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Thursday, December 8, 2022

Sesamoid Injury: Email Advice

Dr. Blake -

     On October 24th I was doing a tempo run as part of my half marathon training when I noticed my left foot hurting (on top) I took a week off and thought it to heal but it still hurt. I went to get an x-ray which revealed a clear break in my sesamoid bone.

Dr. Blake's comment: The sesamoid fracture should give you only pain when it first presents under the big toe joint.  I am assuming the examination showed pain under the sesamoids. 

     They gave me a CAM boot and said wear for 6 weeks and scheduled an mri to confirm it. 3 weeks after I got the boot I had the mri which confirmed the break. They said they want me in s boot for 12 weeks.

Dr. Blake's comment: So far, the advice is sound. The boot should be worn with an EvenUp on the other side. If there is pain in the boot over 0-2, you have to wear off weight bearing padding to shift the weight lateral. Also, this is the time to cross train with stationary bike, swimming, etc (just no impact). Also, winter stress fractures always have me concerned about Vitamin D deficiencies, so please have it checked.  

     I am on week 6 and it seems to hurt worse than it did at first. I am an avid runner and exerciser and I feel like I am losing my mind. They mentioned most likely me having to have my sesamoid removed. I want to try anything to avoid this. I am current in a post op hard soled shoe and want to know if I am doing everything I can to heal in the next 8 weeks. ANy advise would be greatly appreciated. I can pay you and can send over my x ray if needed.

Regards,

Dr. Blake's comment: Yes, you can send xrays and MRI to Dr.Richard Blake, 900 Hyde Street, San Francisco, California, 94109. Why are you not in a CAM walker now? Have they designed off weighting orthotic devices for you which can be worn in the boot? Boots can cut off the circulation, and sometimes patients wear too much (only need for walking). Is there alot of swelling, which can give you pain? Send a photo to the rlb756@gmail.com of the top and bottom of your foot. You can see if contrast bathing, usually very helpful, soothes the foot. Start with one minute hot and one minute cold water and rotate up to 20 minutes each evening. No surgery considerations until after you have had 9 months of Exogen bone stimulator for a non healing fracture. Typically repeat MRI at the 6 month interval, although 3-6 months are considered okay. I like to wait as long as I can, but sometimes we need to know sooner. Hope this helps. You have create that constant 0-2 pain level if you are going to predictably heal well. 

Patient answered:

Thank you so much!!! I can’t find anyone in my area that seems to be experienced with this break. They all say surgery most likely. The CAM boot hurt other areas of my foot and my opposite hip. It’s so heavy, I haven’t been fitted for orthotics as I’m not even sure where to start. I don’t really have much swelling and it looks a little bruised on the top of the ball of my big toe. I’ll send my records to you. I will also post this on your site.

Dr Blake's response: Try this local Podiatrist who is a member of our national sports academy, the AAPSM. 

David E. Linde, DPM205-445-0661One Independence Plz. #530BirminghamAL35209
Also, try bike shoes with embedded cleats instead of the boot to immobilize. 

Wednesday, December 7, 2022

Sesamoid Injury: Email Advice

Hi Dr. Blake,

I have been managing my sesamoiditis since August, from an injury sustained 
in April due to 10k training. Initially diagnosed as arthritis until I saw 
a podiatrist in August who diagnosed sesamoiditis after x ray. By October I 
was in a boot without orthotic and improving, but unfortunately my 
podiatrist encouraged me to get out of the boot and go back to normal shoes 
with tape without a wean out period, and pain returned by Thanksgiving to a 
5-7 pain scale. I discovered your blog at the end of November, and have 
been doing boot (used felt to offload sesamoid) constantly, contrast baths 
BID, icing BID, and had some custom orthotics made to offload the sesamoid.

I decided to get a second opinion from an orthopedist, who took some x rays 
and found no fractures in my sesamoid itself, but that I had a stress 
fracture in the middle part of my navicular bone of my foot. He assures me 
this is unrelated to my sesamoiditis. The navicular area itself doesn't 
hurt. I wanted to see if you have ever heard of a navicular stress fracture 
causing sesamoid problems. I'm currently maintaining a 2-4 pain at my 
sesamoids and am hoping to start transitioning into shoes with orthotics 
next week when my pain is at a 0-2.

Any perspective you can offer would be valued.

