Foot Possible Stress Fractures: Email Advice

hi doc,

i'm a former patient (i can't remember when exactly, but it has been a while). at the time i was seeing you, i had problems w/ stress fractures in both feet (revealed via MRI). you had me do contrast baths, taping, wearing orthotics and i had to wear a walking boot at one time or another on either foot.

during a recent tennis match, i was forced to make a shot which had me land a bit awkwardly on my left foot. i felt "something" right away, but it wasn't enough to prohibit me from playing the remainder of the match. since then, i've felt some things that make me think (more like know) that my left foot is broken. i've had the same type of throbbing at night that has kept me awake at night on the top and bottom of the ball area of the foot. there is no swelling, only slight discomfort when walking - pain in the 3-4 range that varies during the day - and the pain is not constant.

i've been able to play tennis, but i've been taping my foot (amazing how i remembered to do it just like that!) for support.

think it's best to actually come in or do you think i can just tape and immobilize for a while to see if that has any positive effect (or possibly no effect)?


very truly yours,

Dr Blake's comment:

     Ralph (name changed), thanks for the email. It is so difficult to play tennis (or most sports) with a stress fracture, that you either have a small one, or just a sprain of the ligaments. I agree that it sounds like a stress fracture however by how sudden it came on. These scenarios are always stress fractures until proven otherwise. Stress fractures always give swelling, but with some of the deep ones, you can never see the deep swelling. Small stress fractures, if given time to heal, normally take 3 months to heal. So, you can wait the 3 months, and if you are not appreciably better, than let's take some xrays. Read my blog post on Good vs Bad Pain, and avoid bad pain. No limping or sharp pain while playing or you will hurt something worse like your knee. If wearing the old removable boot during the work day makes it feel a lot better, I would do that (even for 4 hour periods can rest the area and help healing). Remember to get 1500 mg Calcium and 1000 units Vit D, check the foods you eat for average amounts and supplement if you have to. If tape helps, tape daily for 2 weeks longer than you think you need too. 3 times daily work on the inflammation with 10 minute ice packs and/or contrast baths. I sure hope this helps. Rich

Foot Stress Fractures: Why do they occur?

These 3 photos should the fracture of a 4th metatarsal while the patient was not in an overuse situation. Questioning did not reveal any history of osteoporosis, although we talked about her VitD3 and Calcium intake. When I x rayed her foot, the fracture could be seen the best on an oblique view. Dr Susan Lewis, orthopedist at the Center For Sports Medicine in San Francisco told me that even though the bones on X-rays look strong, it takes a 40% loss in bone density before it is noticeable on X-ray. What is apparent on these X-rays is that the bone that broke has a probable benign bone tumor present, making the bone weaker. Any San Francisco Giant's baseball fan remembers when our All-Star Pitcher Dave Dravecky broken his arm pitching in a game only to find out that the the bone was weakened by a bone tumor. See the subtle changes in the 4th metatarsal which lean the walls of the bone making it prone for fracture. 

See the thinning of the walls of the fourth metatarsal.

This is an oblique view. An MRI has now been ordered. 

Foot Stress Fractures: Answers to an Email

Hello Dr. Blake,


I'm not sure if you remember, but I emailed you a couple of weeks back about Vibram Five Fingers for my school newspaper.

I am now writing about stress fractures and I thought you may know something about them. So I would love it if you could answer a few questions for me about them, or if you're really busy or something, if you could pass them along to a colleague, that would be wonderful.

So I'll tell you the questions anyways, and I look forward to hearing back from you or a fellow orthopedic/podiatrist.



1. What exactly is stress fracture on the anatomical level?

2. What long-term effects does sustaining a stress fracture have on a person?

3. Is there a particular sport or activity that is a person most likely to sustain a stress fracture?

4. What can an athlete do to try and prevent this type of injury? What is the best thing for a player to do after incurring something like this?



Thanks, as always for the help,

Elizabeth
 
     Elizabeth, a stress fracture is a tiny crack in a bone when the stress load it receives is higher the stress load it can withstand. A better term that means the same thing is a "fatigue fracture". The bone fatigues with stress and cracks when the stress is too much to bear.
 
