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The Jones fracture (base of the 5th metatarsal): 2026 update

Two fractures a few millimetres apart, on the same bone, after the same misstep. One heals on its own in six weeks and deserves little more than a rigid shoe. The other sits in a zone where two vascular networks meet without overlapping, fails to heal in nearly one case in three without surgery, and refractures one time in ten even when operated on. Telling them apart on the radiograph is the central act of this article.

A synthesis written from primary sources verified one by one on PubMed: identifier resolved, journal, year and author list checked, abstract read before citation. Full bibliography at the end of the article.

The Jones fracture in three figures

Three independent pieces of work that explain why this fracture is not an ankle sprain that went wrong

Three key figures on the Jones fracture A union rate of 71.4 per cent without surgery against 97.3 per cent after intramedullary screw fixation; an odds ratio for non-union of 5.74 with non-operative treatment; a refracture rate of 10.2 per cent despite surgery. 71 % / 97 % union rate without surgery against with screw fixation, in athletes ATTIA 2021 OR 5.74 for non-union without surgery 95 % CI 2.65 to 12.40 YATES 2015 10,2 % refractures despite surgery: the bone stays fragile afterwards ATTIA 2021

Sources: Attia AK et al., Am J Sports Med 2021, meta-analysis of 22 studies and 646 Jones fractures in athletes (PMID 33740393); Yates J et al., Foot (Edinb) 2015, meta-analysis of 6 studies and 237 patients (PMID 26481787). These figures concern sporting populations: they do not transfer as they stand to the sedentary patient.

Clinical summary

What to have in mind

  • Everything turns on a few millimetres. The Lawrence and Botte classification divides the base of the fifth metatarsal into three zones: avulsion of the tuberosity (zone 1), the metaphyseal-diaphyseal junction extending to the joint between the 4th and 5th metatarsals (zone 2, the true Jones fracture), and the proximal diaphysis (zone 3)12.
  • Zone 2 is a vascular crossroads, and that is demonstrated anatomically. On ten injected cadaveric specimens, Smith showed that the arterial supply of the tuberosity meets that of the proximal diaphysis exactly in the region of poor prognosis: a relative deficiency of blood supply that explains delayed union and non-union3.
  • Zone 1 is benign, and how common it is feeds the confusion. Avulsions of the tuberosity heal well with functional treatment, including when they are comminuted, displaced or intra-articular4. Taking a zone 2 for a zone 1 means treating by walking a fracture that has a one in three chance of not uniting.
  • In athletes, surgery from the outset is justified. Attia's meta-analysis measures union of 97.3 % after screw fixation against 71.4 % without, return to sport of 98.8 % against 71.6 %, and a delay of 9.6 against 13.1 weeks5.
  • But not everyone is an elite athlete, and a serious systematic review disputes the three-zone reading: Polzer argues that zone 2 fractures unite well with functional treatment, and that the real problem is zone 34. That tension is set out as it stands in the corresponding chapter.
  • Failure does not stop at union. The refracture rate reaches 10.2 % after surgery5, and 13 of the 18 refractures in a series of 168 athletes occurred within six months of the start of rehabilitation11. The timetable for return is therefore a clinical subject in its own right.

Three red flags in pain along the lateral border of the foot

  • Prodromal pain for several weeks before the “fracture” : this is not an acute fracture but a decompensated stress fracture, whose prognosis for union is worse and which makes it necessary to look for an energy or vitamin deficiency10.
  • Pain that persists beyond three months with a fracture line still visible: delayed union, not to be allowed to progress to established non-union6.
  • A return to sport before radiological union : that is the situation that produces refractures, and a systematic review explicitly advises against it6.

At the base of the fifth metatarsal, the prognosis is read not in the appearance of the fracture line but in its position. A few millimetres separate a fracture treated in a shoe from a fracture that gets a screw.

Where exactly does the fracture line run, and why does that decide everything?

The classification is not an academic exercise here: it is the only thing that distinguishes two opposite kinds of management.

The three zones of Lawrence and Botte

The most widely accepted classification is that of Lawrence and Botte, which divides the proximal portion of the fifth metatarsal according to the location of the fracture line, and not according to its appearance. Bušková et al., in their critical review published by JBJS Reviews, are a reminder that it was indeed the potential for union that guided that division1 :

  • Zone 1: avulsion of the tuberosity. The fracture line involves the tuberosity (styloid), at the proximal end of the bone. Union is as a rule excellent, non-operative treatment usually recommended1.
  • Zone 2: metaphyseal-diaphyseal junction. This is the Jones fracture proper. The fracture line sits at the junction between metaphysis and diaphysis and extends as far as the joint between the fourth and fifth metatarsals2. This is the zone of the vascular problem.
  • Zone 3: proximal diaphysis. Beyond the intermetatarsal joint. This is the preferred site of stress fractures and, according to Polzer, the zone whose treatment failure is best documented4.

The three zones of the base of the fifth metatarsal

The decisive landmark is the joint between the fourth and fifth metatarsals: zone 2 extends to it, zone 3 is beyond

Diagram of the three zones of the base of the fifth metatarsal Dorsal view of the base of the fifth metatarsal. Zone 1 corresponds to the tuberosity, where peroneus brevis and the lateral band of the plantar fascia insert, and heals well. Zone 2, at the metaphyseal-diaphyseal junction, extends as far as the joint between the fourth and fifth metatarsals: this is the Jones fracture, at high risk of non-union. Zone 3 is the proximal diaphysis, the site of stress fractures. Dorsal view: right foot, lateral border width of zone 2 4th-5th metatarsal joint the landmark that separates zone 2 and zone 3 peroneus brevis and lateral plantar fascia ZONE 1 avulsion: heals well ZONE 2 Jones: non-union ZONE 3 diaphysis: stress fractures towards the forefoot

Diagram built from the description of the Lawrence and Botte classification as reported by Bušková K, Bartoníček J, Rammelt S, JBJS Rev 2021 (PMID 34673663) and Cheung CN, Lui TH, Arch Trauma Res 2016 (PMID 28144601). The insertions of peroneus brevis and of the lateral band of the plantar fascia are shown after the anatomical study by DeVries JG et al. on 10 cadaveric specimens, J Foot Ankle Surg 2015 (PMID 25441854). The proportions are schematic and are not a measuring template.

The tendon insertions, and what they say about the mechanism

The anatomical study by DeVries et al., conducted on ten frozen cadaveric specimens, measured precisely the insertions in the proximal 1.5 cm of the bone. From it they draw a subdivision into three zones A, B and C, whose value is that it ties each site to a mechanism :

  • Zone A, the most proximal: it is the lateral band of the plantar fascia that inserts there, 6.6 ± 2.2 mm from the inferior border. The authors propose that fractures sitting there arise from traction by that fascia, and can be treated by immobilisation with weight bearing.
  • Zone B : this is peroneus brevis, inserting 12.0 ± 2.2 mm from the inferior border. The authors see fractures there as arising from traumatic tension in the tendon, justifying strict non-weight-bearing immobilisation, or even fixation.
  • Zone C : the portion articulating with the cuboid14.

