Metatarsal stress fractures, resultant from increases in load due to altered mechanics of the foot, occur most frequently in athletes but also in patients with diminished function of the first metatarsophalangeal joint, neuropathy, metabolic disorders, and hindfoot malalignment. Diagnosis depends on a careful history and physical examination, with select use of imaging techniques. Nonoperative treatment usually is successful, but surgery (partially threaded cancellous screw with overdrilling of the fracture site to stimulate healing) is recommended for the athlete with a fifth metatarsal stress fracture or the nonathlete with a Torg-type-II or III injury. Malalignment or instability of the foot or ankle must be addressed at the time of surgical treatment.