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Cortisone for stress fracture treatment

Discussion in 'General Issues and Discussion Forum' started by DrZetter, Oct 16, 2013.

  1. DrZetter

    DrZetter Member

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    I do not think this is an appropriate treatment method for a stress fracture, however I do have a patient who was convinced by her DPM to give a round of cortisone a shot to treat a metatarsal stress fracture. I am a chiropractor so this sort of treatment is out of my scope, therefore it is not even an option for me, yet, I would never be inclined to refer a stress fracture case out for cortisone. Have a missed something in the recent years? I hate telling patients that the previous course of treatment was inappropriate, but I do find myself a bit dumbfounded by this approach from the DPM.


    Megan Zetter, DC
    Portland, OR
    Ultra Chiropractic and Rehab
  2. Craig Payne

    Craig Payne Moderator

    Are you sure that the patient got it right? I have never heard of cortisone being used for a stress fracture, except once - in that case it was misdiagnosed as "capsulitis" and they were given the cortisone for that by the family doc.
  3. DrZetter

    DrZetter Member

    That's exactly what I thought too, "Huh, what?!!" Yes, it was a cortisone injection.
  4. Paul Bowles

    Paul Bowles Well-Known Member

    Post forefoot surgery dexamethasone is used liberally as it reportedly provides excellent post operative pain relief. Is it really that different? Food for discussion!
  5. DrZetter

    DrZetter Member

    Is pain relief really a goal when treating a stress fracture though? Yes, you want the patient comfortable, but typically with some off loading, appropriate rest and protection, that happens organically. A false sense of "healing" is not what a highly active runner (my patient) needs.

    Thanks for your input.
  6. terigreen

    terigreen Active Member

    Medical / Legal one would never give a cortisone shot for a stress fracture. The lawyers would eat that up.

    Atlas Biomechanics
  7. DrZetter

    DrZetter Member

    I didn't want to say that, but that is exactly what I was thinking.
  8. terigreen

    terigreen Active Member

    But is probably would help the pain, :rolleyes: I had a stress fracture as a kid and I know that they hurt. All my doctor did then was tell my mom to make me wear hiking boots.

    Atlas Biomechanics
  9. Lab Guy

    Lab Guy Well-Known Member

    How is 4 mg Dexamethasone mixed with a local anesthetic combined with appropriate off-loading going to make a stress fracture worse?

  10. drsarbes

    drsarbes Well-Known Member

    First: I think our image and even our definition of what a stress fracture is can vary.

    If you are dealing with a typical "stress" fracture, say 2nd metatarsal, that hardly even shows up on an xray, then yes, if it's been 3 or 4 weeks and the patient still has inflammation, then I would inject a short acting cortisone.

  11. DrZetter

    DrZetter Member

    What is the benefit? Less pain? I've had three calcaneal sfx and yes, they were painful/uncomfortable, but not so bad that my daily life was impacted from
    the pain. You have the weigh the risk to be benefit ratio. And people being what we are, less pain often makes one think that they are healing. This would not be true. And in the case of an athlete they would likely resume training too soon. Additionally cortisone slows the healing process.
  12. terigreen

    terigreen Active Member

    Dr. A: Yes it most likely would help with the inflammation pain and no problems would occur. But and it is a big butt, if anything and I mean anything wrong happens with the stress fracture our legal "profession" would be licking their chops.

    Atlas Biomechanics
  13. drsarbes

    drsarbes Well-Known Member

    Dr. A: Yes it most likely would help with the inflammation pain and no problems would occur. But and it is a big butt, if anything and I mean anything wrong happens with the stress fracture our legal "profession" would be licking their chops.

    I don't see this as a big deal. I'm not sure where you practice or what type of practice you have, but we inject dex routinely post op ortho procedures. With a simple stress fracture...the ones you see sometimes several times a day...sometimes they do still hurt even after several weeks. Xrays at that point look good with good bone callus. Cortisone is not contraindicated here.