John (name changed)

Dr Blake's comment: John, thanks for reaching out. There is no obvious connection, and the navicular diagnosis is suspect due the lack of pain in that area. Sounds like you are doing well. Make sure you experiment with cluffy wedges and spica taping as you attempt to leave the boot behind. I also recommend Hoka shoes for their rocker platform at least as a part time shoe. Rich 

Tuesday, December 6, 2022

Comparing Child's Shoe Sizes to Women's Shoe Sizes

https://www.hibbett.com/expert-advice/how-to-convert-womens-to-kids-shoe-sizing.html

Dr. Rue Tikker demonstrating Foot Manipulations

https://youtu.be/TYMdab8ITi4

     Dr Rue Tikker practiced Foot Manipulation. He taught his Podiatry Partner Dr. Timothy Shea, who then taught Podiatry Students at the California College of Podiatric Medicine. I use some of these manipulations (called Grade 5 Mobilization) in my practice 40 years later. I thank Dr. Eddie Davis for finding this old video. 

More about Dr Timothy Shea

Monday, December 5, 2022

Heel Raises: So Important for Seniors and Overall Health

https://youtu.be/0r6w8K6ckQk

     This video highlights one of the two most important exercises in the lower extremity and is well done. The end of the video discusses negative heel positions and this is where I would differ as I prefer to have my patients stay away from negative heel positions. However, the logical progression to this video of gradually adding more difficulty is wonderful. The goal standard in sports medicine is 25 single leg heel raises, and the video shows you how to get there. The video also does not delve into the complexity of separating the gastrocnemius and soleus muscles, but again it is a great starting place. You want to gradually, probably on a weekly basis, add 2 more repetitions from her starting point of 1 set of 5 repetitions. Work your way through two sided heel raises, to two sided up and one down, to single sided (one up and down). Have fun getting your achilles tendons stronger. 

Sunday, December 4, 2022

Accessory Navicular: Excerpt from Book 2: Practical Biomechanics for the Podiatrist

The following is an excerpt from Chapter 6 of Book 2: Practical Biomechanics for the Podiatrist

https://store.bookbaby.com/book/practical-biomechanics-for-the-podiatrist1



Accessory Navicular Syndrome

 



CT scan image of an Accessory Navicular

 

     The accessory navicular is part of the navicular bone, a second ossification center, that never fuses with the main part of the bone. It starts to form around 8-9 years old and is fully formed no later than 16 years old. 10% of your patients will have them and 30% of those will have them on both sides. The prominence caused by this accessory bone has been called the second ankle bone, os tibiale externum, or os navicularis. When they begin to hurt, it is important to actively treat, as a percentage will need surgical removal. The pain can be from the the posterior tibial tendon attachment, from the junction of the accessory and main part (either syndesmosis, synchondrosis, or synostosis), from obvious shoe pressure like from a bunion deformity, or from symptoms arising from the arch collapse. One of the main reasons the medial arch stays strong is the incredible anchoring of the posterior tibial tendon first into the navicular and then spreading out plantarly across the midfoot. If you disrupt this in any way, by having a small amount of the posterior tibial tendon diverted into the accessory bone instead, the foot can strain to hold up the arch and pain ensues. A definite weak spot is created.

     To tie this into Chapter 3 and 4 on gait and biomechanical examinations, when a patient presents with accessory navicular syndrome,  the most important examinations to do in 10 minutes (or 20 minutes) are:

       Signs of Excessive Pronation and Medial Column Overload

       Medially Deviated STJ Axis

       Functional Hallux Limitus

       Posterior Tibial Strength

       RCSP

       AJ Dorsiflexion

 

Common Mechanical Changes for Accessory Navicular Conditions (with the common ones in RED)

  1. Cam Walker with or without Crutches in the Immobilization Phase
  2.  Inverted Orthotic Devices or another high medial support Orthotic Device (like the Mueller PTTD device)
  3. Circumferential Taping with a Hole Cut Out for the Prominence
  4. J Strap with Leukotape for Pronation Control
  5. Progressive Posterior Tibial Strengthening Program
  6. Metatarsal Doming and Single Leg Balancing
  7. Strengthening of the 2 Long Flexors
  8. 2 Positional Single Leg Heel Raises
  9. Off Weighting of the Prominence (including shoe modifications)

 

