903259

research-article2020
FAIXXX10.1177/1071100720903259Foot & Ankle InternationalNishikawa et al

Article

Foot & Ankle International®

Treatment of Zone 1 Fractures of the

1­–5
© The Author(s) 2020
Article reuse guidelines:
Proximal Fifth Metatarsal With CAM- sagepub.com/journals-permissions
DOI: 10.1177/1071100720903259
https://doi.org/10.1177/1071100720903259

Walker Boot vs Hard-Soled Shoes journals.sagepub.com/home/fai

Danilo Ryuko Cândido Nishikawa, MD1,2 ,

Fernando Aires Duarte, MD1,2, Guilherme Honda Saito, MD3 ,
Katrina E. Bang, BA4,5, Augusto César Monteiro, MD, MSc1,
Marcelo Pires Prado, MD, PhD3, and Cesar de Cesar Netto, MD, PhD4

Abstract
Background: Zone 1 fractures of the proximal fifth metatarsal are usually treated nonsurgically using some type of
immobilization. The aim of this study was to compare clinical and functional outcomes, time to return to prior activity levels,
and rate of bone healing when using a hard-soled shoe (HSS) vs a controlled ankle motion (CAM)–walker boot (CWB).
Methods: Seventy-two consecutive patients with zone 1 fractures of the fifth metatarsal base were treated conservatively
with either an HSS or CWB by 2 different providers. We included 57 women and 15 men, average age of 41.3 (range,
16-88) years. Radiographic findings, visual analog scale (VAS) for pain, and American Orthopaedic Ankle & Foot Society
(AOFAS) midfoot score were assessed. Patients were followed at 4, 8, 10, 12, and 24 weeks or until asymptomatic and able
to return to prior level of activities. Statistical analysis was performed using Mann-Whitney U, Fisher exact, and chi-square
tests. P values <.05 were considered significant.
Results: Age and gender distributions were similar in both groups (P = .23 and P = .57). Patients had similar VAS and
AOFAS scores after 8 (P = .34 and P = .83) and 12 (P = .87 and P = .79) weeks. Average time for bone healing was
significantly faster using the CWB (7.2 weeks) when compared to the HSS (8.6 weeks) (P < .001). The average time to
return to prior level of activities was similar in both groups (8.3 weeks for CWB and 9.7 weeks for HSS) (P = .11). Fracture
displacement was equal in both groups, with a mean of 1.9 mm of displacement in patients using the HSS, and a mean of
1.6 mm in those using the CWB (P = .26).
Conclusion: Zone 1 fractures of the proximal fifth metatarsal can be treated conservatively with either a hard-soled shoe
or a CAM-walker boot. Even though patients treated in the CAM-walker boot demonstrated earlier signs of complete
healing, similar clinical and functional results were achieved with both treatments.
Level of Evidence: Level III, retrospective comparative series.

Keywords: fifth metatarsal, metatarsal fractures, avulsion fractures, nonoperative treatment, conservative treatment

