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Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Fracture, Metatarsal Bones


Text Only Home | Graphic-Rich Site | Overview | Risk and Causation | Diagnosis | Treatment | Prognosis | Differential Diagnosis | Specialists | Rehabilitation | Comorbid Conditions | Complications | Factors Influencing Duration | Length of Disability | Duration Trends | Ability to Work | Failure to Recover | Medical Codes | References

Medical Codes

ICD-9-CM:
825.25 - Closed Fracture of Metatarsal Bone(s)
825.35 - Open Fracture of Metatarsal Bone(s)

Related Terms

  • Broken Foot
  • Chopart's Fracture
  • Jones Fracture
  • Lisfranc's Fracture Dislocation
  • Marcher's Fractures
  • Metatarsus Fracture

Overview

Image Description:
Fracture, Metatarsal - A profile of the right foot reveals the phalanges bones of the toes and the metatarsal bones of the forefoot Breaks are shown in the 2nd metatarsal shaft leading to the second toe and the proximal end of 5th metatarsal leading to the little toe.
Click to see Image

A metatarsal bone fracture is a break in one of the five metatarsal bones in each foot. These long thin bones are located between the toes and the ankle (between the tarsal bones in the hindfoot and the phalanges in the forefoot). Most stress fractures involve the legs and feet (lower extremities); the metatarsals are the most common site of stress fracture.

Fractures of the metatarsal bones often are associated with dislocations and often are unstable (displaced). They are classified by their location: head, shaft/neck, or base. The most common fracture site is at the base of the fifth metatarsal (Jones fracture) and occurs as a result of inversion of the forefoot. The location of the fracture must be carefully evaluated since the treatment for a Jones fracture is radically different from fractures of the shaft of the fifth metatarsal. Fractures may develop in the metatarsals from repetitive use as well as from acute injury. More force is placed on the second and third metatarsals when walking; therefore, stress fractures and bone remodeling from stress are common in the second or third metatarsal, a condition sometimes called a “marcher’s fracture” after its high incidence among military recruits.

Many metatarsal fractures are caused by twisting injuries or direct impact (e.g., a heavy object falling on the foot). Athletes, individuals who are obese, and individuals with osteoporosis or rheumatoid arthritis have an increased risk of developing metatarsal fractures.

Incidence and Prevalence: Metatarsal fractures represent 5% to 6% of all fractures treated in primary care (Hatch). They are equally common among men and women and among all racial groups.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals involved in running, ballet, gymnastics, and high-impact aerobic activities are at increased risk of fractures and stress fractures of the metatarsals.

Source: Medical Disability Advisor



Diagnosis

History: A complete medical history should be obtained including prior fractures or orthopedic surgery, underlying medical conditions (especially bone disease, neoplasia, arthritis), medications, allergies, and occupation. A description of the mechanism of injury including the magnitude, location, and direction of impact is helpful. Individuals may report a traumatic event such as a motor vehicle accident, fall, or jump from a height. Stress fractures usually are associated with an increase in intensity or duration of repetitive activities such as jogging, ballet dancing, or walking. Individuals will report pain in the forefoot that is worse with walking. Pain may be severe enough to prevent weight bearing. There also may be swelling (edema) and discoloration or bruising (ecchymosis) of the skin (ecchymosis).

Physical exam: Careful observation and examination of the entire foot and ankle is crucial in the detection of associated injuries. Deformity, edema, and ecchymosis may be noted on observation. The exam may reveal bony tenderness to gentle touch (palpation) and an inability to bear weight. Limitations of active and passive range of motion should be noted. A thorough neurovascular examination is essential.

Tests: Routine x-rays (anteroposterior [AP], lateral, and oblique views) usually are sufficient to diagnose the fracture. Comparison views of the other (contralateral) foot may be necessary. CT scans or MRI may be needed to rule out other injuries. Plain film radiographs often do not reveal early stage stress fractures, although periosteal callus formation often can be seen 2 to 3 weeks after the onset of symptoms. If a stress fracture is suspected and a diagnosis is essential, a bone scan may be helpful. MRI and an imaging method called triple phase nuclear medicine bone scan are often used for confirming the diagnosis.