     Stress fractures are very common and there are no long term sequellae from them. The body completely heals stress fractures, in fact they heal them better than they were originally, called "double healing". The bone around a stress fracture is probably 2 times stronger than before it broke due to the remodelling process of the bone for at least 5 to 10 years. Thus the saying "you can't break a bone in the same place twice". Quite accurate for a few years.
 
     Stress fractures are fatigue spots in bones, and every sport can produce them due to some over use pattern of activity. Judo experts intentionally stress their fifth metacarpal of the hand by repeatedly striking a hard object to build up the thickness of that bone. This is why they can break those bricks on TV. Ballet dancers en pointe are prone for 2nd metatarsal stress fractures since the weight with proper technique goes primarily into the 2nd metatarsal. The male dancers in ballet get shin (tibial) stress fractures with their overuse landing from jumps. Rowers on a crew team are prone for rib stress fractures due to the force of the chest muscles pulling on the ribs. If the bone is weaker than the muscles, the bone breaks. Cross Country runners get tibial stress fractures due to either the impact pounding or the pull of the powerful soleus muscle at push off. And the list goes on, and on, and on.
 

Stress Fracture with Bony Remodeling in the Bone under the Ball of the Foot. Compare the 2 bones seen under the first metatarsal and tell which one is injured.

     If the athlete is on a team, smart coaches know alot about preventing stress fractures by avoiding overuse situations, and varying workouts. As an athlete, getting the recommended doses of 1500mg of calcium per day during months of strenuous workouts, getting some sun without block in the early morning or late afternoon, consuming 400 units of Vit D daily, training at at least a  50 % level during the off season for a sport to avoid the excessive loads at the beginning of a season, making sure that your workout shoes are well padded and fairly new, getting plenty of rest allows tissues to heal and when we exercise with tired muscles more stress goes to the bones, and never working through pain or extreme fatigue.

 

     If you develop a stress fracture, you have to respect that the bone needs time to heal. This is the world of cross training so that you do not decondition as much. Runners bike, bikers swim, etc. There are so many cross training avenues out there to keep your muscles in tone and your heart and lungs pumping. Try to analyze why this happened. If you have a coach, work with them to attempt full discovery. Play Sherlock Holmes. It is normally 2 to 4 factors which all pile up against you.  Do you have a family history of osteoporosis? Is your diet low in Calcium or Vitamin D? Do you wear sun block at all times? Are your workout shoes fairly well padded or relatively new? Did you just increase your activity too abruptly with a poor off season program? Is there something in your walking or running style, or a short leg, that adds too much stress to an area? And there are many more factors. It is always a fun challenge.

 

     Elizabeth, I must sign off but I hope this helps. Good luck with your article. Dr Rich Blake

Sesamoid Fractures: Advice when not healing well

Subject: question about fibular sesamoid non-union fracture in dancer from Milwaukee, WI
(photo above pointing to the tibial sesamoid, the fibular sesamoid is the closest one to the second metatarsal)

Hello Dr. Blake,

I am writing today because in conducing online research about my injury, I came across your healing sole blog, and you offered your contact information so that folks might contact you with foot-related concerns. Thank you for extending yourself in this way. I could not find anything on your website about my particular injury, and so I thought I would write you. I have seen an orthopedic surgeon and a podiatrist, but I'd like to have another opinion. Also, I find it very difficult to get answers out of these doctors, as they only have a few minutes scheduled to talk to me.

I am a 29 year old female. I started dancing in college (modern and some ballet) about 8 years ago, and have continued on and off since then. I took some time off, but started taking classes about 3 - 4 days per week in July 2009. I am not a professional dancer, but have received scholarships for dancing at my studio, and have been involved in pre-professional training programs for modern dance. It is very important to me.

