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

Developed a Stress Fracture: Consider Bone Density Screening

Bone Density Screening can begin can begin probably around 20 years old and normally tests the hip area and the lower back area. This image and graph is of one spot on the neck of the femur near the hip joint. The screening is calibrated by 2 methods for accuracy--- T scores and Z scores. Above the middle line for your age is normal density for age, height and weight. This patient score was right on the line, so borderline bone weakness. 

Before classifying a patient, 5 spots on the hip are used. The above image is a summation of these 5 spots indicating the bone density of the hip area is osteopenic (weakness) with a higher likelihood of fracture. I want my athletes well above the middle line. 

The lower back bone density screen uses 4 spots from L1 disc to L4. This is a different patient (my wife Pat) that is off the charts strong. I could not resist bragging!! Go Girl!!

The patient seen in the first two images had a low bone density at the hip and also a low bone density at the spine shown above. Compare her back bone density to my wife Pat's bone density. Pat works out 6 days a week and uses muscles in the low back doing her Pilates, Yoga, running, and spin classes. It is muscle contraction that pulls on the bones of the low back that give it strength.

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. 

Vitamin D Deficiency: A Podiatrist View on the Crisis

http://www.dreamstime.com/free-stock-image-umbrellas-on-the-beach-rimagefree1019661-resi2565486

Wouldn't you just love to be there? Where ever it is!! Of course, I have been stuck in the coldest summer in 40 years in San Francisco, California, which makes my day dreaming even worse. The image of the umbrellas on the beach highlights our need to protect our skin and avoid sun exposure. We lather up the Sunscreen as dutiful health conscious individuals but one of the side effects is a sudden crisis in Vitamin D Deficiency. What is the big deal? Vitamin D is essential to move calcium into your bones. As a podiatrist, I see too many patients low on Vitamin D and developing stress fractures and joint problems. So, find out your Vitamin D level (read the link below) at your next blood test.

http://www.vitamindcouncil.org/health/deficiency/am-i-vitamin-d-deficient.shtml

http://www.drblakeshealingsole.com/2010/04/patient-footlight-1-followup-on-foot.html