     Cam Walker with or without Crutches in the Immobilization Phase may be your first treatment. Its mechanical function is in immobilization. If you suspect this problem, you need to err on the conservative side since the problem can lead to surgery if correctly or incorrectly treated. Any patient who first presents with a problem in my practice, that may need a surgical intervention, raises my red flags. You do not know how the injury is going to turn out. Usually looking at the prominence at first sight, before you take x- rays, you are going to know that you are dealing with an accessory navicular (or gorilloid navicular), and that some of these will require surgery. My goal is to get the patient to level 2 pain as quickly as possible on a consistent basis. If that requires a boot and time off work to drive the pain to 0-2, so be it. The goal is to create an environment that will allow them to heal. The crutches may be necessary initially as I experiment with tape, design an insert for the boot, or work on their inflammation. It is important to remember an EvenUp when you use a Cam Walker.

 



Here an EvenUp slips over the side not being immobilized to level the hips some

 

Practical Biomechanics Question #302: 3 patients present with accessory navicular pain with 3 different scenarios. Match the pain with the Phase of Rehabilitation.

  1. Pain walking each step
  2. Pain only when attempting to run
  3. Pain only at 3 miles into running

 

     Inverted Orthotic Devices or another high medial support Orthotic Device (like the Mueller TPD Foot Orthosis) is crucial quickly to stabilize that medial column. Their mechanical function is in reducing pronatory forces on the injured tissue. I am not an advocate of pre-fabricated orthotic devices for children who present with this problem regularly. If a growing child needs an orthotic device, I feel it should be designed for them as exactly as possible. Since most patients who present with significant problems from accessory navicular are juveniles, I discuss with the parents why we have to protect them, even if surgery is needed. I discuss that the presence of this problem will be a weak spot their entire lives and custom support is so crucial. In my book entitled “The Inverted Orthotic Technique” I discuss how this is prescribed.

 





This shows the high medial column support from an Inverted Orthotic Device

Practical Biomechanics Question #303: How much inversion is placed into an Inverted cast to change the foot position one degree?

 

     Circumferential Taping with a Hole Cut Out for the Prominence is typically made from kinesio tape or RockTape perhaps 12-14 inches long and 2 inches wide. Its mechanical function is in light immobilization and support of the injured tissue. Before the tape is placed on the foot, and even without the backing removed, about 1 inch from the start a one inch diamond is cut in its center. The backing is then removed. The one inch diamond cut is placed over the medial prominence as the tape is applied gently over the dorsum of the foot from medial to lateral. When you get to the plantar surface of the foot, the tape is now pulled with “some force” from lateral to medial and up back to its origin and a little further usually slightly more distal (not an exact overlap so it grabs more skin). This type of tape needs to be rubbed in for a minute to activate the glue. You have to play with the tension implied by “some force.” The patient can learn this skill and the tape typically lasts 3-4 days.

 



Leukotape J Strap to create supination moments placed on with the foot slightly inverted and the Coverall protects the skin

 

     J Strap with Leukotape for Pronation Control is the most powerful way of taping for posterior tibial problems, including accessory navicular issues. Its mechanical function is in reducing pronatory moments across the injury and slightly immobilizing. Leukotape is by far the strongest tape I use. It is so strong, it has to have a layer of material called “Coverall” applied to the skin first. No Leukotape should ever touch the skin. Leukotape and Coverall are typically sold together with the Leukotape slightly narrower. Both types of tape of course are applied with the same pattern and it is called a “J Strap”. Occasionally, I tell patients to use 2 layers of Coverall overlapped by 50% to make a wider base to place the Leukotape on with. The tape is started just under the lateral malleolus and brought down and under the heel with no tension, then the foot is slightly inverted to neutral subtalar joint, and the tape is brought up medially over the accessory navicular and up at least 18 inches up the leg. The longer up the leg, the more you are spreading the force to stabilize over a bigger area. Again, like the circumferential taping, this tape should last 3-4 days before being removed. You typically remove it at night, so that you can rest your skin, and re-apply in the morning. It can be used in all of the Phases of Rehabilitation, with some of my recovered patients still using it for long backpacking trips months later.

 

Practical Biomechanics Question #304: Explain why some immobilization of the ankle is needed at times for an accessory navicular problem.