Source: Medical Disability Advisor



Treatment

Fractures where the bones have not moved out of their normal anatomical alignment (nondisplaced fractures) of the metatarsal shaft are easiest to manage and are treated initially with RICE therapy (rest, ice, compression, and elevation). Conservative treatment for nondisplaced metatarsal fractures is continued with a soft padded elastic dressing, stiff-soled shoe, fracture brace, or walking cast. Weight bearing is allowed as tolerated. More severe fractures may require a nonweight-bearing cast for several weeks followed by gradual transition to full weight bearing. Stress fractures of the metatarsal shaft typically heal well after 4 to 8 weeks, but the causative activity must be stopped to allow healing to occur.

Fractures of a single metatarsal bone with lateral or medial displacement usually heal well without surgery and may be treated like nondisplaced fractures (Hatch). Other displaced fractures may require surgical intervention (open reduction internal fixation [ORIF]). Displacement is more likely with multiple fractures. Diminished blood supply or other neurovascular complication will also necessitate ORIF.

Source: Medical Disability Advisor



Prognosis

A good outcome can be expected for simple, nondisplaced fractures without complications. Healing usually occurs within 6 to 8 weeks. Complicated fractures with associated injuries (e.g., dislocations) that require surgery will take longer to heal and the outcome may be less successful, especially if treatment has been delayed and circulation compromised.

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Orthopedic (Orthopaedic) Surgeon
  • Orthotist
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Sports Medicine Physician

Source: Medical Disability Advisor



Rehabilitation

The duration of treatment of a fracture of the metatarsal bones is related to the location and type of fracture, and fracture management (Bucholz; Chapman). Weight bearing, as advised by the treating physician, may enhance healing and can minimize rehabilitation requirements (Bucholz). Resumption of pre-injury status is the goal with consideration of any residual deficit. Protocols for rehabilitation must be based upon stability of the fracture and fracture management (operative, nonoperative). Stress fractures may frequently be treated with a walking boot or stiff-soled shoe (DeLee; Maguire). However, stress fractures are sometimes treated by ceasing activity for 4 to 8 weeks (Hatch). Fractures of the base of the 5th metatarsal may require operative care followed by a functional brace for 4 weeks to reduce the risk of re-injury (DeLee). Other non-displaced fractures without ligament disruption may be casted (Hatch).

The goal of rehabilitation is to decrease pain and to return the individual to full function with a painless foot. If the injury is managed conservatively and not casted, the individual should follow the PRICE (protection, rest, ice, compression, elevation) procedure until the swelling has stabilized, up to the first 48 hours (Hatch). Gait training using appropriate assistive devices is indicated to promote independent ambulation. Begin gentle range of motion, stretching, and strengthening exercises when the fracture is stable. The individual may be instructed in home exercises to be performed in conjunction with supervised rehabilitation. Progress exercise intensity as indicated until full function is achieved.

If initially immobilized, after the cast is removed, therapy should begin with range of motion, strengthening, and proprioceptive exercises of the involved lower extremity, proceeding with the activities recommended for a non-casted case. Resumption of pre-injury activity level is faster when managed with a soft dressing as compared with a cast (Hatch). Following management with a cast or soft dressing, use of orthotics may be beneficial for some individuals.

If operatively managed, the treating physician will dictate the protocol of rehabilitation.

Bone healing may occur within 6 to 12 weeks; however the bone strength and the ability of the bone to sustain a heavy load may take up to several years (Chapman). Once healing has occurred, the individual may resume full activities of daily living. It is important to instruct the individual not to overload the fracture site until the bone has regained its full strength. The resumption of heavy work and sports should be guided by the treating physician.

