The Elite Football Players with a Fifth Metatarsal Fracture

OBJECTIVES: Fractures of the proximal fifth metatarsal can be a difficult clinical problem, especially in the athlete who wishes to return to competition. Clinical and radiographic evaluation cannot always be relied upon to assess complete healing. Refracture, after operative and nonoperative treatment, of a fifth metatarsal is a known phenomenon. The purpose of the study was to characterize and describe the prevalence of fifth metatarsal fractures in athletes at the NFL Scouting Combine and test the hypothesis that radiographic healing and symptom free return to play in college predict length of career and risk of re-injury. METHODS: A retrospective review was performed of the database of players presenting to the annual NFL National Invitational Camp from 2005 to 2010 to identify athletes in whom fifth metatarsal fractures occurred. Each of these players underwent anteroposterior (AP), oblique, and lateral foot radiographs that were analyzed for indicators of hindfoot malalignment in addition to the presence or absence of a residual fracture gap. The date of the injury, the date of surgery (if applicable), and the number of games missed after the injury were also obtained from history. An internet search and NFL.com was used to determine the effect of their prior fifth metatarsal injury on the player’s career (games played, career length, and re-injury). RESULTS: 87 feet (81 players; 4.4% of all players) were identified. 52.9% of these injuries occurred in the left foot. Among all NFL Scouting Combine participants, fifth metatarsal fractures most commonly occurred in offensive linemen (20.7%), wide out receivers (20.7%), defensive linemen (17.2%), and defensive backs (11.5%). 78.2% of players were treated with an intramedullary screw. A persistent fracture gap was noted in 18.4% of players. 17.2% of players had a re-injury during their career. No radiographic measurements differed between players that had a residual fracture gap or re-injury. Players that played at least one full collegiate season after injury were less likely to have re-injury during professional play (5.6% vs. 46.7%; p < 0.001) or a residual fracture gap (9.7% vs. 60%; p < 0.001). Players without a residual gap were also less likely to have a re-injury (7% vs. 37.5%; p < 0.001). Players treated with surgery were less likely to have re-injury (10.3% vs. 21.1%) but more likely to have gap formation (20.6% vs. 10.5%). CONCLUSION: Players who are able to complete at least one full year of collegiate football after a fifth metatarsal fracture are less likely to have re-injury or a residual fracture gap. No radiographic measurements are predictive of re-injury or residual fracture gap.