This reading by mechanism sheds light on an everyday clinical observation: the fracture most often occurs on a foot in forced inversion, a movement that simultaneously tensions peroneus brevis, which opposes inversion, and the lateral plantar fascia. It is the same movement that produces the lateral ankle sprain, which is why the two injuries are so often confused in practice.

Key points

  • The decisive anatomical landmark is the joint between the 4th and 5th metatarsals : zone 2 extends to it, zone 3 is beyond2.
  • Zone 1: avulsion of the tuberosity, good prognosis. Zone 2: the true Jones fracture, poor vascular prognosis. Zone 3: diaphysis, the site of stress fractures1.
  • The usual mechanism, forced inversion, is that of the lateral ankle sprain : it is the main source of missed diagnoses.

Why does zone 2 unite so poorly?

It is one of the rare occasions, in foot trauma, where an anatomical explanation was demonstrated experimentally before being invoked clinically.

Smith's study, and what it establishes exactly

The founding work is that of Smith, Arnoczky and Hersh, published in 1992 in Foot & Ankle. Ten fresh cadaveric or amputation specimens were studied after arterial injection of India ink or barium sulphate. The result comes down to three observations, which must be read in order3 :

  1. The tuberosity receives its blood from numerous metaphyseal vessels that enter the non-articular surfaces in a radial, random arrangement. It is a rich, redundant network.
  2. The proximal diaphysis is supplied mainly by the nutrient artery, which gives longitudinal intramedullary branches. It is a single network, in series.
  3. The two supplies meet in the region just beyond the tuberosity, and that region corresponds exactly to the one with a poor prognosis for union.

The authors conclude that a relative deficiency of blood supply following a proximal diaphyseal fracture may contribute to delayed union and non-union. The term is not in their abstract, but that is the very definition of a watershed zone: a territory served by the far ends of two networks, where each arrives at the limit of its reach.

The vascular watershed of the base of the fifth metatarsal

Two networks, one junction, and a fracture line that falls precisely on it

Intraosseous blood supply of the base of the fifth metatarsal The tuberosity receives numerous metaphyseal vessels arranged in a fan. The proximal diaphysis is supplied by a single nutrient artery giving longitudinal branches. The two territories meet just beyond the tuberosity, at the exact place where the Jones fracture sits. Metaphyseal network numerous vessels, in a fan, redundant: the tuberosity unites Nutrient artery a single supply, longitudinal branches: no back-up route if the fracture cuts it ZONE 2 where the two networks meet “the region of poor prognosis”

Built after Smith JW, Arnoczky SP, Hersh A. The intraosseous blood supply of the fifth metatarsal: implications for proximal fracture healing. Foot Ankle 1992;13(3):143-52 (PMID 1601342), a study on 10 cadaveric specimens after arterial injection. The diagram illustrates the authors' description; it does not reproduce a plate from their paper.

What this explanation does not explain

It would be convenient to stop the reasoning here. Honesty requires it to be pointed out that the vascular argument has never been linked directly to a measured non-union rate : Smith describes an anatomy, the clinic observes failures, and matching the two remains a hypothesis, a solid, coherent one, but not tested as such.

That matters all the more because the systematic review by Polzer et al. disputes, on prospective data, the clinical description usually drawn from that anatomy. We come to it in the treatment chapter.

Key points

  • The tuberosity has a rich, redundant network; the proximal diaphysis depends on a single nutrient artery3.
  • The two territories meet just beyond the tuberosity, in the region of poor prognosis3.
  • It is an anatomical explanation that has been demonstrated, but whose causal link with the failure rates remains a hypothesis.

Who fractures the base of the fifth metatarsal, and how?

Two very different populations share the same bone: the woman over forty who twists her foot, and the pivoting athlete.

Four figures that place fifth metatarsal fractures

Data from two population series and a critical review

Four epidemiological statistics on fifth metatarsal fractures Proximal fifth metatarsal fractures account for 61 to 78 per cent of all foot fractures. The fifth metatarsal is the most frequently fractured metatarsal. Women sustain 75 per cent of zone 1 injuries. The dancer's fracture accounts for 25 per cent of fifth metatarsal fractures, of which 80 per cent in women. 61-78 % of all foot fractures for proximal 5th MT fractures alone n° 1 the most fractured metatarsal out of 411 metatarsal fractures, mean age 42 75 % of zone 1 injuries in women out of 1,275 fractures; twisting = predictor of zone 1 25 % dancer's fractures 80 % women, 80 % over 40

Sources: Bušková K et al., JBJS Rev 2021, for the proportion of foot fractures (PMID 34673663), Petrisor BA, Ekrol I, Court-Brown C, Foot Ankle Int 2006, 411 metatarsal fractures (PMID 16539897), Kane JM et al., Foot Ankle Spec 2015, 1,275 fifth metatarsal fractures (PMID 25666689); Schwagten K et al., Foot Ankle Surg 2021 (PMID 33229215).

The mechanism predicts the zone

One clarification first: out of 411 metatarsal fractures recorded in one year in a Scottish series, of mean age 42, the fifth metatarsal is the most often fractured of all, with an increasing proportion of women in the higher age bands20. It is this bone that is seen, and it is at its base that the prognostic distinction is played out.

The series by Kane et al., which reviewed 1,275 fifth metatarsal fractures in a multicentre orthopaedic practice, delivers a result directly usable in the clinic: the injury mechanism predicts the location. Twisting injuries are a statistically significant predictor of zone 1 injuries. Women sustain 75 % of zone 1 injuries and 84 % of dancer's fractures. In young patients, men predominate; in older patients, it is women19.

That age-related swing is not trivial. Schwagten et al., who studied the dancer's fracture specifically (a spiral fracture of the distal shaft, distinct from the three proximal zones), find that in the group over 40, all patients had a low-energy mechanism, against only 27 % in those under 40. From that they draw a strong clinical conclusion: treat this fracture as a fragility fracture17.

A low-energy 5th metatarsal fracture after the age of 50 is a bone signal

An ordinary twist that breaks a bone in a patient over fifty deserves a question about bone quality, as with any fragility fracture. That reasoning is developed in our article on osteoporosis and the prevention of fragility fractures. The physiotherapist who receives the patient for return to weight bearing is often the first clinician to have the time needed to ask the question.

The athlete, the other population

The true Jones fracture, the zone 2 one, preferentially affects the pivoting athlete: football, basketball, American football. Attia's meta-analysis, which includes only studies covering athletes exclusively, brought together 646 Jones fractures from 22 studies, with return-to-sport rates detailed by discipline: 99.0 % in American football, 96.6 % in football, 91.1 % in basketball5.

That gap between disciplines, modest but consistent, draws out the logic of the injury: basketball, with its pivoting on a foot planted on the floor and its landings from jumps, loads the lateral border of the foot harder than running in a straight line.

Key points

  • Proximal 5th metatarsal fractures account for 61 to 78 % of foot fractures1.
  • The mechanism predicts the zone : twisting points towards zone 1, the benign one19.
  • After the age of 40, a low-energy 5th metatarsal fracture should be treated as a fragility fracture17.

