Acute metatarsal fractures are a common extremity injury. While surgery may be recommended to reduce the risk of nonunion or symptomatic malunion, most fractures are treated with nonoperative management. However, there is significant variability between practitioners with no consensus among clinicians on the most effective nonoperative protocol, despite how common the form of treatment. This systematic review identified published conservative treatment modalities for acute metatarsal fractures and compares their non-union rate, chronic pain, and length of recovery, with the objective of identifying a best-practices algorithm. Searches of CINAHL, EMBASE, MEDLINE, and CENTRAL identified clinical studies, level IV or greater in LOE, addressing non-operative management strategies for metatarsal fractures. Two reviewers independently screened the titles, abstracts, and full texts, extracting data from eligible studies. Reported outcome measures and complications were descriptively analyzed. Studies were excluded if a rehabilitation program outlining length of immobilization, weight-bearing and/or strengthening approaches was not reported. A total of 12 studies (8 RCTs and 4 PCs), from the 2411 studies that were eligible for title screening, satisfied inclusion criteria. They comprised a total of 610 patients with acute metatarsal fractures, with a mean age of 40.2 years (range, 15 – 82). There were 6 studies that investigated avulsion fractures, 2 studies on true Jones fractures, and 4 studies with mixed fracture types. Studies assessed a variety of treatment modalities including: WB and NWB casts, elasticated support bandages, hard-sole shoes, plaster slippers, metatarsal shoe casts, and air cast boots. Most studies investigated the outcomes of NWB casts and elasticated support bandages. The NWB short leg cast had no reported non-unions, delayed-unions, or refractures for avulsion fractures. In true Jones fractures, there was an average non-union rate of 23.6% (range, 5.6 – 27.8%), delayed-union rate of 11.8% (range, 5.6 – 18.8%), and refracture rate of 3% (range, 0 – 5.6%). Overall, the average AOFAS score was 87.2 (range, 84 – 91.7) and the average VAS score was 83.7 (range, 75 – 93). The elasticated support bandage had an average non-union rate of 3.4% (range, 0 – 12%), and delayed-union rate of 3.8% for acute avulsion fractures, with no reported refractures. No included study arm investigated outcomes of elasticated support bandages for the true Jones fracture. The average AOFAS score for elasticated support bandages was 93.5 (range, 90 – 100). The average VAS score was 88.9 (range, 90 – 100). Most acute metatarsal fractures heal well, with good-to-excellent functional outcomes and moderate-to-high patient satisfaction. Conservative strategies for avulsion fractures are highly successful and based on this data the authors recommend patients undergo a schedule that involves 3 – 4 weeks in an elasticated support bandage, short leg cast, or equivalent, and WB thereafter as tolerated, with return-to-activity after clinical union. Despite poorer conservative outcomes for true Jones fractures, patients should undergo 8 weeks in a NWB short leg cast, followed by a walking cast or hard-sole shoe for an additional 4 – 6 weeks, or until clinical union. However, surgical consultation is recommended

Introduction. Foot and ankle injuries are a common occurrence amongst all footballers. The aim of this study was to establish the frequency and variation of foot and ankle injuries within one English Premier League (EPL) professional football club over the course of a season and attempt to identify any factors associated with the injuries. Method. Data was collected prospectively for all foot and ankle injuries suffered by first team players over the 2008–09 and 2009–10 EPL season at one EPL club. Each player's demographics were recorded along with various factors concerning or influencing the injury including ground conditions, foot posture index score (FPIS), type of injury, ability to continue playing, recovery time, mechanism of injury and footwear type. Results. The most common injury was 5th metatarsal fracture seen in 33%. Lateral ligament sprain was seen in 28% and syndesmosis injury in 17%. The mean recovery time following 5th metatarsal fractures was 76 days. 67% of all injuries (100% of 5th metatarsal fractures) were sustained while wearing blade footwear, 17% wearing the more traditional studded footwear. Supination was the most common FPIS, present in 43%. 56% of injuries were in the dominant (kicking) side while 50% of injuries were sustained in the tackle. There were no ankle fractures observed. Conclusion. 5th metatarsal fractures are the most common foot & ankle injury amongst professional footballers, ankle fractures are relatively rare in comparison. Injuries occur more frequently with blade footwear, with supination being the most common foot posture at the time of injury

Introduction. Fifth metatarsal fractures are a common injury suffered by professional footballers. It is frequently reported in the media that such an injury will result in a 6-week absence from play. The purpose of this study was to assess frequency of media reporting of fifth metatarsal fractures, the time that is predicted by the media before the player will return to soccer and the actual time taken for the player to return to play. Methods. Internet search engines identified 40 professional footballers that suffered 49 fifth metatarsal fractures between 2001 and 2011. Information was collected from various media and team websites, match reports, photography and video evidence to provide data regarding the mechanism of injury, playing surface conditions, frequency of fractures per season, fracture treatment, estimated amount of time to be missed due to the injury and time taken to return to play. Results. 49 fractures were identified in the 40 players. 6 players suffered a recurrence of a previous fifth metatarsal fracture. 3 players sustained 5. th. metatarsal fractures in their contralateral foot. There was a trend of increased reporting of fifth metatarsal fractures over the course of the decade. 43% of fractures were sustained without contact with another player, 24% were suffered in a tackle. 77% of fractures were sustained in dry conditions. 90% of fractures were treated surgically. Mean return to play time was 14.6 weeks (range 5 to 34 weeks). The mean estimated absence in the media was 7.8 weeks (range 2 to 16 weeks), median 6 weeks. Conclusions. Fifth metatarsal fractures are being commonly reported in professional footballers with an increasing trend. Most are treated surgically. It appears that the commonly quoted period of 6 weeks before return to play is unrealistic. It should be expected that a player would be unavailable for 3 months

The Royal Marines regularly deploy to Norway to conduct Cold Weather, Arctic and Mountain Warfare training. A total of 1200 personnel deployed to Norway in 2010 over a 14-week period. Patients, whose injuries prevented them from continuing training, were returned to the UK via AEROMED. The aim of this investigation was to describe the epidemiology of musculoskeletal injuries during cold weather training. All data on personnel returned to the UK was prospectively collected and basic epidemiology recorded. 53 patients (incidence 44/1,000 personnel) were returned to the UK via AEROMED. 20/53 (38%) of cases were musculoskeletal injuries (incidence 17/1000 personnel). 15/20 musculoskeletal injuries were sustained while conducting ski training (incidence 13/1,000): 4/20 were non-alcohol related injuries, 1/20 was related to alcohol consumption off duty. Injuries sustained whilst skiing: 5/15 sustained anterior shoulders dislocation, 5/15 Grade 1-3 MCL/LCL tears, 2/15 sustained ACJ injuries, 1/15 crush fracture T11/T12, 1/15 tibial plateau fracture and 1/15 significant ankle sprain. Non-Training injuries: 1 anterior shoulder dislocation, 1 distal radial fracture, 1 olecranon fracture, 1 Scaphoid Fracture and one 5th metatarsal fracture. 60% of injuries were upper limb injuries. The most common injury was anterior shoulder dislocation 6/20 (Incidence 5/1000). Our results suggest that cold weather warfare training has a high injury rate requiring evacuation: 4% of all people deployed will require AEROMED evacuation, and 2% have musculoskeletal injuries. Ski training causes the majority of injuries, possibly due to the rapid transition from non-skier to skiing with a bergen and weapon. Military Orthopaedic and rehabilitation units supporting the Royal Marines, should expect sudden increases in referrals when large scale cold weather warfare training is being conducted. Further research is required to see if musculoskeletal injury rates can be decreased in cold weather warfare training