It may be one of the body's smaller bones, but yet again there is an awful lot hanging on the humble metatarsal. This bone in the foot can destroy the dreams of the money-making machines that are professional footballers. More specifically, it is now playing a decisive role in the chances of England achieving any success in this year's World Cup.
As if the Football Association hadn't already had enough trouble last week, with the farcical search for the replacement for Sven Goran Eriksson, the Big Phil Affair has now been overtaken by the Affair of Wayne Rooney's Fourth Metatarsal.
When Rooney collapsed in agony on Saturday after a tackle during the final stages of Manchester United's 3-0 defeat by Chelsea, the 'Ere we go, 'ere we go chants of the home supporters in eager anticipation of a second successive Premiership title were soon muffled by the nation's collective gasp of 'Ere we go again at the spectre of one of England's star players decked by a broken metatarsal just a few weeks before the biggest tournament of his career.
The sense of déjà vu among football fans - as well as those with only a passing interest in the game - was verging on the incredulous. This was almost identical to the injury that struck down captain David Beckham three months before the last World Cup in 2002 and which, he later admitted, led to his unfitness during the tournament.
It was a broken metatarsal that led to Rooney himself dramatically limping off during England's quarter-final match with Portugal at Euro 2004, which the latter eventually won. And it is a metatarsal injury which has kept Michael Owen, the other key English striker, off the pitch since he broke it during a match on New Years Eve; he returned on Saturday but admitted being "not 100 per cent sure" about the match-readiness of his foot.
But they are not the only England players to be affected by metatarsal injuries over the past two or three years - Gary Neville, Steven Gerrard, Ashley Cole, Ledley King and Danny Murphy have all suffered, as well as other footballers such as the former Manchester United captain Roy Keane and the Arsenal and France defender Gael Clichy.
Metatarsal breaks now account for more than a third of all foot fractures among footballers. So, the questions now inevitably arise: exactly what is the metatarsal, a bone few people outside the readers of Gray's Anatomy had heard off until a few years ago? And why is it doing this to us?
To fully understand the metatarsal, it is necessary to move beyond the simplicities of the children's rhyme about "the leg bone connected to the knee bone, and the knee bone connected to the thigh bone...."
There are, in fact, five metatarsals. They connect the bones of the ankle to those of the toe and are numbered from the first, which links to the big, to the fifth, on the outer foot, which links to the little toe. Each have their own individual characteristics, which affect their liability to injury and the way they recover from damage. So the injuries suffered by Rooney, Beckham et al are all actually different in cause, effect and recovery.
Collectively, said Professor Angus Wallace, an orthopaedic surgeon and former chairman of the National Sports Medicine Institute, the metatarsals form a "sort of springboard" within the foot, which help it bounce up and down as we move around.
The first, second and fifth metatarsals are the ones most prone to injury. The first is shorter and wider than all the others and is thought to bear up to one-third of our body weight; a fracture almost always requires surgery but fortunately, none of the recent metatarsal injuries involving football players have affected the first.
The second and third metatarsals, the longest and narrowest respectively, as well as the shaft of the fifth metatarsal, are the ones most likely to succumb to a stress fracture - that is one that is the result of a process of wear and tear.
It was a fracture of the second that was suffered by David Beckham in April 2002 and which first really woke the football world, and the rest of the country, up to metatarsals, so to speak; never before have X-rays of a footballer's feet loomed so large on the front pages of national newspapers. It put Beckham out for nine weeks, undermining his performances during the World Cup, particularly when playing in the crucial Brazil match.
Although Rooney's damage is to his fourth, Professor Wallace believes that stress on the bone may have played its part: "I think the reason why we appear to be seeing more metatarsal fractures than we did going back 15 years or so is that footballers train and play a lot more than they used to. This means that bones becomes stressed with constant use and then suddenly the stress becomes too great for the bone to bear and it gives way. That may be what has happened to Rooney. It would be interesting to know if he has complained of any soreness in that foot over the last game or so."