Introduction for most patients, but can take up to 6 months of treatment

Avulsion fractures of the base of the fifth metatarsal are
common injuries that are usually managed nonoperatively
with satisfactory outcomes.10,12 These fractures often result
from an inversion injury of the hindfoot with the forefoot
fixed on the ground, wherein a sharp rise in tension travels
along the lateral band of the plantar aponeurosis to its inser-
tion on the base of the fifth metatarsal, causing it to avulse
from the bone.4 Such fractures of the proximal fifth meta-
tarsal are classified as zone 1.2,8,12
Different options for conservative treatment are avail-
able and include elastic bandages, immobilization in a cast,
controlled ankle motion (CAM)–walker boot (CWB), and
hard-soled shoes (HSSs).4,5,10,12 The protocols for weight-
bearing status are variable depending on surgeon preference
and fracture displacement. Complete recovery is expected
for full return to prior level of activities.4 The aim of this
1
Department of Orthopaedics, Foot and Ankle Surgery, Hospital do
Servidor Público Municipal de São Paulo (HSPM), São Paulo, SP, Brazil
2
Department of Orthopaedics, Clínica de Ortopedia Ortocity, São
Paulo, SP, Brazil
3
Department of Orthopaedics, Hospital Israelita Albert Einstein, São
Paulo, SP, Brazil
4
Department of Orthopaedics and Rehabilitation, University of Iowa,
Iowa City, IA, USA
5
Department of Anatomical Sciences, St. George’s University School of
Medicine, St. George’s, Grenada, West Indies
Corresponding Author:
Danilo Ryuko Cândido Nishikawa, DN, MD, Foot and Ankle Surgery,
Department of Orthopaedics, Hospital do Servidor Público Municipal
de São Paulo (HSPM), 60, Castro Alves Street, 4th Floor, Liberdade, São
Paulo, SP 04002-010, Brazil.
Email: dryuko@gmail.com
2 Foot & Ankle International 00(0)
Figure 1.  Photographs of (A) hard-sole shoe and (B) CAM-
walker boot. CAM, controlled ankle motion.
study was to compare the results of 2 different conservative
treatment modalities for zone 1 fractures of the proximal
fifth metatarsal, using either an HSS or a CWB. Our hypoth-
esis was that both treatment modalities would provide simi-
lar clinical, functional, and radiographic outcomes.
Methods
In this institutional review board–approved retrospective
comparative study, we included consecutive patients diag-
nosed with acute zone 1 fractures of the base of the fifth
metatarsal, from March 2014 to November 2018. During
this period, 93 patients with zone 1 fractures of the fifth
metatarsal were screened. We excluded patients with
comorbidities that could interfere with bone healing such as
smoking, diabetes, and inflammatory joint disease, as well
as patients with associated major injuries to the ligaments of
the ankle joint. Patients with prior history of pain or injury
to the fifth metatarsal were also excluded.
A total of 72 patients were included in the study, 56
females and 16 males, mean age 41.3 (range, 16-88) years.
Patients were treated conservatively, independent of the
degree of fracture displacement, by 2 different fellowship-
trained foot and ankle surgeons. The preference of one of
the attendings was to treat all patients in a CWB. The other
attending treated all patients in an HSS (Figure 1). Patients
were randomly assigned to one of the 2 attendings regard-
less of clinical profile and radiographic characteristics.
From the 72 patients included in our study, 39 were treated
in a CWB and 33 in an HSS.
All patients followed the same weightbearing protocol,
that consisted of protected weightbearing as tolerated in
either a CWB or HSS, for 6-8 weeks. Patients treated with
the CWB were advised to remove the immobilization device
and mobilize the ankle joint on a daily basis to minimize
risks of deep venous thrombosis and ankle joint stiffness.
All patients were followed up clinically and radiographi-
cally at 4, 6, 8, and 12 weeks after the initial evaluation, or
until full resolution of the symptoms.
We investigated radiographic findings of complete heal-
ing of the fracture, defined by healing of 3 of 4 cortices of
the fifth metatarsal, using anteroposterior and lateral con-
ventional radiograph views. Images were reviewed by a
third independent, blinded fellowship-trained foot and
ankle surgeon. Fracture displacement was measured and
incidence of nonunion at final follow-up was recorded.
We also evaluated visual analog scale (VAS) for pain at
8 and 12 weeks, American Orthopaedic Foot & Ankle
Society (AOFAS) midfoot score at 8 and 12 weeks, and
time to return to prior level of activities.
Statistical Analysis
Raw data was analyzed using JMP14.0. Continuous vari-
ables were evaluated for normality using the Shapiro-Wilk
test. Normally distributed variables were compared using
independent t tests, and non-normally distributed variables
were compared using Mann-Whitney U and chi-square
tests. Categorical variables were compared using Fisher
exact tests. A multivariate regression analysis was also per-
formed to evaluate which variables significantly influenced
the time to return to activities. P values of less than .05 were
considered significant.
Results
Age and gender distribution were similar in patients treated
with either the CWB or HSS (P = .23 and P = .57, respec-
tively) (Table 1). Both groups showed similar fracture dis-
placements (P = .26). Mean fracture displacement in HSS
and CWB patients was 1.9 and 1.6 mm, respectively.
Patients treated with CWB had slight, but statistically
significant, faster mean radiographic healing times as
compared to those treated with HSS (P < .0011), with
CWB averaging 7.2 weeks and HSS averaging 8.6 weeks
(Table 1). Of all groups, only 1 case demonstrated radio-
graphic nonunion after 12 weeks. The case was an
18-year-old patient without comorbidities that had been
Nishikawa et al 3