  14. Paul Bowles

    Paul Bowles Well-Known Member

    Less pain - check
    Better return to function - check

    Doesnt better better return to function lead to more weight bearing and more weight bearing lead to osteogenisis!

    I love science!
  15. DrZetter

    DrZetter Member

    NO, you can't rush nature. Bone takes upwards of 16 week,s and sometimes more, to be strong enough to withstand high mileage running. Take it from me, I have had a calcaneal stress fracture for over TWO years. It barely hurts, just a slight irritation, but if I do too much on it the damn thing will never heal -- so it seems. Inject me with something that diminishes the annoying sensation even more, I'd be out there running and, sure as you know what, making it worse.

    Pain is a good thing. Chronic pain is a whole different beast, but pain from a fracture or acute injury is necessary to protect us from further injury. Blunting pain via chemicals also blunts the natural healing process, osteogenesis included.
  16. drsarbes

    drsarbes Well-Known Member

    "Blunting pain via chemicals also blunts the natural healing process, osteogenesis included."

    Hmmmmmm. Really.

    Guess we'll stop Rx oxycodone post operatively, or injecting Marcaine for pain control, or morphine drips or paravertebra injections for back spasms, on and on.....

    Let's not get carried away here. We're talking about a simple met stress fracture not a crush injury. The old adage about metatarsal stress fractures is true...."as long as the patient and the foot are in the same room, it will heal."

    Patients come to us, 99 out of a hundred, for pain relief. What good are we doing if they leave our office in as much pain as when they entered?

  17. Paul Bowles

    Paul Bowles Well-Known Member

    So why do we weight bear most post surgical stable osteotomies and minor traumatic fractures immediately? The standard of care for your patient with a stress fracture would be camwalker for 6-8 weeks on diagnosis. Is this not weight bearing?

    Sorry Dr Zetter you don't seem to be abiding by the rules of evidenced based medicine or normal physiology. "Would you care to explain your statement that blunting pain also blunts the natural healing process" as far as osteogenesis is confirmed? Surely it is far better to return a patient to protected normal function to assist with osteogenesis and cortical bone healing rather than palliate them, off weight bear them and take them away from all physical activity.

    I'd hate to ask your thoughts on internal and external bone stimulators!

    As a Chiro do you manipulate these sort of patients?

    I'm with Dr Sarbes above and agree whole heartedly!
  18. DrZetter

    DrZetter Member

    I don't want to get in a battle over this. My question was simply, is cortisone something that a doctor would use as a treatment for a stress fracture. As far as pain goes, YES, I strongly feel that artificially decreasing pain sets a patient up for continual aggravation as they will not sense that the injured area is still vulnerable. If the patient was 100% compliant, wore a cam boot, and if needed, was non weight bearing for some amount of time, some form of pain relieving method would not be harmful. But I'm talking about and referring to is a high level athlete who is very anxious to return to running. I know without a doubt, that given a way to mask the pain, she will run.

    And NO I do not manipulate a broken bone!!! Soft tissue work and gentle mobilization to facilitate blood flow and to reduce adhesions, yes, but absolutely no HVLA. Don't insult me.

    And YES, I'm very much aware of and recommend "bone stimulators", class IV laser and microcurrent for my fracture patients. Of course this is in addition to the regular course of care: protection and rest.
  19. Paul Bowles

    Paul Bowles Well-Known Member

    I didnt try to insult you - I asked a question - see I am not a Chiropractor and nor do I profess to know how or why a Chiro treats certain things. I actually posed a comment for thought which was relevant to your initial question. In fact now we know you are dealing with a high level athlete I would suggest return to activity is even more important in their rehabilitation and management. If you patient is compliant and happy to follow recommendations to quickly return to activity they will usually do anything to achieve a positive outcome.

    I think you have answered your own question - and I believe several posts her have given you answers as well.

    There are a million ways to skin a cat. Generally one persons views are not the only way to achieve an outcome.