How do you distinguish a zone 1 avulsion from a true Jones fracture?

This is the central point of this article. The two fractures look alike on a poorly read radiograph, and what you do differs completely.

The question to ask in front of the film

One question alone decides it: does the fracture line extend to the joint between the fourth and fifth metatarsals? If yes, it is a zone 2: a Jones fracture. If the line stays proximal to it, confined to the tuberosity, it is a zone 12.

Two errors are made in opposite directions, and they must be named:

  • Taking a zone 2 for a zone 1 : the serious error. The patient leaves in a rigid shoe with permission to walk, for a fracture that has a one in three chance of not uniting without surgery in an athlete5.
  • Taking a zone 1 for a zone 2 : the costly error. You immobilise without weight bearing, you delay the return, you propose surgery for a fracture that would have healed on its own4.
Features distinguishing the three zones. The failure rates come from the series cited and concern different populations, which makes it impossible to compare them term for term.
CritèreZone 1: avulsionZone 2: Jones fractureZone 3: diaphyseal
Site of the fracture lineTuberosity (styloid)Metaphyseal-diaphyseal junction, extends to the 4th-5th jointProximal diaphysis, beyond the joint
Dominant mechanismTwisting, inversion: a statistical predictor19Adduction load on a fixed forefootRepeated loading: stress fracture
Background75 % women19, all agesPivoting athlete, young manEndurance or loading athlete
Prodromal painAbsentSometimesFrequent, suggestive
Prognosis without surgeryExcellent, even when displaced or intra-articular4Union 71.4 % in athletes5 ; 76 % in systematic review6The worst: significantly higher failure without surgery4
Usual approachFunctional treatment, weight bearing allowed4Functional treatment possible; screw fixation from the outset in athletes15Early screw fixation recommended4

The radiographic false friends

Three images can be mistaken for a fracture, and a fourth for a zone 1 when it is something else:

Os vesalianum

This is an accessory ossicle at the lateral border of the foot, immediately adjacent to the base of the fifth metatarsal. The most recent meta-analysis of it, covering 21,312 feet from 22 studies, puts the pooled prevalence at 0,6 % (95 % CI 0.4-0.9), with a comparable distribution between the sexes and a prevalence of 0.6 % on radiographic examinations. The authors conclude explicitly that it must be differentiated from fifth metatarsal fractures and from Iselin's disease15.

What distinguishes it: smooth, corticated margins, a constant position, and above all, when doubt persists, its usual presence on the opposite foot, which a comparative film reveals.

Iselin's apophysis in the child and adolescent

In the adolescent, the secondary ossification centre of the tuberosity appears on the radiograph as a separate fragment. It runs parallel to the axis of the metatarsal, whereas a zone 1 fracture line is usually transverse, that is, perpendicular to that axis. That difference in orientation is the simplest reading criterion. The subject is developed in our article on growth conditions of the lower limb in children and adolescents.

The dancer's fracture

This is not a trap of interpretation but a neighbouring entity, often confused in everyday language. It is a spiral, oblique fracture of the distal shaft, therefore far further out than the three proximal zones. O'Malley, Hamilton and Munyak described the original series of 35 dancers from two national ballet companies: the line starts distal-lateral and runs proximal-medial. Treatment was mainly non-operative, including for displaced fractures, with pain-free walking at a mean of 6.1 weeks, return to the barre at 11.6 weeks and return to performance at 19 weeks. All the dancers returned to their professional activity without limitation18.

The distinction matters because the prognosis is the opposite of that of zone 2: the dancer's fracture is a fracture with a good prognosis, whatever its displacement.

The error that costs the most

Pain along the lateral border of the foot after an inversion is labelled “ankle sprain” in a great many cases. The mechanism is the same, the pain sometimes sits in the same place, and the examination concentrates on the anterior talofibular ligament. Palpation of the base of the fifth metatarsal is part of the Ottawa rules for the foot, and it is precisely by that route that the case report published in JOSPT led a direct-access physiotherapist to request imaging that revealed a fracture27. Our article on the lateral ankle sprain sets out that approach.

Key points

  • The question that decides it: does the fracture line reach the joint between the 4th and 5th metatarsals?2
  • Os vesalianum: 0.6 % of feet, corticated margins, often bilateral15.
  • In the adolescent, the apophysis is parallel to the axis of the bone; a zone 1 fracture is transverse.
  • The dancer's fracture is a distal shaft fracture with a good prognosis, even when displaced18.

Acute fracture or stress fracture: what does the distinction change?

Two different clinical histories can produce the same image, and they do not call for the same strategy.

Two entities that coexist on the same bone

The classic Jones fracture is acute: a step, immediate pain, inability to bear weight. The stress fracture of the fifth metatarsal is something else entirely: prodromal pain along the lateral border of the foot, increasing over weeks, which ends by completing itself, sometimes abruptly, on an ordinary step that gives the illusion of trauma.

This is the distinction Polzer makes: zone 3 fractures are explicitly described as “diaphyseal stress fractures”, at the distal limit of the intermetatarsal joint or just beyond, and it is they that show a significantly higher failure rate when treated without surgery in a non-weight-bearing boot4.

Our article devoted to stress fracture in the athlete deals with the general mechanism, the imbalance between microdamage and bone repair under cyclical loading, with imaging and with relative energy deficiency. This article does not repeat it : it deals with one particular site, where the acute fracture and the stress fracture coexist and get confused, and where the site of the fracture line governs the prognosis more than the mechanism does.

What the history must look for

The question to ask is simple and rarely asked: “Did it hurt there before?” A positive answer changes three things:

  • The prognosis for union : a bone already in trouble, with a periosteal reaction or sclerosis of the line, unites less well than a healthy bone broken cleanly.
  • The search for a systemic cause. The case-control study by Shimasaki et al., covering 37 athletes of whom 18 had a history of fifth metatarsal stress fracture in zone 2 or 3, measured a striking link: a serum 25-hydroxyvitamin D level below 30 ng/mL multiplies by 23.3 the odds of fifth metatarsal stress fracture, after adjustment for multiple confounders. A level of 10 ng/mL corresponded to odds 5.1 times higher, and 20 ng/mL to 2.9 times10.
  • Training load, which must be reconstructed over the preceding weeks, exactly as for any bone overload injury.

Read the odds ratio of 23.3 with caution

This is a case-control study covering 37 athletes in total, of evidence level III. An odds ratio of that size in such a small sample necessarily has a wide confidence interval, and the association measured does not establish causality: an athlete in energy deficiency readily combines vitamin D deficiency, excessive load and low bone density. What the result justifies: measuring vitamin D in a fifth metatarsal stress fracture. What it does not justify: promising that supplementation will prevent recurrence.

Key points

  • Any prodromal pain turns the diagnosis of acute fracture into a decompensated stress fracture, with a more guarded prognosis4.
  • A 25-OHD level below 30 ng/mL is associated with odds of 5th MT stress fracture multiplied by 23.3, in a sample of 37 athletes10.
  • The general mechanism of stress fractures is dealt with in the dedicated article ; here it is the site that governs.

Should you operate from the outset, and on whom?

