Has surgery become the default approach for fifth metatarsal stress fractures—and should it be?

In this episode of the Podiatry Today Podcasts, Dr. Jennifer Spector welcomes back Dr. Patrick DeHeer, President of the American Podiatric Medical Association, to revisit the ongoing debate surrounding operative versus non-operative management of fifth metatarsal stress fractures.

The conversation takes a fresh turn with discussion of a 2023 randomized controlled trial comparing intramedullary screw fixation to high-energy shockwave therapy in competitive athletes. With similar healing rates, functional outcomes, and complication profiles—and even a faster return to play in the shockwave group—the findings challenge long-standing assumptions about surgical necessity.

Dr. DeHeer also provides critical context around study limitations, patient selection, and real-world barriers such as insurance coverage and access to advanced therapies. He shares practical insights on when surgery may still be appropriate, particularly in elite or highly active patients, and emphasizes the importance of long-term strategies like lateral column offloading to reduce refracture risk.

Key topics include:

Surgery vs non-surgical management of fifth metatarsal stress fractures

Shockwave therapy as an emerging alternative to fixation

Evidence from RCT data in athletic populations

Patient selection and real-world treatment considerations

Preventing recurrence through biomechanical offloading

This episode is essential listening for clinicians navigating evolving evidence in stress fracture management.

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