Table 1.  Demographic Data and Radiographic Results.a

Fracture
Group Patients, n Gender, n Mean Age, y Displacement, mm Healing Time, wk Nonunion, n
HSS 33 24 F / 9 M 37.8 (31.4, 44.2) 1.9 (1.6, 2.2) 8.6 (7.9, 9.4) 0
CWB 39 32 F / 7 M 44.3 (38.4, 50.2) 1.6 (1.3, 1.9) 7.2 (6.5, 7.9) 1
P .57 .23 .26 <.001 .54

Abbreviations: CWB, CAM (controlled ankle motion)–walker boot; F, female; HSS, hard-soled shoe; M, male.
a
Generated by Fisher exact Mann-Whitney U test. Values within parentheses are 95% confidence interval.

Table 2.  Clinical and Functional Outcomes of Both Groups for Time to return to prior level of activities was comparable
the Visual Analog Scale for Pain in 8 and 12 Weeks.a between both groups (P = .11). Patients treated with HSS
Group VAS Score, 8 wk VAS Score, 12 wk immobilization returned to activities after an average of 9.7
weeks and those treated with a CWB returned after an aver-
HSS 0.8 (0.4, 1.2) 0.2 (–0.2, 0.6) age of 8.3 weeks (Table 3). Multivariate regression analysis
CWB 1.3 (0.8, 1.8) 0.2 (–0.0, 0.8) showed that healing time and VAS score at 12 weeks were
P .34 .87 the only factors that significantly influenced time to return
Abbreviations: CWB, CAM (controlled ankle motion)–walker boot; HSS, to prior level of activities (P < .001).
hard-soled shoe; VAS, visual analog scale.
a
Generated by Mann-Whitney U test. Values within parentheses are 95%
confidence interval. Discussion
Avulsion fracture represents a relatively common injury of
Table 3.  Clinical and Functional Outcomes of Both Groups for the fifth metatarsal accounting for up to 93% of all fractures
the AOFAS Midfoot Score in 8 and 12 Weeks, and Return to of the base of the fifth metatarsal.3,7 Different nonoperative
Activities. treatment options have been described in the literature.
However, few studies have compared the success rate of
AOFAS Score, AOFAS Score, Return to
Group 8 wk 12 wk Activities, wk each treatment modality.5,9-11 To our knowledge, the present
study is the first to report a formal comparison between the
HSS 90.6 (87.8, 93.4) 98.6 (95.8, 101.4) 9.7 (8.3, 11.1) radiographic and clinical outcomes of HSS and CWB for
CWB 88.6 (84.7, 92.5) 97.7 (93.8, 101.6) 8.3 (7.0, 9.6) the treatment of zone 1 fractures of the fifth metatarsal. We
P .83 .79 .11 used similar retrospective cohorts with no significant differ-
Abbreviations: AOFAS, American Orthopaedic Foot & Ankle Society; ences in patient age, gender distribution, or fracture dis-
CWB, CAM (controlled ankle motion)–walker boot; HSS, hard-soled placement, thereby minimizing selection biases. Our study
shoe. found that patients treated with CWB had slight, but statisti-
a
Generated by Mann-Whitney U test. Values within parentheses are 95% cally significantly quicker, rates of radiographic healing as
confidence interval.
compared to those with HSS. However, both treatment
options demonstrated similar clinical results for VAS pain
treated in a CWB and was clinically asymptomatic after scores, AOFAS midfoot score, and time to return to prior
24 weeks. level of activities.
At 8 weeks, patients in both HSS and CWB groups dem- HSS is a less restrictive immobilization compared with
onstrated similar VAS for pain, with an average of 0.8 and the CWB that offers the potential advantage of providing
1.3, respectively (P = .34) (Table 2). AOFAS scores at 8 more patient comfort without limiting tibiotalar mobility. A
weeks were not found to be significantly different between few case series have reported satisfactory radiographic heal-
groups, with an average of 90.6 for patients treated with ing and clinical outcomes when using less restrictive immo-
HSS and 88.6 for patients treated in a CWB (P = .83) bilization for treatment of zone 1 fifth metatarsal fractures.
(Table 3). Clapper et al1 treated 68 military patients that sustained the
After 12 weeks, no significant differences in VAS for fracture with an HSS or a short-leg cast and allowed weight-
pain were observed between groups. HSS patients aver- bearing as tolerated. They reported that all fractures healed