 



Resistance Bands exercise to isolate the posterior tibial tendon with inversion and ankle plantar flexed

 

     Progressive Posterior Tibial Strengthening Program is part of the Re-Strengthening Phase of this injury and vital to its success. Its mechanical function is to strengthen the posterior tibial fibers attaching into the navicular stabilizing the area. Chapter 11 (Book 3) will go through the aspects of strengthening for injuries, so I will just make three points here I want to highlight. First, the goal with all accessory navicular patients, is to progress them to 2 sets 25 repetitions at Level 6 resistance band. This can take months to accomplish so the health care provider has to be clear with the patient that even if they do not hurt, if they remain technically weak, that they can break down again. Second, the posterior tibial nerve which runs right next to the posterior tibial tendon, can make the exercises hurt. I always tell a patient if an exercise hurts they could be hurting themselves. This does not seem to include many patients strengthening their posterior tibial tendon. So, you have to have them do the exercise, and if there is no problem within the first 2 days, have them continue. For that reason, I have them strengthening the posterior tibial tendon every other day initially to check their response. And third, if you rely on anyone else to show your exercises, always check at the first visit. The posterior tibial tendon is strengthened with the ankle plantar flexed (pointed) and the foot inverted (abducted). Over half the time when I check the patient is not doing the exercise correctly.

 

Practical Biomechanics Question #305: What tendon are you strengthening if the foot is inverting against resistance, but the ankle is in neutral to dorsiflexed?

 

     Metatarsal Doming and Single Leg Balancing have both been described multiple times, including the last section on Cuboid Syndrome. Their mechanical function is to stabilize the injured area with muscle strength increases. Typically, with accessory navicular patients, metatarsal doming can be started immediately to keep the foot intrinsics in tone. The Single Leg Balancing is quite jerky and added at the end of the Re-Strengthening Phase or early in the Return to Activity Phase. You typically want the patient at Level 4 or 5 of the resistance bands before starting single leg balancing to ensure that they are strong enough.

 



Single Leg Balancing with Light Touch on Door Frame

 

     Strengthening of the 2 Long Flexors is basically to help the posterior tibial tendon in its ankle plantarflexion and inversion functions, and probably some with arch support. Its mechanical function is to strengthen agonist muscles to the posterior tibial tendon. The posterior tibial tendon, along with the 2 long flexors, run alongside each other under the laciniate ligament under the medial malleolus. They have shared functions, so our strengthening should take some strain off the medial tissues. The classic toe curl exercise, where you build up to 100 curls of the toes as you grab the towel and pull it backwards, is a perfect way to strengthen the two tendons.

 



This is a common gym version where a Bosu Ball is used to balance on single and double legged. The toe flexors can be activated as you lean forward and try to maintain your balance.

 

     2 Positional Single Leg Heel Raises is one of the most powerful exercises you can prescribe and an important monitor of the success of a patient. Their mechanical function is to strengthen the foot and ankle taking stress off the injured area. The ability to do 25 straight knee (gastrocnemius) single heel raises and 12 bent knee (soleus) single heel raises is an indicator of the health of the tissue. However, it is more for the Return to Activity Phase, or later aspects of the Re-Strengthening Phase of Rehabilitation. When the patient presents with accessory navicular syndrome, the testing of whether they can perform a Single heel raise on that side is crucial. It has to be painless. As soon as your heel lifts from the ground, in the next ¼ of an inch of heel rise, the posterior tibial tendon will pull hard on the navicular to assist that heel raise. It is an important overall exercise as the gastrocnemius and soleus supinate the subtalar joint strongly, but it is also an important exercise to sense the strength or frailty of the accessory navicular complex with the posterior tibial tendon.

 

Practical Biomechanics Question #306: What muscles/tendons will help a weak achilles tendon to lift the heel off the ground (any of these structures can be injured because of this)?

 

     Off Weighting of the Prominence (including shoe modifications) is of course really common in ice skaters when they make custom boots and downhill skiers. Its mechanical function is to off weight the sore area. From the age the accessory navicular completely forms, they can become shoe fit nightmares or at least projects. Besides the shoe fitters tasks, on a daily basis the patient may need the use of some ¼ inch adhesive felt to off weight the prominence. The two common ways are 1) a one inch square piece above or proximal to the prominence, and 2) an “upside down smile” making a tent around it, but as close to it except plantarly. This usually is only needed for shoes which seem to bother it. I tell my patients, like my bunion patients, if they remove the shoe at night and the tissue is red at all, the habit of protecting it in those shoes should begin.