One plus factor for Rooney is that the inner three metatarsals - the second, third and fourth - are helped in recovery from injury by the "splint effect" of the bones to each side of them. Additionally, Rooney's fracture is to the base of the bone, which is known to heal quicker than the stem. Treatment is likely to be a combination of rest, ice packs, strapping and the specialised Aircast boot that Beckham used in 2002.
The balance of medical opinion yesterday seemed to be that Rooney could be back within six weeks, aided by his youth - young bones heal quicker - and evident fitness, although as Professor Christopher Bulstrode, clinical reader in orthopaedics at the University of Oxford, said, to play him so soon after injury would be a calculated gamble: "It's going to be a very, very close call."
It appeared to be a risk Sven Goran Eriksson, the England manager, was prepared to take, when he said yesterday that Rooney would definitely travel to Germany, although the question of whether he will play in the opening matches - against relatively weaker opponents - must be open to debate, particularly since he will have been unable to take part in most training to keep his general level of fitness up to par. A matter of a few extra days for recovery could be crucial, said experts.
And so to the fifth metatarsal - the one Rooney broke in Portugal that kept him out of action for 14 weeks; it's the same bone that has led to the long-term absences of Clichy and Owen.
"It is the really problematic one," said Professor Wallace. Stress fractures of this bone are common among athletes, ballet dancers and soldiers. "It was known as the 'march' fracture during the First World War because it was caused by soldiers marching everywhere and was enormously important.
"Some soldiers who suffered from it were shot as deserters," said Professor Bulstrode.
Fifth metatarsal fractures are often slow to heal because the break can disrupt the blood flow while the treatment often involves surgery to screw the bone together, while the foot is then covered with a cast.
However, the surgery is prone to failure and long-term recovery can be slow.
The causes of all this metatarsal madness remain complex. Some believe it is a simple consequence of the greater demands placed upon elite athletes: "They are being asked to do things, like run on studs, for which the knee, ankle and foot was never designed. But if you take the studs away, they move slower and there is less spectacle for the public," said Professor Bulstrode. Both he and Professor Wallace take the view that the new lightweight and flexible boots which have been introduced over the past few years have contributed to the problem by providing less protection and rigidity for a player's foot.
Professor Wallace believes other factors come into play that add to the likely stress suffered by the foot bones: "As well as the amount of football being played, a lot of training now takes place on artificial surfaces. These are associated with higher impact and low shock absorbency."
But he said that all theories as to the rise of the metatarsal injuries remained unproved: "There is no real scientific basis for this, it's very very difficult to prove."
Clearly, there are scientific grants for the taking here. But the outcome of any proper research is unlikely to come soon enough for Rooney, as he rests up in his mansion, while his partner, Coleen McLoughlin, goes out shopping for a nice Burberry cover for the ice pack on his foot and the nation keeps its fingers crossed.
And only six weeks to go....
A nightmare for Nike?
By Geneviève Roberts
Wayne Rooney had hoped to celebrate his first match wearing a new set of Nike football boots by finding the net.
"Hopefully I can mark the occasion with a goal but knowing me, I will probably score with a header," he said. As it turned out, his first appearance in the Total 90 Supremacy will have sent shivers down the spine of every Nike executive.
The impact of the injury on Rooney's various sponsorship deals remains unclear, but if he fails to appear in the World Cup, a number of big companies are going to feel extremely short-changed. Rooney is, after David Beckham and Ronaldinho, estimated to be the highest earning football player in the world, with a total value of more than £30m.
As well as the Nike contract, worth several million, he has lucrative deals with Nokia, Ford and Coca-Cola, the latter leading to his picture featuring on more than 500 million Coke cans. In March, he signed the largest sports-book deal in history with Harper Collins - £5m for a minimum of five books over 12 years.
Nike says Rooney has played an extensive role in developing the boots over the past two years, testing prototypes and training with revised versions to provide feedback.
The contoured boot was designed to generate power and accuracy and to enhance Rooney's striking power, like all the boots favoured by the professionals. The boots, which go on sale to the public from 1 June, cost £120. But whether they will sell out after yesterday's nightmare debut is far from certain.Reuse content