aged 0.18, whereas CWB patients averaged 0.23 (P = .87) in an average of 4.7 weeks and all patients were able to
(Table 2). Similarly, there were no significant differences resume full active military service. Although these authors
in AOFAS scores between HSS and CWB groups at 12 used immobilizations with different rigidities, a comparison
weeks, with averages of 98.6 and 97.7, respectively between both treatment modalities was not performed and
(P = .79) (Table 3). clinical outcomes were not measured.1 In another study,
4 Foot & Ankle International 00(0)
Egol et al4 reported a series of 49 patients with zone 1 frac-
tures treated with HSS and early full weightbearing as toler-
ated. They found that 83% of fractures were radiographically
healed by 12 weeks, that all patients were asymptomatic
after 12 weeks, and that patients lost an average of 22 days
of work. Out of 49 patients, 42 (85%) could return to their
preinjury functional status after 6 months, and by 1 year all
patients returned to previous activities.4
Our results are in agreement with these studies regarding
satisfactory outcomes for radiographic healing when treat-
ing patients with less restrictive immobilization. Out of all
patients treated with either an HSS or CWB, 98.6% (71/72
patients) achieved radiographic union. One hundred percent
of patients (33/33) treated with the less restrictive HSS, and
97.4% of patients (38/39) treated with the CWB, achieved
complete radiographic union. Furthermore, we found that
patients treated with the CWB had slight, but statistically
significant quicker rates of radiographic healing when com-
pared to the HSS, with average healing times of 7.2 weeks
with the CWB and 8.6 weeks with the HSS. However, the
difference between 7 and 8 weeks may not be important
clinically. Another important aspect to be mentioned is that
we performed more frequent radiographic imaging of the
treated patients aiming to assess the comparative rate of
radiographic union. Our conventional radiographic follow-
up is usually performed at 6 and 12 weeks following the
injury. One could hypothesize that if the conventional time
points were used, no difference in the rate of radiographic
healing would have been noted.
Results from Clapper et al1 have suggested that use of
less rigid immobilization devices may result in improved
clinical outcomes, such as faster pain relief and earlier
functional recovery, when compared with more rigid
devices.2,5,8,10,11 However, our results do not support these
conclusions. We identified no significant differences between
groups regarding pain relief or return to the same preinjury
level of activities. With respect to clinical and functional
outcomes, patients treated with an HSS had similar results
for VAS and AOFAS scores when compared to the CWB
group. This finding may be explained by the fact that all
patients were allowed full weightbearing from the first day
of treatment, and that patients treated with the CWB were
directed to remove the boot and mobilize the ankle, subtalar
joint, and toes on a daily basis.
Patients with zone 1 fractures of the fifth metatarsal base
are known to experience limitations in their ability to work,
perform daily activities, and engage in sports. Studies have
suggested that less rigid immobilization yields earlier return
to full activity. Wiener et al11 reported the results of 60
patients treated with either a short-leg cast, or soft dressing,
and full weightbearing as tolerated. Patients with the soft
dressing returned to their preinjury level of activities within
33 days while those with the short-leg cast took 46 days.11
Shahid et al10 compared treatment with aircast walking boot
and bellow-knee walking cast. Employed patients took a
mean of 35.8 days off work. Out of 39 patients in the study,
the time taken to return to work was lower in those treated
with the boot (31.5 days) as compared to those with the
short-leg cast (39.2 days).10 In the present study, we did not
find a significant difference between groups regarding time
to return to previous level of activities. Those treated with