FREQUENCY OF REHABILITATION VISITS
ClassificationSpecialistTopicVisit
Nonsurgical Physical TherapistFracture, Metatarsal BonesUp to 12 visits within 6 weeks
SurgicalPhysical TherapistFracture, Metatarsal BonesUp to 6 visits within 4 weeks
Note on Nonsurgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Comorbid Conditions

Source: Medical Disability Advisor



Complications

Compartment syndrome, soft tissue damage, wound infection, or bone infection (osteomyelitis) may complicate the injury. Nonunion, malunion, or delayed union of fracture may complicate healing. Secondary osteoarthritis and reflex sympathetic dystrophy (complex regional pain syndrome) are possible long-term complications. Dislocation of the metatarsal-tarsal joint(s) associated with metatarsal fracture(s) is a more serious injury with longer recovery times and with a greater likelihood of chronic pain. The dislocation component of this injury can be subtle on x-ray and at times is not recognized, leading to a poor result.

Source: Medical Disability Advisor



Factors Influencing Duration

The particular metatarsal bone involved and the location of fracture—head, shaft/neck, or base—determine healing time and duration of disability. Though displaced fractures usually require surgery, healing time for both displaced and nondisplaced metatarsal fractures is roughly the same. Severity of the fracture, any associated injuries, and response to treatment may affect duration. Job requirements, the ability to modify them as needed, the presence of comorbid conditions, and the rate of healing may also affect the disability period.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Weight bearing may be restricted for several weeks. This will affect the individual's ability to climb stairs or ladders, stand for even short periods, stoop, squat, or walk short distances. Crutches, canes, walkers, or wheelchairs may be required. Safety issues regarding work in a confined space and ability to ambulate should be reviewed. The individual may be unable to drive for a time until adequate foot, ankle, and the associated lower extremity muscle control is demonstrated. Frequent rest periods with the opportunity to elevate and ice the foot to control edema may be necessary. Temporary work restrictions may be necessary due to walking boots, casts, or other special footwear requirements. A gradual, rather than abrupt, return to activity is advised, particularly with stress fractures, which may recur if return to activity is premature or too rapid. Proper fitting, supportive footwear may be needed to maintain pain-free recovery and ability to be functional in the workplace.
Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual present with symptoms consistent with a metatarsal bone fracture?
  • Was diagnosis confirmed with x-rays?
  • If the diagnosis was uncertain, were other conditions with similar symptoms ruled out?
  • If diagnosis was uncertain after plain x-rays, were x-rays repeated at 3 weeks to look for periosteal callus formation?
  • Was a bone scan considered to rule out a stress fracture?

Regarding treatment:

  • Was treatment appropriate for the type of fracture?
  • Was surgery required?
  • Are the weight-bearing ends of all five metatarsals on the same level, or has one or more of the metatarsals healed in poor position causing pain and calluses on the bottom of the foot?
  • Would the individual benefit from consultation with a specialist (orthopedic surgeon, podiatrist, or physiatrist)?
  • Has individual been prescribed rehabilitative therapy?

Regarding prognosis:

  • Has individual been compliant with prescribed rehabilitative therapy?
  • Did the individual experience any complications that may affect ability to recover?
  • Does individual have any condition that might affect ability to recover?
  • Have appropriate work reassignments and accommodations been made?

Source: Medical Disability Advisor



References

Cited

Braddom, Randolph L. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia: W.B. Saunders, 2006.

Bucholz, Robert, and James D. Heckman. Rockwood and Green's Fractures in Adults. 6th ed. Philadelphia: Lippincott, Williams & Wilkins, 2005.

Chapman, Michael W. Chapman's Orthopaedic Surgery. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 2001.

DeLee, Jesse C., David Drez, and Mark D. Miller, eds. "Chapter 14, Overuse Injuries; Lower Extremity Stress Fractures." DeLee and Drez’s Orthopaedic Sports Medicine. 3rd ed. Saunders Elsevier, 2009.

Hatch, R. L., J. A. Alsobrook, and J. R. Clugston. "Diagnosis and Management of Metatarsal Fractures." American Family Physician 76 6 (2007): 817-826. National Center for Biotechnology Information. National Library of Medicine. 2 Mar. 2009 <PMID: 17910296>.

Maguire, Sandra. "Chapter 84 -Metatarsalgia." Essentials of Physical Medicine and Rehabilitation. Eds. Walter R. Frontera, Julie K. Silver, and Thomas Rizzo. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.

Source: Medical Disability Advisor