appropriate management requiring specialist review

⚡ Yellow Flags

  • •Excessive training volume or sudden increases in activity (overuse culture)
  • •Disordered eating patterns or restrictive diet associated with female athlete triad
  • •Perfectionist personality with difficulty accepting activity modification
  • •Pressure from coaches or peers to return to sport prematurely
  • •Body image concerns or preoccupation with training despite injury
  • •Social isolation if unable to participate in team sports
  • •History of previous stress fractures suggesting chronic biomechanical or systemic issues

Osteopathic Techniques

Refer first

A metatarsal stress fracture needs a confirmed diagnosis and relative rest or non-weight-bearing, usually for 2–6 weeks, before a gradual return to activity. X-rays are unreliable, so MRI is recommended when one is suspected. The 2nd–4th metatarsals are low-risk sites, but the 1st and 5th are high-risk and more likely to need surgery. Refer before using manual techniques on the foot.

Rehabilitation Exercises

Ankle Alphabet Exercise

Range of MotionBeginner

Plantar Fascia Stretch (Calf Stretch Against Wall)

StretchingBeginner

Toe Extension Stretch (Long Sitting, Pull Toes Back Gently)

StretchingBeginner

Short Foot Exercise (Intrinsic Foot Arch Activation)

StrengtheningBeginner

Towel Scrunches (Seated, Curl Toes to Draw Towel)

StrengtheningBeginner

Marble Pickup Exercise (Toes Grasp and Lift Marbles)

StrengtheningBeginner

Single-Leg Standing (Eyes Open, Progress to Eyes Closed)

BalanceIntermediate

Tandem Stance (Heel-to-Toe Standing)

BalanceIntermediate

Four-Point Kneeling with Hip Extension (Core and Gluteal Activation)

PosturalIntermediate

Calf Raises (Double-Leg, Progress to Single-Leg)

StrengtheningIntermediate

Lateral Band Walks (Hip Abduction with Resistance Band)

StrengtheningIntermediate

Pool Walking or Swimming (Non-Impact Cardio, Pain-Free)

CardiovascularBeginner

Referral Criteria

  • •Severe pain with signs of displaced or complete fracture on clinical assessment or imaging
  • •Failure to show clinical improvement after 6-8 weeks of appropriate conservative management
  • •Recurrent stress fractures suggesting underlying metabolic bone disease (osteoporosis, vitamin D deficiency) requiring endocrinology review
  • •Suspected or confirmed compartment syndrome requiring immediate surgical intervention
  • •Signs of osteomyelitis or systemic infection requiring infectious disease specialist
  • •Significant swelling with neurovascular compromise requiring vascular assessment
  • •Female athlete with recurrent stress fractures and eating disorder concerns requiring sports medicine and mental health assessment
  • •Fracture with vascular compromise or complex multi-metatarsal involvement requiring orthopedic surgical consultation