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Saturday, March 24, 2018

Fractured 5th Metatarsal: Email Advice

Hello Dr. Blake,

My 14-year old daughter just got out of a cast (2 weeks) for a fractured 5th metatarsal (no displacement). Apparently, she's had the fracture for up to 7 mths and has been doing up to 30 hrs of gymnastics on it per week (competitive gymnast). It finally got to the point where she couldn't walk (up until then, it was on and off pain). So, after 2 weeks of a hard cast, her xrays were 'good' (whatever that means). Her doctor (orthopedist) put her in an ankle brace (??), which after wearing for a day, was hurting her foot, as it cuts right into the fractured area. 

Next step was "no jumping/running" for 4 weeks. She says she still has pain when she walks. 

Is there something specific we should be doing?? How should she be taping? I feel like her doctor was in and out--not giving us much to go on. 

Dr. Blake's comment: 
     I am very late in this response, so if you like, please get me up to date. Yes, you are right to question this. Ankle braces do cut right across the area of injury so I do not understand its use at this time. You have to create the 0-2 pain level so walking in pain is not desirable at all. You typically advance from the hard cast to a removable boot while a lab is preparing an orthotic which will protect it out of the cast. 2-3 weeks out the patient can tend wean from the protection of the removable boot to the protection of the orthotic. I use KT tape (or some other similar) circumferentially around the foot once or twice to stabilize even in the removable boot. It takes 3-5 times of doing it yourself to get the right tension, without irritation. I have copied more from my book on this subject below. Sorry for the delay. Hope she is doing better. Rich

This is an excerpt from Secrets to Keep Moving. It is hard to know which of these rules are important for your daughter, but they are definitely at least asking questions about if the treatment is stalled. The fact that every step she takes places full weight on the fifth metatarsal unless she is severely limping makes the progression from cast to full activity a thoughtful process. 

. Fifth Metatarsal Fractures: A Special Breed

    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 the surgeon and not purpose of this writing.
  3. If conservative care is chosen, some form of immobilization for 8-12 weeks is typically done based on injury (Immobilization Phase).
  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. The 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 as a 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 10-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 an 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. 

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.