This is the question where the literature frankly contradicts itself, and where the contradiction itself is instructive.

The dominant position: operate on the athlete

Three pieces of work converge, with different methodologies. The review published by the Journal of the American Academy of Orthopaedic Surgeons sums up the current position: the Jones fracture, sitting at the metaphyseal-diaphyseal junction, carries an increased risk of non-union and persistent pain, and delayed union and refracture can occur despite excellent surgical technique and postoperative management16.

Attia 2021, American Journal of Sports Medicine. A meta-analysis conducted according to PRISMA, 22 eligible studies, 646 Jones fractures exclusively in athletes. The results:

  • Overall return to sport 98,4 % (95 % CI 97.3-99.4); 98.8 % after intramedullary screw fixation against 71.6 % with non-operative treatment (95 % CI 45.6-97.6, a very wide interval).
  • Three studies compared the two strategies directly: significant superiority of surgery (odds ratio 0.033; 95 % CI 0.005-0.215; p < 0.001).
  • Time to return to sport 9.6 weeks after screw fixation against 13.1 weeks without surgery.
  • Union rate 97,3 % with surgery against 71,4 % without.
  • Delayed union 2.5 %, refracture 10.2 %.

The authors recommend surgical fixation for all Jones fractures in athletes5.

Roche and Calder 2013, KSSTA. A systematic review of 26 studies, of which 22 were level 4 and only one a randomised trial. Union of acute fractures: 76 % non-operatively, 96 % after screw fixation. For delayed unions: 44 % against 97 %. For screw-fixed non-unions: 97 %. Return to sport after screw fixation of an acute fracture: 4 to 18 weeks. The authors explicitly advise against returning before complete radiological union, because of the risk of refracture6.

Yates 2015, The Foot. A meta-analysis of 6 studies and 237 patients: the non-operative group had significantly higher odds of non-union, OR 5.74 (95 % CI 2.65-12.40; p < 0.001), with a longer time to union and to return to sport7.

The dissenting position, and why it must be read

Polzer et al. published in Injury a systematic review whose conclusion directly contradicts the three-zone reading. Their method is explicit: include only prospective trials comparing either the same treatment for different fractures, or different treatments for the same fracture. Six prospective trials met that criterion. Their conclusions4 :

  • All avulsions of the tuberosity (zone 1) unite well with functional treatment, including multifragmentary, displaced and intra-articular ones. A plaster boot significantly delays return to the previous level compared with functional treatment.
  • Jones fractures (zone 2) likewise give good to excellent results and complete union with functional treatment.
  • By contrast, diaphyseal stress fractures (zone 3) show a significantly higher failure rate with non-operative treatment; early intramedullary screw fixation significantly shortens the time to union and to return to sport.

The authors therefore propose reducing the classification to two entities : metaphyseal fractures not going beyond the distal end of the intermetatarsal joint, to be treated functionally whatever the number of fragments, the displacement and the joint involvement; and metadiaphyseal fractures sitting at that limit or just beyond, which require early screw fixation.

How to hold both together without picking a side

The contradiction is less radical than it looks, and it resolves through the population and through the outcome measure.

Attia speaks only of athletes, and his primary outcome is return to sport and its timing. Polzer speaks of the general population treated in prospective trials, and his outcome is union. A sedentary patient who unites in fourteen weeks instead of nine has been well treated; a professional footballer in the same situation has missed half a season, with a probability of returning to play twenty-seven points lower.

A second factor separates them: the surgical series often cover complete, displacedfractures, whereas the prospective trials of functional treatment readily include incomplete lines. It is not the same fracture.

The honest reading is therefore not “Attia is right and Polzer is wrong”, but: the stronger the requirement on timing, the more surgery is justified; the more distal the fracture line, the more it becomes necessary whatever the patient.

Union and return to sport, surgery against non-operative treatment

Figures from two syntheses covering sporting populations, not transferable to the sedentary patient

Comparison of results between surgery and non-operative treatment The union rate reaches 97.3 per cent after screw fixation against 71.4 per cent without surgery. The return-to-sport rate reaches 98.8 per cent against 71.6 per cent. The time to return to sport is 9.6 weeks against 13.1 weeks. The refracture rate after surgery remains 10.2 per cent. Union rate Screw fixation 97,3 % Not operated 71,4 % Return-to-sport rate Screw fixation 98,8 % Not operated 71,6 % 95 % CI 45.6-97.6: a very wide interval, few non-operative studies Time to return to sport, in weeks Screw fixation 9.6 wks Not operated 13.1 wks What surgery does not settle: 10.2 % refractures, and 2.5 % delayed unions.

Source: Attia AK, Taha T, Kong G, Alhammoud A, Mahmoud K, Myerson M. Am J Sports Med 2021;49(12):3422-3436, meta-analysis of 22 studies and 646 Jones fractures in athletes (PMID 33740393). An exclusively sporting population: these values do not apply to the sedentary patient, in whom Polzer's 2012 review finds good results with functional treatment (PMID 22465516).

A fourth synthesis, not restricted to athletes, points the same way without having the same force: Wang's meta-analysis, on 11 papers and 404 participants of mean age 29.8, finds a medium to large favourable effect of surgery on the non-union rate, the time to union and the time to resuming activity22. Its value is that it covers a less selected population; its limitation is that it mixes the zones.

Zone 1: the case where surgery changes little

The comparison by Valkier et al. covers 51 feet with an avulsion fracture, of which 31 treated without surgery and 20 operated on. An unexpected and instructive result: 11 of the 31 non-operated patients (35.5 %) developed a non-union, against none of the operated ones (p = 0.004). But (and this is the second half of the sentence, which people often forget to quote), all the patients were asymptomatic at one year, whichever group they were in. The authors recommend surgery for avulsions displaced by more than 2 mm, and insist on realistic expectations13.

It is a useful reminder: a radiological non-union is not a clinical non-union. On the tuberosity, a fragment that never fuses can remain perfectly painless. A Chinese randomised trial in 46 young or sporting patients with an avulsion displaced by 2 to 3 mm points the same way: the functional score was better at 6 months in the operated group, but no longer differed at 12 months ; only the time to full weight bearing and to returning to work were significantly shortened by surgery25.

Treatment strategies and level of evidence

An appraisal of the level of evidence following the GRADE principles, from the sources cited in this chapter

Moderate

Intramedullary screw fixation from the outset for a zone 2 fracture in an athlete : union, rate and timing of return to sport all superior, across 646 fractures and 22 studies, with three concordant direct comparisons5, corroborated by two other syntheses67.

Moderate

Functional treatment of zone 1 avulsions, including displaced and intra-articular ones : six concordant prospective trials; a plaster boot significantly delays return to the previous level4.

Low

Early screw fixation of zone 3 stress fractures : significantly higher non-operative failure rate, shorter time to union and to return, across few prospective trials4.

Low

Lateral off-loading insole after a zone 2 fracture on a varus hindfoot : 100 % union and no refracture in a series of 21 fractures, but with no control group8.

Very low

Very early return after screw fixation, before radiological union : a series of 26 fractures in 25 collegiate athletes, mean return at 3.6 weeks with no major complication23, but a systematic review explicitly advises against this practice6.