In about September 2009, I noticed some pain in the left ball of the foot. I stopped dancing for 1 week and it got better, so I resumed. However, the pain returned very gradually. I visited a sports medicine orthopedic doctor in February 2010 for a different concern (right ankle stability), and also mentioned the pain in the left ball of the foot. He diagnosed it as "sesamoiditis," and seemed confident of his diagnosis, so I declined an x-ray. I avoided jumps in dance classes as I had been since the onset of the pain, but I continued dancing. The pain very gradually became worse. At the end of May 2010 I decided to stop dancing and seek physical therapy, as the orthopedic doctor had said this was an option. After three sessions of physical therapy (involving ultrasound, iontophoresis, soft tissue mobilization, taping and home exercises), my foot was much worse - it was swollen and painful to walk. Prior to this, my main pain came from dancing, not walking. At the beginning of June 2010, I went to a different orthopedic surgeon and he took x-rays, diagnosing my injury as a non-union fracture of the fibular sesamoid. (A pre-injury x-ray from 2008 ruled out bipartite sesamoid.) I was in a walking boot for the month of June and non-weight bearing (on crutches) beginning in July. Upon recommendation from a friend and family doctor, I sought a second opinion from a podiatrist. The orthopedic surgeon said that if my bone wasn't healed by the end of August (after 8 weeks non-weight bearing), it would require surgical excision of the fibular sesamoid. The podiatrist has been more conservative in his treatment. On August 18, I began using a bone growth stimulator once a day for 30 minutes. It is the DonJoy Condensed Magnetic Field (CMF) stimulator. After my 4-week check-up on September 8th, the podiatrist added a twice daily contrast bath to my regimen, along with the bone growth stimulator. I will see him in another four weeks. I am still non-weight bearing, and I have been conscious to take calcium supplements, drink milk and eat yogurt this whole time.

Here sesamoids shown in a CT Scan

http://www.youtube.com/user/drblakeshealingsole#p/a/u/2/rRt5hC24Afg for information on contrast bathing.
My concerns/questions are:

1) Is there anything else I should be doing to heal this bone (without surgery)?

2) I am a very patient person and would do anything to save my bone rather than have it surgically removed, as I fear it will compromise my dancing. However, is there a point at which we can be fairly certain that the bone won't heal, and I will have to resort to the surgery?

3) What risks would surgical removal of fibular sesamoid involve? Again, my main concern is with the function of my foot - I am very active and want to be able to dance for the rest of my life! I read on the Internet that removal of the sesamoid affects a persons balance and power, may lead to hallux varus as the tibular sesamoid loses its counterbalance, and may affect the tendons (adductor hallucis). My concern is that the doctors all tell me the surgery has no effect and I will be back to normal. I am a smart woman who has done her research and recognize that this isn't the case. Could you please provide me with an honest, realistic representation of what might happen over the course of my lifetime as a result of sesamoid excision?

4) Is arthroscopic surgery an option?

5) Are bone grafting or pinning options?

6) I have struggled to trust my doctors. What do I look for in a surgeon (if it comes to that)? Should I go with a podiatrist or an orthopedic surgeon?

7) When I get back to dancing, how can I avoid future injury to the fibular and tibular sesamoids? I realize that the impact is greater if both sesamoids are removed, and want to avoid that at all costs!

Dr. Blake, I apologize this is such a long email. I hope you are able to offer me some advice. Thank you for your help.


Sincerely,

Jenni

See how sesamoids are under the first metatarsal

Dear Jenni, I will try to answer your questions in this blog posting. There are 2 sesamoid bones under each first metatarsal which make up the "ball of the foot". These sesamoid bones act like the knee cap in function: they protect the first metatarsal from direct pressure, and they separate the tendons from the joint axis increasing the lever arm of these tendons. Increased lever arm means increased power from these tendons which need, at times, to handle the force generated up to 5+ times body weight. The photo below shows these sesamoids sitting under the first metatarsal with the fibular (closest to the second metatarsal) having a fracture. In this example, you can clearly see how the fibular sesamoid looks irregular. The actual fracture occurred 10 months previous to this fracture.

     At times, the sesamoid bones never completely fuse in adolescence, and so xrays show that they are in 2 (bipartitie) or 3 (tripartite) pieces. The photo below shows a non painful bipartite tibial sesamoid.

 Fractures can be misread on xray as bipartite or tripartite sesamoids (false negatives), and bipartite/tripartite sesamoids can be misread on xray as fractures (false positives). Bone scans or MRIs clearly make the diagnosis of sesamoid fracture when not completely obvious as in the photo above.
On an aside, ultrasound is contra-indicated for stress fractures, probably why physical therapy aggravated the situation. Golden Rule of Foot: If ultrasound irritates the injured area, consider an underlying fracture may be present.