 

Here a double layer of ¼ inch adhesive felt is applied proximally in the shoe to off weight the sore point.

News about Our Biomechanics Seminar Just Held from the VA system


Western Foot and Ankle Seminar dates set: June 22-25, 2023


Dr Jack Reingold and myself seem to be the face of the Western Foot and Ankle Conference this coming June 22 to 25th, 2023. Quite fun!!

Saturday, December 3, 2022

Taking A Good Biomechanical History: Excerpt from "Secrets to Keep Moving"

 Biomechanical Approaches to Treating Pain

 This is the start of Chapter 1 from the book "Secrets to Keep Moving" about taking a good history (or giving one).

Golden Rule of Foot:  With so many pain syndromes having a mechanical component, it is important to treat painful areas with mechanics in mind.

The topics included in this chapter are:

  1. Taking a Good Biomechanics History (which is the topic of this blog post)
  2. Understand the symptoms related to pain syndromes of 5 Common Mechanical Problems
  3. General Principles for Foot Orthotic Devices
  4. Treatment of Short Leg Syndrome
  5. Hannaford Devices for Shock Absorption and Memory Foam Accommodation
  6. Common Shoe Modifications
  7. Running Shoe Choices, Evaluation, and Orthotics
  8. Right Handed vs Left Handed
  9. Taping Techniques

1. Taking a Good Biomechanics History


    This is where it all begins in the doctor/patient or therapist/patient relationship. The time spent here discussing the historical facts of an injury or pain syndrome, and important contributing factors, can be vital in the success or failure of treatment. Why is it so vital? Follow up visits work off the success or failure of the treatment plan set on that first visit (it is why I am anal with staff to allow that patient ample time, and allow me to see them on time). If the information collected is inadequate, the entire sequence of events following may be subpar. Please review Chapter 3 on History Taking now before we go further.

    The biomechanics history related to injuries is looking for patterns or facts that can cause injuries to occur. Here are some of the many questions that normally get asked, or at least you should add to your thoughts prior to seeing a doctor or therapist. These include:

 

  1. Do you know if you have a short leg?
  2. Do you believe you have weak or tight muscles in general, or around the injured part?
  3. Do you have loose ligaments in general?
  4. Are you right or left handed?
  5. When you were a child did you have to wear braces or shoe inserts?



6.            Have you ever been prescribed shoe inserts?

7.            Have people told you that you walk or run funny?

8.            What has your history been of overuse injuries (non traumatic)?

9.            Have all or most of your injuries been to one side of your body?

10.         Do you have high arches, flat feet, bow legs, knock knees, bunions, hammertoes, or other abnormalities?

                                                   High Arches or Pes Cavus

    

11.         Do you have any arthritis from your hips downward and where?

12.         Do you feel unstable in any joints? 

    A skilled practitioner knows the relevancy of the answers to your problem. The answers will help point the course of treatment in the right direction. I sure hope it helps you.

 


Wednesday, November 30, 2022

Arch Height In Custom Orthotic Devices

The "H" is the High Point for the Medial Arch in a Custom Device

     The power of custom orthotic devices are so minimized by our society, and sometimes even by Podiatrists. The foot is the foundation of our bodies. If you have foot pain, you know what that means exactly when you can not walk. When you have ankle, knee, hip and back pain that has been improved by orthotic devices, you understand the importance of this foundation. 
     I just attended the 10th Annual Richard O Schuster DPM Memorial Biomechanics Seminar. We talked biomechanics for 2 straight days. For me, it was Podiatry Heaven. Those like me felt the same. Many of the speakers come from different approaches to Biomechanics which is all the better. You want your ideas and concepts to grow. 

Tuesday, November 29, 2022

Sesamoid Injury: Cortisone Shot or Not?

Hi Doctor Blake,

I stumbled upon your blog after lots of sesamoid research! And now I am asking for your help with my recovery... 