an HSS and CWB required an average of 68.1 days and 58.3
days to return to similar activity levels, respectively. This
supports our finding that treating fifth metatarsal zone 1
fractures with less restrictive immobilization, such as HSS
does not necessarily lead to increased rates of pain relief or
earlier return to the same level of function before injury.
However, it is our impression that less restrictive devices
have the practical advantage of increasing patient comfort
and functional independence.
As opposed to other studies, we defined time to return to
previous activities as the time required for patients to make a
full recovery (defined as return to work and routine physical
activities). This definition may have induced some degree of
bias, as study participants held varied occupations with differ-
ent company policies and some patients were not permitted to
return to work with an HSS or CWB. Despite this definitional
nuance, the results of the current study are supported by previ-
ous reports where treatment with HSS led to complete clinical
and radiographic recovery.1,4 Interestingly, we found that nei-
ther the amount of fracture displacement nor treatment type
(HSS vs CWB) influenced time to return to prior level of
activities. The only 2 variables that were found to correlate
with time to return to prior level of activities was healing time
and VAS scores at 12 weeks follow-up.
Hunt et al6 studied contact and peak pressures at the base
of the fifth metatarsal in 3 different footwear devices:
walker boot, HSS, and running shoes. They concluded that
there was a significantly less contact and peak pressure in
the walker boot compared with the HSS. In our study, we
found a slight, but statistically significant quicker rate of,
radiographic healing with the CWB as compared to the
HSS. As suggested by previous studies,7 this difference
could be explained by decreased pressures in the CWB,
indicating that the additional protection offered by the CWB
may impact the rate of bone healing. However, we note that
this difference may not be clinically relevant.
One of the strengths of this study was that it compared
outcomes of 2 equivalent cohorts (with similar gender, age,
and fracture displacement) treated with immobilization
devices with different rigidities. Patients were followed
closely with clinical and sequential radiographic examina-
tions until they were fully asymptomatic and able to return
to their previous activities. The main limitation of our study
was its retrospective design. The fact that patients presented
with wide ranges of age and activity levels within each
cohort may have also influenced our outcomes. However,
no statistically significant differences were observed
Nishikawa et al 5
between groups regarding demographic data or fracture
characteristics. Another important limitation is the fact that
we have used a convenience sample of consecutive patients
treated in our hospital from March 2014 to November 2018,
and no formal power analysis was performed, which might
have underpowered our study to demonstrate minor varia-
tions in patient responses to treatment.
In conclusion, the results of our study support the asser-
tion that zone 1 fractures of the base of the fifth metatarsal
can be effectively treated either with an HSS or a CWB.
Both treatment modality was equivalent in terms of clinical
outcomes, functional outcomes, and return to previous level
of activities. However, radiographic fracture healing was
slightly quicker in CWB.
Author Note
This work was performed at the Hospital do Servidor Público
Municipal de São Paulo (HSPM), Department of Orthopedics.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this arti-
cle. ICMJE forms for all authors are available online.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iDs
Danilo Ryuko Cândido Nishikawa, MD, https://orcid.org/
0000-0003-0227-2440
Guilherme Honda Saito, MD, https://orcid.org/0000-0002
-1211-9258
Cesar de Cesar Netto, MD, PhD, https://orcid.org/0000-
0001-6037-0685
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