     I will try now to answer your questions.
#1 Is there anything else you can do to heal the bone in an attempt to avoid surgery?
     First of all, anything that you do now to help yourself avoid surgery, even if you need surgery, will help you post surgery immensely. This is a perfect time when the bone is sensitive to design perfect orthotic devices that protect them. These modifications in orthotic devices are a post in themselves, but most sports medicine podiatrists and physical therapists can design deceit orthotics for this problem. You may have a biomechanically challenging foot, with a very prominent first metatarsal and this could actually take the work of a biomechanical expert (hope this is not you). The goal of any othotic device for you, and athletic shoe ones are made first to wean you eventually from the boot, is to shift weight back onto the arch and onto the 2nd and 3rd metatarsals. Without a corrective orthotic device, at some point in each step, 100% of your body weight goes through the big toe joint and sesamoids. In the front of the orthotic device is a "dancer's pad", also called a reverse Morton's pad, and sometimes an additional metatarsal pad.

Here an additional met pad is used to shift more weight off of the sesamoids.

     The bone stimulator for a nine month period is great, just do not stop it too early. If you are using the bone stimulator, best to be committed to it for 9 months. Remember, pain is going to be a poor guide on healing. As you continue non weight bearing, the area will get stiffer, weaker, more swollen, and with more bone and nerve sensitivity. You are in the easy stage of rehabilitation. It is getting you back on your feet gradually that the work begins. The doctor managing your care will need to balance the pain you have with a gradual increase in function. It can be a trade off to allow more function with some more pain initially. This is the same issues that have to be dealt with post operatively.
     Learn to do spica taping to restrict big toe joint dorsiflexion with kinesiotape. The 3 photos show the placement of 1" kinesiotaping. It should be applied easy, not to pull the toe down, but to restrict the upward motion of the toe. It should not feel like it is tight or jerky on the toe. You can experiment with longer arms of the tape under the arch. The 1" tape is split in 2 for 1" to wrap around the toe. An upcoming post will show a video on this technique.
     Stay strong with all those foot intrinsic muscles, but also you knees, hips, and core. The stronger you stay, the faster you heal, surgery or no surgery. The weaker you become, the more collapse of your arch into the ball of your foot, the more pressure on the sesamoids. You are in the Immobilization Phase, but you need to be blending the Restrengthening Phase into it. You need a smart physical therapist to begin restrengthening your body. Golden Rule of Foot: Begin Restrengthening the Injured Area even before you injure it.

     Get a Vit D 25 level now, and a bone density screen, to make sure everything is perfect in those two areas.

     You should be taking 1500 mg of calcium (normally 5 daily servings of calcium rich food, or you can supplement diet with 500mg sugarfree TUMS at the end of each day to make up the difference.

Papertape is used to secure the arms when they begin to loosen.

   

 Eat a balanced, healthy diet.

     Make sure you stay with a relatively painfree environment (see link to post on Good Pain vs Bad Pain) as they wean you from non-weight bearing to a weightbearing removable cast, then removable cast to athletic shoe and orthotic and tape, to smaller orthotic with dressier shoes and tape, to dance shoes with dancers pads and Hapad archs and tape, to gradually return through the various levels of difficulties in dance.

Spenco is glued to the bottom of a shoe insert as a dancer's pad.

http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html

#2 When are you sure that the bone needs surgery?

    

     Sesamoid on CT Scan shows irregularity at the interface with the bottom of the metatarsal head that you know will break down the metatarsal head cartilage over time and cause a worse problem. This is the case of the patient with the xray above when I first met her. I knew at 30+ that she couldn't coexist with this for the next 70 years.
     Surgery is also indicated if the MRI shows damage to the underlying first metatarsal. However, a bone stimulator with serial MRIs may show healing over a 1-2 year period of time.
     I definitely feel surgery for this injury is an individual thing. You are a candidate for surgery 3 months after your injury. No one would blame you for having surgery. Personally, I would try to perfect all of the factors that could delay or eliminate the need for surgery (diet, strengthening, physical therapy, spica, orthotics, padding, etc.) Anything that you learn before surgery, may help you prevent surgery, but definitely help you in the post operative period.

#3 What are the risks, especially in an active person, to remove the bone?