Not supported

Treating a zone 2 as a zone 1 : that is, allowing free weight bearing without monitoring union. No source consulted supports this course, which arises from a reading error and not from a therapeutic choice.

An appraisal built following the GRADE principles from the sources cited, and not taken from a published GRADE assessment: none of the reviews consulted produced a formal GRADE table on this question.

Key points

  • In athletes, screw fixation gives 97.3 % union against 71.4 %, and a return to sport 3.5 weeks earlier5.
  • Polzer disputes the three-zone reading : according to the prospective trials, zone 2 unites well functionally, and it is zone 3 that fails4.
  • The contradiction resolves through the population and the outcome : uniting is not playing again.
  • In zone 1, radiological non-union reaches 35.5 % without surgery, and all the patients are asymptomatic at one year13.

What factors predict non-union and refracture?

Three families of factors, of which two can be corrected, and that is where the physiotherapist has purchase.

The alignment of the foot: an attractive hypothesis, half confirmed

Raikin, Slenker and Ratigan measured hindfoot alignment in 20 patients operated on for a Jones fracture. The result is clear-cut: 18 of the 21 hindfeet were in radiographic varus, and clinical varus was present in 16 cases. The mean calcaneal pitch angle was 28.5° and Meary's angle 13° with an upward convexity. All the patients united and none refractured, at a mean follow-up of 49 months: the patients in varus having been fitted postoperatively with a lateral off-loading insole for the hindfoot and the forefoot8.

The authors' hypothesis is mechanically clear: a varus hindfoot overloads the lateral column of the foot, predisposes to the fracture, and predisposes to treatment failure.

A recent meta-analysis seriously tempers that reading. Riegger et al. pooled eight studies (296 patients), five of them in quantitative synthesis (132 patients), to compare three angles between fractured patients and controls. Result: only the midfoot adduction angle stands out, with a pooled mean difference of 4,62° (95 % CI 1.31-7.92) and considerable heterogeneity (I² = 76.1 %). Neither calcaneal pitch nor Meary's angle differs significantly. In other words: midfoot adductus seems correlated with risk, but the relationship with hindfoot varus and pes cavus has not been demonstrated9.

Factors associated with the fracture, with non-union and with refracture

Each factor is placed according to the strength of the evidence supporting it, and not according to how often it is cited

Risk factors for fracture and for treatment failure Established in meta-analysis: midfoot adduction with a difference of 4.62 degrees. Established in comparative series: high body mass index, protrusion of the fifth metatarsal head and a plantar gap greater than one millimetre. Suggested but not confirmed in meta-analysis: hindfoot varus and pes cavus. Measured in a small case-control study: vitamin D insufficiency. CONFIRMED IN META-ANALYSIS Midfoot adduction: mean difference 4.62° (95 % CI 1.31-7.92) Riegger 2022, 8 studies, heterogeneity I² = 76.1 %: the only angle that stands out MEASURED IN A COMPARATIVE SERIES High body mass index and protrusion of the 5th metatarsal head Lee 2013: 4-5 intermetatarsal angle significantly larger in those who refractured (168 elite cases) Plantar gap ≥ 1 mm on an incomplete fracture Lee 2013: union in 115.5 days against 73.9 days if the gap is smaller than 1 mm MEASURED IN A SMALL SAMPLE 25-OHD < 30 ng/mL: odds × 23.3 Shimasaki 2016, case-control, 37 athletes in total, level III Justifies measuring it, not promising that supplementation protects. NOT CONFIRMED Hindfoot varus, pes cavus Observed in 18 patients out of 21 in Raikin's 2008 series, but neither calcaneal pitch nor Meary's angle differs in meta-analysis.

Sources: Riegger M et al., J Foot Ankle Surg 2022 (PMID 35039196); Lee KT et al., Foot Ankle Int 2013, refractures (PMID 24216284) and plantar gap (PMID 23637237); Shimasaki Y et al., Foot Ankle Int 2016 (PMID 26596794); Raikin SM et al., Am J Sports Med 2008 (PMID 18443278).

When failure has already happened: what becomes of a non-union

The question often arises in rehabilitation, faced with a patient who arrives with a fracture line still visible months later. The series by Hunt and Anderson covers 21 elite athletes operated on for a revision for non-union or refracture of a Jones fracture, by intramedullary screw fixation combined with autologous cancellous bone graft or with a mixture of bone marrow aspirate and demineralised bone matrix. All regained their previous level of competition, at a mean of 12.3 weeks, with complete clinical and radiographic cortical union, and only one had a further refracture. The authors recommend a solid, large-diameter screw (5.5 mm or more) and an autologous graft21.

The message is useful to pass on to the worried patient: a first-line failure is not a dead end, and revision surgery has good documented results.

The timetable for return: the most actionable factor

This is the item most directly useful to the physiotherapist, and it comes from the series by Lee et al. covering 168 fifth metatarsal stress fractures in elite athletes, treated by modified tension band wiring. Eleven non-unions and eighteen refractures were recorded. The factors associated with refracture were a higher weight and two radiological parameters reflecting protrusion of the fifth metatarsal head (4-5 intermetatarsal angle on the AP view, lateral deviation of the 5th MT on the oblique).

But the most telling observation is chronological: all the refractures occurred after a new injury, once union had been achieved; 13 of the 18 within six months of the start of rehabilitation, and 8 within three months. The authors conclude that patients with a prominent 5th metatarsal head and a high body mass index must approach rehabilitation cautiously before considering a return to their previous sporting level11.

The window of vulnerability does not close at union. It stays open for the six months following the start of rehabilitation, and that is exactly the period when the patient feels cured.

The plantar gap, a radiographic sign worth knowing

A second series from the same team, covering 86 fifth metatarsal stress fractures, tested a simple radiographic criterion: the presence of a plantar gap of 1 mm or more on incomplete fractures. Result: incomplete fractures with a gap of ≥ 1 mm united in 115.5 ± 45.4 days, against 73.9 ± 26.7 days for those whose gap was smaller (p < 0.001). Counter-intuitively, complete fractures united faster (67.5 ± 28.8 days) than incomplete ones taken as a whole (103.2 ± 47.7 days)12.

This result deserves to be known by the rehabilitation clinician, because it contradicts intuition: faced with two radiographs, the one that looks less serious (an incomplete line, with a thin plantar lucency) may herald a union twice as long.

Key points

  • Only midfoot adductus is confirmed in meta-analysis; varus and pes cavus are not9.
  • 13 refractures out of 18 occur within six months of the start of rehabilitation11.
  • Any plantar gap of ≥ 1 mm lengthens union from 74 to 116 days12.
  • An incomplete fracture can unite more slowly than a complete one12.

What do you rehabilitate, and on what timetable for return to weight bearing?

With this fracture, rehabilitation is not first of all analytical work: it is the management of a return to weight bearing in a window where the bone is not yet safe.

What the sources allow you to state, and what they do not

It has to be said directly: none of the sources consulted describes a validated rehabilitation protocol for the Jones fracture. The studies measure times to union, return-to-sport rates and complications; they do not compare rehabilitation programmes with each other. What follows is therefore built from three solid elements (the measured times to union, the chronology of refractures, and the factors predicting failure) and not from a published protocol.