Long story short I’ve been off from dancing (just wearing special sneakers with dancer’s pads) for 7 weeks now for a micro fracture of my sesamoid. I just received an MRI with these results below (apologies if the translation from another language is weird):

Presence of bone edema of the entire medial sesamoid, with low T1 hypersignal T2 signal.  No fracture-separation of the bone, no sign of necrosis, and in particular no deformation of the bone surface.  Reactive joint effusion of the MTP 1. Light hallux valgus (confirm on radiography under load).  No sign of sesamoido-metatarsal osteoarthritis.  A little edema of hyperfunction of the plantar tissue in contact with the medial sesamoide.  No anomaly of the stabilizer of the sesamoid.  No abnormality of the hallux tendons.  Moreover no anomaly of other MTP and inter-capito-metatarsal spaces.  CONCLUSION: Appearance confirming medial sesamoiditis, without fracture or underlying necrosis.  Light hallux valgus (confirm on x-ray in charge)

I am seeing two different specialists in my country but now I have run into the problem of opposing medical solutions and I am not sure which to go with. 

One doctor recommends a cortisone injection and the other recommends oral anti-inflammatory medication. The doctor who recommended the oral medication told me that the cortisone injection is very dangerous for a sesamoid as it damages the foot’s natural padding, therefore exposing the sesamoid to further damage... 

The doctor who recommended the injection told me that the oral medication will not do anything to help the sesamoid and that all stories about sesamoid’s being made worse by injections are mainly myths and cannot be proven.

I am emailing to ask your advice on this debate? I am hesitant to get the injection because of all the mixed reviews online but it is a more “immediate” and localized option which is tempting. Do you have any feedback or success stories of oral medication? Or any thoughts on cortisone’s long term risks?

Any feedback you could offer would be greatly appreciated! 

My apologies for such a dense email, but your knowledge would be so helpful for me!

I thank you in advance for taking the time to read this email and I hope to hear from you soon.

Sincerely,

Here on this MRI image healthy bone is dark. The light tibial sesamoid indicates a healing response from the body. Hard to tell stress fracture (can not see) from bone bruise in these cases


Dr. Blake's comment: 

 I must side with the oral medications, which can not be taken before you dance (only after). Your MRI shows that the sesamoid has been slightly injured. Cortisone will mask pain for up to 3 days (short acting cortisone and not dangerous) to 9 months (long acting cortisone). Your dance career can not risk masking pain where the sesamoid injury worsens. You can ice twice daily and do contrast bathing every evening. You must float the sesamoid with Dr. Jill's dancer's pads of either one eighth or one fourth inch (3 to 6 millimeters). These can be bought on line and worn even walking around barefoot to protect the sesamoid. I have my patients get 2 lefts (both sizes) and 2 rights (both sizes) since the adhesive is on one side and at times you are wearing it on your foot, and at times you are putting it over or under inserts in shoes. Whatever you put on your injured foot, should be on the other foot for balance. I hope this helps. Rich 

Video On Designing Dancer's Padding for Big Toe Joint Problems

Sunday, November 27, 2022

Video from Dr Richard Blake on Injury Rehabilitation General Rules

https://prezi.com/v/view/wyPiHlcIQ9LKeHoi88I2/

POSE Running: Video on the Basic Components

https://youtu.be/shwi2MfxSok

     I have treated runners of over 40 years. The POSE running concept is a sound one. I would just at a lecture by Dr Jim Losito in Miami. Dr Losito is an expert in sports medicine and past president of the American Academy of Podiatric Sports Medicine. He is a huge proponent of POSE running for injury prevention and running efficiency. This blog and accompanied video is merely to say "yes" to have you learn the basic concepts in other videos. 

Friday, November 25, 2022

Love Your Podiatrist: Consider Book 1 or Book 2 for Practical Biomechanics for the Podiatrist as a Christmas Present


They will think you are very special!! Happy Holidays!! Rich 

Shock Absorption Problems: A Common Cause of Lower Extremity Problems

     Many of my patients have problems with shock absorption. This excerpt from Secrets To Keep Moving ebook mention a few. We watch patients walk and see if there are any problems, then we watch them run (if they run). We listen to their histories on how they were injured. I am looking for internal vulnerabilities (reasons that the foot or gait causes poor shock, or for external stress like poor shoes, excessive downhill walking, etc. As podiatrists we focus too much on over pronation, when poor shock absorption, limb length discrepancy, inherent instability, weak and tight muscles, over supination, and forefoot deformities can be equally the causal effect of an injury or pain syndrome. Rich 

 Poor Shock Absorption
  • Tibial Stress Fractures
  • Knee Pain

  • Calcaneal (heel) stress fractures
  • Metatarsal stress fractures
  • Heel Bursitis or Heel Bruise
  • Femoral Stress Fractures
  • Where there are many causes of poor shock absorption, patients who have excessive supination always have poor shock absorption. You need contact phase pronation to absorb the shock at heel strike.
 
