Stress Fracture Foot

Patient Seen 3-30-10

Patient presents with 10 day history of pain in his left foot. There was no acute injury that the patient remembers. Pain was first felt waking up in the morning. Few days later, bruising and swelling were noticeable at the top of his foot in the metatarsal area. Patient normally walks everywhere. Now pain develops after 6 blocks, but has no pain walking flatfooted around his apartment (pain only with bending his toes in push off). He noted that his walking shoes were fairly broken down on self examination. Pain level, on a scale of 0 to 10, was around a 7. Patient states he takes no special supplements, except vitamin C, but does feel he has a healthy diet.

Examination showed swelling and redness on the top of his 2nd and 3rd metatarsals. Significant pain and swelling like this in this area of the foot is a stress fracture until proven otherwise (golden rule of foot). With a sprain of the tissue, you probably would have had to have tripped. With any swelling or redness in the foot, gout or infection must be in the examiner’s differential diagnosis. There were no open wounds suggesting possible infection. Gout however could not be ruled out at present.

I advised the patient that stress fractures may not show for 2 to 3 weeks on x-ray. Many patients get xrays during this time frame only to be told they have no broken bones, when they really do. He was given an x-ray Rx for the next week if he was not getting a lot better. We discussed the role of a good healthy diet, 1200mg to 1500mg of calcium daily, and 400-1000 units of Vitamin D daily(see links below). He was told to ice pack the area to calm it down 2 or 3 times daily for 10 to 20 minutes each time. Please see the post on Ice. After discussing his options on footwear, since he walks daily a significant amount, he purchased a removable cast for the injured side and an Even up® www.EvenUpCorp.com for the good side as shown in the photo above.

He was also given a compression sock for 24/7, and advised on some elevation AMAP (as much as possible) to shrink swelling, at least getting his feet off the ground. For around the house, he purchased a post operative shoe with a stiff sole to avoid bending his toes. The removable cast works well since it has a built in rocker so you do not bend your toes. Can you recognize all the basic components of R.I.C.E. at work here?

• When a suspected fracture is present, patients are told to minimize their use of anti-inflammatory medications since they have been known to delay bone healing. NSAIDs inhibit bone healing - The Boston Globe
Jun 22, 2009 ... NSAIDs inhibit bone healing by blocking a natural substance in the body, prostaglandin, which supports the activity of bone-building cells, ...
www.boston.com/news/health/articles/2009/06/22/nsaids_inhi... - Similar

Follow up of Patient #1 will be given when appropriate for teaching. This patient, as with all I will use in my posts, has given his permission to use the basic information of their care for teaching purposes.

• Preventing vitamin D deficiency — the new breakthrough in ...
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www.womentowomen.com/healthynutrition/vitamind.aspx - Similar

• Dietary Guidelines, calcium requirements, vitamin D requirements
Feb 9, 2010 ... The Dietary Guidelines for Americans have been published every 5 years since 1980. The Guidelines provide authoritative advice for people 2 ...
www.dairycouncilofca.org/Milk-Dairy/dietRequire.aspx - Similar