Markers for return to weight bearing after a fracture of the base of the 5th metatarsal

The boxed timings are measured in the sources cited; the session contents belong to everyday practice

Timetable for return to weight bearing by fractured zone In zone 1, weight bearing is allowed from the outset with functional treatment, with pain-free walking at around six weeks. In non-operated zone 2, union takes about thirteen to fourteen weeks. In screw-fixed zone 2 in athletes, return to sport occurs at a mean of 9.6 weeks. The refracture window stays open for the six months following the start of rehabilitation. S0 S6 S10 S14 6 months Zone 1: weight bearing from the outset pain-free walking ~6 wks (dancer's fracture: 6.1 wks) Screw-fixed zone 2: mean return to sport 9.6 wks union 8.2 wks after screw fixation Non-operated zone 2: mean return to sport 13.1 wks, union 13.7 wks Refracture window: 13 of the 18 refractures within 6 months of the start of rehabilitation Plantar gap ≥ 1 mm 115.5 days to union against 73.9: plan a longer timetable from the outset. Operated varus hindfoot Postoperative lateral off-loading insole: 100 % union, no refracture at 49 months.

Timings: Attia AK et al., Am J Sports Med 2021 (PMID 33740393) for the zone 2 values; O'Malley MJ et al., Am J Sports Med 1996 (PMID 8775129) for pain-free walking at 6.1 weeks in the dancer's fracture; Lee KT et al., Foot Ankle Int 2013 (PMID 24216284 and PMID 23637237); Raikin SM et al., Am J Sports Med 2008 (PMID 18443278). The zone 2 values come from sporting populations.

The four objectives of rehabilitation

1. Steer the return to weight bearing without outrunning the bone

This is the main objective, and it is chronological before it is technical. The marker is simple: pain on weight bearing along the lateral border of the foot is the signal, and the progression follows union, not the theoretical timetable. In zone 1, weight bearing is allowed from the outset and functional treatment does better than a plaster boot on the time to return to the previous level4. In zone 2, the question depends on the strategy chosen and must be settled with the surgeon.

2. Restore the ankle and foot without loading the fracture site

The period of immobilisation or non-weight bearing costs ankle mobility and triceps surae strength. Analytical work on dorsiflexion, mobilisation of the midfoot and open-chain strengthening can start early without loading the lateral border. Work on the peroneals, by contrast, requires caution: peroneus brevis inserts on the tuberosity14, and its resisted contraction tensions the zone 1 fracture site. Our article on peroneal tendinopathies sets out the loading progression for those muscles.

3. Correct what can be corrected in the way the foot loads

Raikin's series provides the only documented item of orthotic care: the patients in varus were fitted postoperatively with a lateral off-loading insole for the hindfoot and forefoot, with 100 % union and no refracture at a mean follow-up of 49 months8. It has to be read for what it is: a series with no control, in which the effect of the insole cannot be separated from that of fixation with a 4.5 mm screw. But the orthosis is cheap and low-risk, which makes it a reasonable option when there is frank clinical varus.

4. Watch the refracture window

This is the objective the literature supports most directly, and paradoxically the one most often forgotten: vulnerability persists for months after union. An athlete who has returned and reports discomfort along the lateral border is not an athlete who has not warmed up properly: it is an athlete to re-examine.

What should make you stop and refer back

  • Pain that persists beyond three months with a fracture line still visible: delayed union, which responds well to screw fixation (97 % union) but poorly to doing nothing (44 %)6.
  • New pain after return, including on a united fracture: all the refractures in Lee's series occurred on a united bone11.
  • Mechanical discomfort over the hardware : skin irritation over a screw head is a reported complication, which led to three removals out of 26 fractures in Watson's series23, and hardware complications are frequent enough to have prompted a call for implants designed specifically26.

Key points

  • No validated rehabilitation protocol exists for this fracture: the markers are deduced from the times to union and the chronology of refractures.
  • Peroneus brevis inserts on the tuberosity : tensioning it against resistance must be progressed cautiously in zone 114.
  • The lateral off-loading insole on a varus hindfoot is the only documented orthotic measure, in a series with no control8.

What do concrete clinical cases teach us?

Two published observations, chosen because they show what meta-analyses cannot: what happens when the patient does not follow the treatment, and what a front-line physiotherapist sees.

Three sumo wrestlers, three interrupted treatments

Hoshino T, Tateishi T, Nagase T, Yuki A, Nakagawa T, Tsuchiya M. Jones Fractures in Sumo Wrestlers: Three Case Reports. Case Reports in Orthopedics 2019;2019:9051327 (PMID 31772802).

The authors report three Jones fractures occurring in sumo wrestlers. All three patients interrupted their treatment on their own initiative24. The two cases treated without surgery progressed to non-union or delayed union; the operated case had a screw breakage. And yet, all three carried on wrestling, with little consequence for their careers.

The authors identify the risk factors particular to this discipline: high body weight, and the training and competition characteristics specific to sumo. Above all they explain why adherence is so difficult there: taking rest means losing your rank, which makes it almost impossible to see out a sufficient duration of treatment.

What the case teaches. Three things, in order. First, weight is a loading factor on the lateral column, which Lee's series on refractures confirms11. Next, a non-union does not necessarily prevent practice, which should make one cautious with catastrophic prognoses. Finally and above all, the best treatment is the one the patient can follow : the authors conclude that it is essential to inform these athletes fully about the options and to decide with each of them. For the physiotherapist, who sees the patient far more often than the surgeon does, that is where adherence is played out.

A 17-year-old tennis player, intermittent lateral pain, direct access

Bittner JS, Hartstein AJ. Fifth Metatarsal Avulsion Fracture in an Adolescent Tennis Player. Journal of Orthopaedic & Sports Physical Therapy 2019;49(8):620 (PMID 31366295).

A 17-year-old tennis player presents to physiotherapy by direct access, with intermittent pain along the lateral border of the left foot. Faced with positive fracture tests and applying the Ottawa foot and ankle rules, the physiotherapist requests an orthopaedic opinion and imaging. The radiographs reveal an undisplaced avulsion fracture of the fifth metatarsal.

What the case teaches. It is the most direct illustration of the physiotherapist's role on this subject, and it comes down to one decision rule: palpation of the base of the fifth metatarsal is part of the Ottawa rules, and exquisite tenderness there after a foot injury justifies imaging. Intermittent pain, in an adolescent, with no frank inability to bear weight, is exactly the picture that does not suggest a fracture, and it is the picture of the published case.

Why these cases and not others

Clinical cases are the classic weak point of review articles: the too-neat story, the athlete cured in eight sessions. The two observations above are published, indexed reports, cited with their PubMed identifier. They were chosen because one documents a real treatment failure, three patients who abandon treatment, and the other a diagnostic process conducted by a physiotherapist. No case in this chapter was composed for the purposes of the demonstration.

How do you apply all this from Monday morning?

What reading the sources changes in practice, for the patient who arrives with a painful foot and a radiograph in their file.

