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Soft casting for met stress #

Discussion in 'Biomechanics, Sports and Foot orthoses' started by MelbPod, Apr 28, 2008.

  1. MelbPod

    MelbPod Active Member


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    Hi,


    Had a young ballet dancer in this afternoon with dorsal forefoot pain localised near base of 2nd met. Most likely diagnosis is a stress fracture.
    This is my first of its kind I have treated.
    She has gone for Xrays tonight to rule out complete fracture. And I dont beleive it to be tendon related.
    Pain has been present for 1 week, I understand stress # not likely to show up on X-ray yet.
    Planning to soft cast her tomorrow with sofban and elastic bandage. Any further advise.
    Thanks
     
  2. pgcarter

    pgcarter Well-Known Member

    Is she planning to dance on it or not?
     
  3. bearl

    bearl Member

    Hey Melbpod

    Just a few questions.
    How old is she?
    Was their any mechanism of injury? ie: transferring weight too far forward while en pointe or demi pointe?
    When and what makes it painful?
    What type of dance shoes is she wearing, blocks yet?
    How many hours per week is she dancing?

    Good luck if this is your first step into the world of dance podiatry, sounds like a good one to start with.

    A word of advice. Try not to focus solely on the dancing. Recovery / school shoes / everytime she uses her feet out of dancing is critical to the treatment outcome.
    The majority of dancers don't like to alter their dance shoes, esp their blocks!

    Brenton
     
  4. MelbPod

    MelbPod Active Member

    Thanks for your replies Phil and bearl

    Phil i think if i had let her, she would have.

    The x-rays came back with a complete non-displaced fracture of base of 3rd met.

    - Pt is 17yo
    - cant remember specific trauma event, pain began after a session of dance which she tried to back up the next night.
    - currently dancing 5 nights a week (15 hours)
    - walks 2km to school each day. shool shoes well-fitting Clarks.
    - yes this is my first (stubborn) dance patient.

    I casted her in an Immobilsing foot/ankle plaster cast. I think this was the only thing that is going to keep her off her foot.

    Thanks for your input and I plan to address all issues after bone healing to assist good outcomes and prevent further injury.

    Again any feedback is warranted. (please)

    Sal
     
  5. Adrian Misseri

    Adrian Misseri Active Member

    G'Day Sal,

    I've dealt with a few dancers myself and know how much of a pain they are, especially the serious ones who will push through almost anything to continue. Good luck!

    One important thing to consider with this girl, and X-ray for after the cast comes off and/or if discomfort persists is Lisfranc fracture-dislocation of the 3rd metatarsal base. Due to the intensity of the dancing, and the amount of time this girl would be spending en-pointe, its is important that you asses the metatarsocunieform joints properly, as a small subluxation can lead to future complications. This may be a big issue if the girl becomes a serious professional dancer.

    X-ray the foot in a planntarflexed stressed weightbearing view, and look for continuity of the lisfranc area. Also on lateral oblique, the 2nd and 3rd cuineforms should line up perfectly with the metatarsal bases and form consistent longitudinal lines along the line of the edge of the met base. Also be aware for foreign bodies in the joints. It's not a common problem, but being that the majority of lisfranc injuries occur from a plantarflexed loaded postion, it should be considered.

    Cheers!
     
  6. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    I assume you mean loose bodies?

    I think a foreign body would be a very rare thing indeed.

    If the fracture has already occured at the base, then this is the area of weakness under load with this activity, and I think it would be unlikely that this would progress to an injury to Lisfrancs joint. There is typically a violent force (eg MVA) applied to the forefoot in abduction or adduction to injury the dorsal and plantar TMT ligaments, and dancing is unlikely to contribute to anything other than excessive sagittal plane load through the metatarsals and stress fatigue injury.

    Has anyone mentioned possible secondary amenorrhea induced loss of bone density as a contributing factor?

    LL
     
  7. bearl

    bearl Member

    I agree with LuckyLisfranc here Sal. This is were my age related question was leading.

    From experience with dancers (esp at this age) menstrual history, adequate rest/sleep patterns and a dietitian ax (if you feel its warranted) will help your treatment success.

    Start looking into what blocks she wears as their are a lot of different pointe shoes out there.

    Look forward to seeing her progress and the ever so fun rehab stage:bang: in 6 weeks time.

    Please keep us informed.

    Brenton
     
  8. MelbPod

    MelbPod Active Member

    Thanks for all your advise guys. Its great. Plan to check Lisfranc etc, Xray views suggessted when she comes out of cast.

    Ok heres the update:
    - she does a variety of dance (ballet, jaz, hiphop?)
    - therefore wheres differing shoes. pointe shoes for ballet, flats and runners at other times.
    - she is at a healthy BMI
    - healthy eater, regular meals confirmed by parents.
    - regular menstruation
    - healthy sleeper

    as mentioned above the fracture was not of the joint and is currently non-displaced so am expecting it to have not interupted lisfranc joint at all when healed (hopefully),

    Plan to get her into an EVA supportive orthotic throughout rehab to prevent XS stress of area. Particularly daily use in school shoes etc.
     
  9. bearl

    bearl Member

    Hi Sal

    Sounds good. Thanks for keeping us updated.

    Just to keep the discussions going.

    How did you decide on your orthotic material choice?

    Brenton Earl
     
  10. Adrian Misseri

    Adrian Misseri Active Member

    As someone who dances a bit and wear orthoses, I've found a ligher density EVA device (150-160 density) white useful as it will flex with the shoe. That being said, i wear more degid devices day to day when I'm not dancing.
     
  11. MelbPod

    MelbPod Active Member

    4 week review and Xray...
    Bone-fusion well.

    "X-ray the foot in a planntarflexed stressed weightbearing view, and look for continuity of the lisfranc area. Also on lateral oblique, the 2nd and 3rd cuineforms should line up perfectly with the metatarsal bases and form consistent longitudinal lines along the line of the edge of the met base. Also be aware for foreign bodies in the joints." (from Bearl)

    - Checked all...and all good.
    - Now in CAM Walker with EVA insole. Still nonWB at this stage.

    Any input/suggestions/advice you would like to make for rehab stage and reintroduction to dance would be great and beneficial for discussion.

    Thanks, I will continue to keep you informed

    Sally
     
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