     When you remove the sesamoid, you can be extremely active at a professional level, but you must always try to protect the other sesamoid for the rest of your life with orthotic devices, dancer's pads, etc. Most doctors underplay the actual time it can take a high level athlete to get back. I believe that there is a 2 year total healing time to a strong and powerful big toe joint following surgery. The first year is all about swelling, initial strength, scar tissue, and biomechanics. The second year is re-strengthening at the level of gaining not tone, but power, endurance, and quickness. And yes, surgery can be have it normal array of problems--excessive swelling, incomplete correction requiring re-operation, excessive scarring causing stiffness/pain, tendon balance problems requiring prolonged taping, and many other issues. Hallux varus is rare, although surgeons know what foot types are prone and can tell you if you are a remote candidate.

#4 Is arthroscopic surgery an option?

     No, the joint is too small. Most surgeons approach the fibular sesamoid from the bottom of the foot for easy access.

#5 Are bone grafting and pinning options?

     No

#6 What should I look for in a surgeon, and should it be a podiatrist or orthopedist? Sesamoid surgery, or trying to avoid sesamoid surgery as you are, is all about rehabilitation and biomechanics. It is an ideal perhaps to find a podiatrist or orthopedist who does surgery, and also pays alot of attention to the rehabilitation part and the biomechanics part. They do exist, and most create a team in dealing with this problem. Our top surgeon will use me for the orthotic devices and some of the rehab, and physical therapists and trainors for the rest of the rehab. Unfortunately, you also must see your limits with your insurance carrier, but also have a clear understanding from the surgeon about how you will be rehabed. I am biased toward my profession, but surgeons in general only have time to focus on surgery. Find a surgeon that embraces the TEAM approach for the rehab phase, after the surgeons have pronounced you "cured".

#7 How can I minimize the risks of re-injury when I return to activity?

     This is really answered in how can I prevent surgery?

     To summarize:

1. Gradually return to dance start with barre work and finishing with grand allegros.
2. Learn to tape your big toe joint.

3. Learn to apply hapad longitudinal metatarsal arches and dancers pads in all your shoes.
4. Make sure your Vit D, Calcium, hormones, bone density, and diet are all great.
5. Gradually learn the Good Pain vs Bad Pain principles
6. When not dancing, have supportive orthotics where you feel no pressure in the sesamoids in all your shoes
7. Learn what shoes are helpful (amount of cushioning, heel height, flexibility or rigidity, etc, can all make a difference) The Golden Rule of Foot with Sesamoids and Shoegear: Follow how you feel, not some general rule--you may be an exception!!
8. Gradually start strengthening your foot, but not through pain. There are so many ways to strengthen an injured area and the body above it. You should be strengthening daily, and keep pushing the limit. You should be biking and/or swimming if you are non-weight bearing, and  perhaps doing some thera-band and other foot strengthening techniques.

Jenni, I sure hope this helps you. Rich

South of France

Stress Fracture Foot: Followup Visit with Xrays

Patient seen on 3/30/10 with a 10 day history of pain in his metatarsals was highlighted in post entitled: Patient Footlight#1: Possible Foot Stress Fracture. The x-ray taken above was during the follow up visit on 4/7/10. The patient was already feeling a lot better with the removable cast. Contrast bathing was initiated at the 1 hot 1 cold cycle (see the post on the secrets of contrast bathing).

The x ray shows the subtle new bone formation (just above the magnifying glass marker) seen in stress fractures. You actually never see the fracture line unless the stress fracture has turned into a full fracture. The patient was again reminded about Calcium and Vitamin D. The patient will spend 6 weeks in the cast, then begin to gradually wean out of the cast over another 2 week period.

Golden Rule of Foot:The patient must be two weeks totally pain free in the cast before the weaning process begins. No increase in pain is tolerated during the weaning process. The patient is followed every two weeks. With metatarsal stress fractures, plastic orthotic devices for a balancing function (see post on Orthotic Devices: General Principles) are normally ordered 2 weeks prior to the weaning process. This insures that the patient is walking with orthotic devices and with the foot taped with every step when out of the cast.

These orthotic devices are worn for up to 2 years in athletic/strenuous activities to prevent re-injury. This particular patient walks everywhere in San Francisco in our very hard cement jungle. Taping (to be taught in a later post) is also used with strenuous activities.

Since bones first heal, then double heal, symptoms related to increased circulation can last for many monthes after the stress fracture heals. It is important to do the contrast bathing daily, and ice after strenuous activity, until all symptoms have been gone for 2 weeks straight. The contrast bathes continue to flush out unwanted swelling and the icing minimizes the aggravation of symptoms.

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?

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