The decision tree, starting from the film

What to do with a fracture of the base of the fifth metatarsal

The first question concerns the site of the fracture line; the second the patient's requirements

Decision tree for a fracture of the base of the fifth metatarsal First question, does the fracture line reach the joint between the fourth and fifth metatarsals. If not, it is a zone 1 avulsion warranting functional treatment with weight bearing. If yes, it is a zone 2 or 3. Second question, is the patient an athlete or is the line in zone 3. If yes, discuss intramedullary screw fixation from the outset. If not, functional treatment is possible with monitoring of union. Fracture of the base of the 5th metatarsal Does the line reach the 4th-5th joint? rule out os vesalianum and Iselin's apophysis first no ZONE 1: avulsion Functional treatment, weight bearing allowed, even if displaced or intra-articular yes ZONE 2 or 3: Jones fracture look for prodromal pain: stress or acute? Athlete, requirement on timing, or line in zone 3? this is where the surgical indication is decided yes Screw fixation from the outset Union 97.3 %, return to sport 98.8 % at 9.6 wks 10.2 % refractures no Functional treatment possible Good results in prospective trials (Polzer), but union to be monitored IN EVERY CASE Prodromal pain: measure vitamin D Clinical varus: lateral off-loading insole

Tree built from the Lawrence and Botte classification as reported by Bušková 2021 (PMID 34673663) and Cheung 2016 (PMID 28144601), from the conclusions of Polzer 2012 (PMID 22465516) and from the figures of Attia 2021 (PMID 33740393). It reproduces no published guideline: none of the learned societies consulted has issued a formal recommendation on this fracture.

What to say to the patient, and in what words

  • When it is a zone 1. “Your fracture involves the most proximal part of the bone, the one with the best blood supply. It heals well, including when the fragment is displaced, and you can walk on it.” It is useful to add that the fragment may never fuse on the radiograph without that causing a problem: in one series, 35.5 % of non-operated patients had a radiological non-union and all were asymptomatic at one year13. That avoids alarm at the follow-up.
  • When it is a zone 2. “Your fracture sits a few millimetres from the previous one, but in a zone where two blood networks meet without overlapping. That is what explains why it unites more slowly, and sometimes not at all.” The image of the vascular crossroads works well in the clinic, and it is accurate3.
  • On returning. “Uniting does not mean being solid. Refractures occur after union, and most of them within six months of the start of rehabilitation11.” It is the most important message to get across, and the least spontaneously accepted.

Five errors that cost dear

Common errors at the base of the fifth metatarsal and their consequence, with the source that documents the point.
ErrorConsequenceWhat avoids it
Confusing zone 1 and zone 2A high-risk fracture treated as a benign avulsionOne question alone: does the line reach the 4th-5th joint?2
Labelling it “ankle sprain” without palpating the base of the 5thA missed fracture, sometimes for weeksPalpation is part of the Ottawa rules27
Not asking whether it hurt beforeA stress fracture taken for an acute fracture, systemic cause not looked forOne question in the history; measure vitamin D if yes10
Immobilising a zone 1 in a plaster bootA significant delay in return to the previous level, with no benefitFunctional treatment does better, with prospective trials to support it4
Considering the matter closed at unionRefracture, of which 13 out of 18 within six months of the start of rehabilitationExtend the monitoring and the loading progression11

The decisive act is not therapeutic, it is radiological: look at whether the fracture line reaches the joint between the fourth and the fifth metatarsals.

On the same ground

Frequently asked questions

What is the difference between a Jones fracture and a fracture of the base of the 5th metatarsal?

All Jones fractures are fractures of the base of the fifth metatarsal, but the reverse is not true. The Lawrence and Botte classification distinguishes three zones: the tuberosity (zone 1), the metaphyseal-diaphyseal junction that extends as far as the joint between the 4th and 5th metatarsals (zone 2), and the proximal diaphysis (zone 3)1. Only zone 2 is a Jones fracture in the strict sense. The confusion is frequent because all three sit within a few centimetres of the same bone.

Why does this fracture not unite well?

Because zone 2 is a vascular crossroads. Smith's anatomical study on ten injected cadaveric specimens shows that the rich, redundant network of the tuberosity meets the territory of the nutrient artery of the diaphysis exactly in the region of poor prognosis3. A fracture there cuts one supply with no back-up route to take over.

Should a Jones fracture be operated on?

In athletes, the answer from the available syntheses is yes: union reaches 97.3 % after screw fixation against 71.4 % without, with return to sport of 98.8 % against 71.6 % and 3.5 weeks gained5. In the patient with no requirement on timing, the question is open: Polzer's systematic review, which includes only prospective trials, finds good to excellent results with functional treatment for zone 24. The decision is made with the surgeon, according to the level of demand and the exact site of the fracture line.

How long before walking again, and before returning to sport?

For a zone 1, weight bearing is allowed from the outset with functional treatment4. For a zone 2 in an athlete, return to sport occurs at a mean of 9.6 weeks after screw fixation and 13.1 weeks without surgery5. These values are averages from sporting populations, and a plantar gap of at least 1 mm on an incomplete fracture lengthens union from 74 to 116 days12. The timetable is set by union, not by the average.

Can you refracture after healing?

Yes, and it is the most underestimated risk: the refracture rate reaches 10.2 % even after surgery5. In a series of 168 fractures in elite athletes, all the refractures occurred after a new injury on a united bone, and 13 out of 18 within six months of the start of rehabilitation11. That is why the loading progression continues well beyond radiological union.

My podiatrist speaks of a varus hindfoot, is that related?

It is a solid but unconfirmed hypothesis. Raikin found radiographic varus in 18 patients out of 21 operated on for a Jones fracture, and proposes that overloading of the lateral column predisposes to the fracture and to its failure8. But Riegger's meta-analysis, on 8 studies, confirms neither hindfoot varus nor pes cavus: only the midfoot adduction angle stands out, with a mean difference of 4.62°9. The lateral off-loading insole remains a reasonable option when there is frank varus, without its effect being something one can promise.

I have a “little bone” next to the 5th metatarsal on my radiograph, is that a fracture?

Perhaps an os vesalianum, an accessory ossicle whose most recent meta-analysis, on 21,312 feet, puts the prevalence at 0.6 %15. It is distinguished by smooth, corticated margins, a constant position, and its usual presence on the other foot: which a comparative film reveals. In the adolescent, it may also be the growth apophysis, running parallel to the axis of the bone, whereas a zone 1 fracture is transverse.

What is a dancer's fracture, and is it the same thing?

No, and the prognosis is in fact the opposite. It is a spiral, oblique fracture of the distal shaft of the fifth metatarsal, well beyond the three proximal zones. The original series on 35 professional dancers reports mainly non-operative treatment, including for displaced fractures, with pain-free walking at a mean of 6.1 weeks and return to performance at 19 weeks; all the dancers returned without limitation18. It accounts for 25 % of fifth metatarsal fractures, of which 80 % in women17.

Bibliography

Twenty-seven references, all verified individually on PubMed: identifier resolved, title, journal, year and author list checked, abstract read before citation. The links point to the PubMed record.

