Blogger Contact Question #3: Rehabilitation from Metatarsal Stress Fracture

Dear Dr. Blake, 

 

     July 2, 2019 put in walking boot for pinpoint pain/circle of swelling over  
4th metatarsal shaft. Crutches, non weight bearing with boot.

    July 12, 2019  MRI

    July 16, 2019. MRI showed increased T2 and subtle diminished T1 marrow  
signal mid 4th metatarsal. Discrete fracture line not identifiable.

    Was put non-weight bearing for 5 weeks with boot; begin adding weight on  
week 6, 25% and then one crutch for 50% week 7 to start 8/16/2019. 

    Began using Exogen 4000 Ultrasound machine; 2X daily Aug 14, 2019.  Have some  

swelling in ball of foot, goes down over night.  Is this normal to add  
weight progressively?

Dr. Blake's comment: Typically with 4th metatarsal stress fractures you do not need non weight bearing, but I will assume your doctor wanted to protect you very cautiously for some reason. The boot, if you are to bear weight must have some accommodation to protect the metatarsals with either metatarsal padding for off weighting and straight off weight padding to place weight on the 1st through 3rd metatarsals and 5th metatarsal. This takes a lot of work and time, so many facilities just off weight the patients. Yes, you want to go from non weight bearing to full weight bearing in the boot gradually, using the 0-2 pain level as a guide. You can not have more pain as you increase weight bearing. Consider doing contrast bathing each evening for a deep flush for the swelling. 

When might I possible be able to walk for recreation/health?

Dr. Blake's comment: Based on your progress, when you are 2 weeks full weight bearing in the boot, you begin a 2 week gradual weaning out of the boot. When you are 2 weeks out of the boot, and having no setbacks, you start 30 minute walks every other day, then add 10% per week. This way you gradually add more stress to the tissue and see how it responds. 
During non-weight bearing swam (no pain), rode stationary bike 30-30 minutes  
(no pain) and weightlifting on gym machines to maintain some fitness/core.

Dr. Blake's comment: Great, as much pain free cross training you can do for cardio and leg strength is wonderful. As you get out of the boot, begin metatarsal doming and some single leg stance strengthening work. A PT can advise. The bone stimulator in this case is a 3 month commitment. Good luck my friend. Rich
  Thanks!

Regards,

Exogen Bone Stimulator and 4th Metatarsal Fracture: Email Advice

Hi Doctor Blake,

I came across your blog when searching about Exogen Bone Stim machines because I couldn't get a question answered that I had. So since you seemed really passionate about all things foot and ankle, I thought I might email you and see if I could get your opinion about my question. So here goes. I got a Exogen in 2012, for what was diagnosed as a small fracture of the fourth metatarsal head, which was not improving over a significant amount of time (six months or more). My doctor said that it could also have been something called a vascular necrosis, but that seems to have been ruled out since I have improved significantly since using the bone stim machine. So I used the machine for a very long time, possibly a year, but it still has uses left on it. Then last week after trying some things during a workout that might have been premature to try, (after feeling my best in easily five years for maybe the last 4 months) I have been feelings some small symptoms in the exact area that I used the machine on. I wondered IF there was any harm in beginning to use the machine again to possibly encourage more blood flow to that area and continued healing. Any advice you have would be greatly appreciated!

Best Wishes,

Dr Blake's comment: 

     I am not sure if the bone stimulator actually increases blood flow, but I know it definitely causes the little bone forming cells (osteoblasts) to have fun!! So, why not use it in case you have a stress fracture, stress reaction, or cartilage weakness. I see no harm. Good luck!! Rich

Patient's response:

Thank you for the response, I appreciate your time greatly. If you have any time at some point, I just wondered if I could ask you another question since you seem to have so much knowledge in this area. I just wanted to know if you thought it was normal for a fourth metatarsal head fracture (described to me as small by way of mri) to still be having problems-since it wad presumably injured due to "overuse" sometime in 2011 and not treated until summer/Nov of 2012. I ceased almost all activity from nov 12' to may 13', used the bone stim machine for over one year, and continued to progress after may of 2013, and this past summer, (14') thought I had made nearly a full recovery.  Currently I have of course increased the intensity of my training regiment (heavy weight lifting) , which was always the goal-and after two months of success, seem to suddenly have slide backwards a bit. I'm considering seeing my doctor here in Virginia if it doesnt calm down but really want to avoid any kind of surgery. My symptoms are mild soreness, tenderness and also at times the surrounding areas and the metatarsal head are tingling almost like pins and needles. At times when I hold the fourth metatarsal head with my fingers I can definitely feel that it feels different from the rest-almost like it is still mildly inflamed and/or has scar tissue. Any additional insight is so greatly appreciated once again.

Respectfully,

Dr Blake's comment:

     Sure, after an injury to the metatarsal, you can be left with some permanent soft tissue changes (internal scar mainly) and some slow to resolve new bone growth (as the metatarsal heals stronger than originally). I am always looking at metatarsal positioning as a possible source of continuing pain. Is the bone lower than normal? Is my link below which discusses 2nd met pain, but can apply to any metatarsal.

http://www.drblakeshealingsole.com/2014/10/painful-2nd-mpj-email-advice.html

Many cases of fourth metatarsal injuries are related to 2 factors:

1. tendency to be too supinated with overload on the lateral side of the foot
2. excessive looseness of the 5th metatarsal, so the weight goes onto the 4th met

So, your biomechanics may need to be evaluated and changed or the problem can continue. 

What to do now? 

1.     Attempt to create a protected weight bearing situation holding the pain between 0-2. 
2.     Ice 2-3 minutes for 10-15 minutes the bottom of your foot
3.     With any bone injury, you have to consider your Vit D and Calcium intakes (may take a discussion with your internist.
4.     I love Kinesiotape circumferential taping for compression, stability, and lowering of the 5th metatarsal. You can also use Rocktape.

http://www.drblakeshealingsole.com/2014/04/arch-taping-with-kinesiotape-kt.html

I hope this helps you. Rich