Sometimes even my smallest slightest patients can walk very heavy and have poor shock absorption

Thursday, November 24, 2022

5th Metatarsal Fractures: A Special Breed (General Rules)

Fifth Metatarsal Fractures: A Special Breed (by Richard Blake, DPM)

 

    The top 10 initial treatments for 5th metatarsal fractures are:

 

  1. X ray evaluation to decide on surgery vs conservative care.
  2. If surgery, protocol to be set by surgeon and not the purpose of this writing.
  3. If conservative care chosen, some form of immobilization for 8-12 weeks is typically done based on injury (Immobilization Phase). You want to get the pain level between 0-2 with 2 weeks, and maintain that during the entire rehabilitation.
  4. During the Immobilization Phase, lower limb strengthening with some cardio should be orchestrated by a physical therapist. Even one legged stationary bike is very beneficial.
  5. Bone health is analyzed with dietary calcium and Vit D3, consideration of a bone density screen, and typically healthy diet.
  6. Transition period from cast to no cast, with or without surgery, can be very difficult. Custom orthotics with full lateral arch support very helpful. At times, extra big shoes during the transition can be purchased so added padding/accommodation can be used.
  7. When not using a permanent cast, 24/7 compression bandages, ice pack 15 minutes twice daily, contrast bathing each evening, as much as possible elevation, 3 times daily 3 minute self massage for desensitization and swelling reduction, and hourly pain free ankle circles are initiated.
  8. Weight bearing for bone mineralization, even in casts or boots, is done as early as safe (Good Pain vs Bad Pain)
  9. All fifth metatarsal fractures, except a few styloid process avulsion fractures, should have a Exogen Bone Stimulator for 6 months (when insurance allows).
  10. Follow up xrays need only be done when symptoms plateau or worsen. As long as the patient makes steady, gradual, progress, it is better to base improvement on function, not x ray or palpable tenderness.

    A. Fifth Metatarsal Fractures: Non Jones Type

 

These images are from a patient of mine that is almost 3 months post injury and her x-rays show a wide gap still. Here are all the thoughts that are meandering through my brain.



Here is the standard Lateral view with quite a large gap noted

 



A Jones Fracture to the Fifth Metatarsal is normally 1 inch closer to the toes. This AP view still shows some displacement.

 



This Oblique view makes the fracture clearer and you can see if the fracture line goes into the joint of the 5th metatarsal/cuboid.


You can see in this post Jones fracture repair xray that the Jones fracture is further forward than a 5th metatarsal avulsion fracture. 

This 5th metatarsal avulsion fractures following some inversion twist of the foot are typically under treated. Because they do not have the stigma of a true Jones fracture (historically more serious), they can be less aggressively treated. Sometimes this is okay, and sometimes not. Again, the goal is to create a pain free environment, which I believe has happened. X-rays for foot fractures, since the healing normally takes place internally first, cannot really reflect the strength of the bone. But, I do not like the gap and I do not like the fact that the joint is involved (possibly future arthritis).

 

    So, what are all the steps we need to make happen?

 

1) Establish a pain free environment if not already occurring

2) Make sure Bone Strength is good (questioning about Vit D3 and Calcium, bone density, healthy diet)

3) Stabilize the fifth metatarsal with orthotic devices, accommodative padding, and kinesiotaping (there are special techniques in orthotic devices for the outside of your foot)

4) Set workout goals that do not over stress this area

5) Avoid anti-inflammatories since they can slow down bone healing

6) Ice Pack 15 minutes twice daily, and contrast baths once daily to reduce inflammation

7) Due to the gap, seek approval for Exogen Bone stimulator

8) Have patient talk to a surgeon to find out what the process of fixing if the above does not work (this keeps the patient well informed)

9) Advise on possible future arthritis

10) Only get future X-rays if treatment has plateaued (there are many cases of pain free non healing) since current healing of the bone is not reflected well on x-rays.