  1. Bušková K, Bartoníček J, Rammelt S. Fractures of the Base of the Fifth Metatarsal Bone: A Critical Analysis Review. JBJS Rev. 2021;9(10). PMID 34673663
  2. Cheung CN, Lui TH. Proximal Fifth Metatarsal Fractures: Anatomy, Classification, Treatment and Complications. Arch Trauma Res. 2016;5(4):e33298. PMID 28144601
  3. Smith JW, Arnoczky SP, Hersh A. The intraosseous blood supply of the fifth metatarsal: implications for proximal fracture healing. Foot Ankle. 1992;13(3):143-52. PMID 1601342
  4. Polzer H, Polzer S, Mutschler W, Prall WC. Acute fractures to the proximal fifth metatarsal bone: development of classification and treatment recommendations based on the current evidence. Injury. 2012;43(10):1626-32. PMID 22465516
  5. Attia AK, Taha T, Kong G, Alhammoud A, Mahmoud K, Myerson M. Return to Play and Fracture Union After the Surgical Management of Jones Fractures in Athletes: A Systematic Review and Meta-analysis. Am J Sports Med. 2021;49(12):3422-3436. PMID 33740393
  6. Roche AJ, Calder JD. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013;21(6):1307-15. PMID 22956165
  7. Yates J, Feeley I, Sasikumar S, Rattan G, Hannigan A, Sheehan E. Jones fracture of the fifth metatarsal: Is operative intervention justified? A systematic review of the literature and meta-analysis of results. Foot (Edinb). 2015;25(4):251-7. PMID 26481787
  8. Raikin SM, Slenker N, Ratigan B. The association of a varus hindfoot and fracture of the fifth metatarsal metaphyseal-diaphyseal junction: the Jones fracture. Am J Sports Med. 2008;36(7):1367-72. PMID 18443278
  9. Riegger M, Müller J, Giampietro A, Saporito A, Filardo G, Treglia G, Guidi M, Candrian C. Forefoot Adduction, Hindfoot Varus or Pes Cavus: Risk Factors for Fifth Metatarsal Fractures and Jones Fractures? A Systematic Review and Meta-Analysis. J Foot Ankle Surg. 2022;61(3):641-647. PMID 35039196
  10. Shimasaki Y, Nagao M, Miyamori T, Aoba Y, Fukushi N, Saita Y, Ikeda H, Kim SG, Nozawa M, Kaneko K, Yoshimura M. Evaluating the Risk of a Fifth Metatarsal Stress Fracture by Measuring the Serum 25-Hydroxyvitamin D Levels. Foot Ankle Int. 2016;37(3):307-11. PMID 26596794
  11. Lee KT, Park YU, Jegal H, Kim KC, Young KW, Kim JS. Factors associated with recurrent fifth metatarsal stress fracture. Foot Ankle Int. 2013;34(12):1645-53. PMID 24216284
  12. Lee KT, Park YU, Jegal H, Park JW, Choi JP, Kim JS. Prognostic classification of fifth metatarsal stress fracture using plantar gap. Foot Ankle Int. 2013;34(5):691-6. PMID 23637237
  13. Valkier C, Fallat LM, Jarski R. Conservative Versus Surgical Management of Fifth Metatarsal Avulsion Fractures. J Foot Ankle Surg. 2020;59(5):988-992. PMID 32684405
  14. DeVries JG, Taefi E, Bussewitz BW, Hyer CF, Lee TH. The fifth metatarsal base: anatomic evaluation regarding fracture mechanism and treatment algorithms. J Foot Ankle Surg. 2015;54(1):94-8. PMID 25441854
  15. Osiowski A, Preinl M, Osiowski M, Baran K, Jasiewicz B, Taterra D. The prevalence and clinical considerations of Os Vesalianum Pedis: A meta-analysis. Foot Ankle Surg. 2025;31(7):612-618. PMID 40268623
  16. Metzl JA, Bowers MW, Anderson RB. Fifth Metatarsal Jones Fractures: Diagnosis and Treatment. J Am Acad Orthop Surg. 2022;30(4):e470-e479. PMID 34932521
  17. Schwagten K, Gill J, Thorisdottir V. Epidemiology of dancers fracture. Foot Ankle Surg. 2021;27(6):677-680. PMID 33229215
  18. O'Malley MJ, Hamilton WG, Munyak J. Fractures of the distal shaft of the fifth metatarsal. “Dancer's fracture”. Am J Sports Med. 1996;24(2):240-3. PMID 8775129
  19. Kane JM, Sandrowski K, Saffel H, Albanese A, Raikin SM, Pedowitz DI. The Epidemiology of Fifth Metatarsal Fracture. Foot Ankle Spec. 2015;8(5):354-9. PMID 25666689
  20. Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int. 2006;27(3):172-4. PMID 16539897
  21. Hunt KJ, Anderson RB. Treatment of Jones fracture nonunions and refractures in the elite athlete: outcomes of intramedullary screw fixation with bone grafting. Am J Sports Med. 2011;39(9):1948-54. PMID 21632977
  22. Wang Y, Gan X, Li K, Ma T, Zhang Y. Comparison of operative and non-operative management of fifth metatarsal base fracture: A meta-analysis. PLoS One. 2020;15(8):e0237151. PMID 32790794
  23. Watson S, Trammell A, Tanner S, Martin S, Bowman L. Early Return to Play After Intramedullary Screw Fixation of Acute Jones Fractures in Collegiate Athletes: 22-Year Experience. Orthop J Sports Med. 2020;8(4):2325967120912423. PMID 32426399
  24. Hoshino T, Tateishi T, Nagase T, Yuki A, Nakagawa T, Tsuchiya M. Jones Fractures in Sumo Wrestlers: Three Case Reports. Case Rep Orthop. 2019;2019:9051327. PMID 31772802
  25. Wu GB, Li B, Yang YF. Comparative study of surgical and conservative treatments for fifth metatarsal base avulsion fractures (type I) in young adults or athletes. J Orthop Surg (Hong Kong). 2018;26(1):2309499017747128. PMID 29228848
  26. Anastasio AT, Parekh SG. Existing fixation modalities for Jones type fifth metatarsal fracture fixation pose high rates of complications and nonunion. World J Orthop. 2022;13(4):408-410. PMID 35582152
  27. Bittner JS, Hartstein AJ. Fifth Metatarsal Avulsion Fracture in an Adolescent Tennis Player. J Orthop Sports Phys Ther. 2019;49(8):620. PMID 31366295

A note on method

The bibliographic base was built before writing, by searching PubMed through the E-utilities interface: every identifier was resolved, every record checked for its authors, journal and year, and every abstract read before being cited. The figures put forward carry their source at the exact place where they are written, and the populations they come from are specified where these limit their scope: most of the union and return-to-sport figures come from exclusively sporting series. One major contradiction in the literature, between Polzer's review and the surgical meta-analyses, is set out as it stands rather than settled. Finally, the absence of a validated rehabilitation protocol for this fracture is stated explicitly, the markers proposed being deduced from the measured times to union and from the chronology of refractures. Article written on 15 August 2026.

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