    May I suggest an easy outcome to this - maybe call the Dr involved and discuss the case with them seeing as though you share a common patient. This can only benefit the patient and is an extremely pro active gesture to improve the patients outcome. Maybe ask the Dr why they chose to do this and their rationale for it. This will provide you with their direct opinion on your patient.

    In the end id imagine on a forum like this you will get a miriad of research, clinical and opinion based answers. All would have their individual merit.
  20. David Wedemeyer

    David Wedemeyer Well-Known Member


    As a fellow DC with a somewhat lurid obsession with the foot and ankle I have seen this type of question arise numerous times over the years. Drs. Sarbes, Bowles and Steve are very experienced and accomplished podiatrists, I've read their posts for years and they are always spot on. I wouldn't doubt their opinions and recommendations. Philosophical differences aside regarding drugs, we dont typically treat stress fractures so why would we second guess their physician?

    I have seen a number of stress fractures where injections of steroids were given for the pain. I don't profess to know much about different steroid preps or drugs in general but dex diluted as Paul describes is much less likely to disrupt healing than poor offloading, rehab etc.

    I agree you should call the doctor and keep an open mind.

    Best regards,
  21. DrZetter

    DrZetter Member

    Actually, I do treat stress fractures as my practice is sports focused with a strong emphasis on rehabilitation.

    Thank you for your input. Regardless, I don't feel that cortisone is proper or indicated, and as some have eluded to, possibly on the boarder of malpractice, treatment option for a stress fracture. But again, my question was whether or not this was a way some doctors, specifically, DPM's treat/address a stress fracture as I was quite surprised by this approach.

    Clearly, as with everything in life, opinions differ. I appreciate the discussion.

    Thank you and I bow out of the conversation. I gathered enough thoughts on the matter.


    Dr. Megan Zetter
    Ultra Chiropractic and Rehab
    Portland, OR.
  22. Paul Bowles

    Paul Bowles Well-Known Member

    ...fair enough everyone is entitled to an opinion. However every day I see lots of patients who have back pain and neck pain but would never comment to them on their manipulation regime by their chiropractor and never would I suggest to them that the treatment they are undergoing from that professional may border on malpractice...

    Discussions like this are professional and very helpful and hearing different opinions always stimulates my thoughts on my own clinical practice. I'd be interested if you could elaborate for us how as a Chiro you manage stress fractures in your clinic? I take it from your above comment you don't manipulate - but you do some sort of soft tissue work. I would be keen to hear what soft tissue work you perform as well as any other pearls of wisdom you may care to impart. I think the broader the understanding we all have of each other work the better off our patients may in fact be. Its not about litigation but about making the patients life and recovery better.

    As fate would have it last night I had a patient present to our clinic and after radiology have just discovered she has a stress fracture in her 3rd metatarsal shaft as well as secondary 2nd MTPJ synovitis and base 2/3 synovitis/effusions.

    Oh the irony of it all..... :)
  23. DrZetter

    DrZetter Member

    OK, you drug me back in.

    How do I treat a stress fracture? In the initial stages, probably not much different than any physician.

    Acute phase:
    cam boot, crutches if needed, rest
    address nutrition if it's poor
    soft tissue work. Depending on where the fracture is. If in the foot, for instance, I focus on the leg; gastroc, soleus, peroneals, etc. I either use IASTM or just my hands. I do this to facilitate nutrient exchange as immobilization creates stagnation and contracture of the muscles, which decreases blood flow to the foot. This also helps when it comes to the rehab phase as you are less likely to have to deal with additional problems due to significant stiffness of the muscles, (ten/lig) and joints. I tend to stay away from the fracture site for at least 3-4 weeks

    Post acute
    get them weight bearing if tolerated
    maybe some light resistance work for the leg
    more soft tissue work

    Rehab phase:
    assess movement patterns/gait to determine whether or not the fx was a result of biomechanical issue
    retrain balance
    regain strength
    slow return to normal ADL's
    return to sport/activity

    If the athlete has recurring sfx's I order blood work. Females; address triad if it's there. Nutrition.

    I will also address other areas of the body that may have been taken on more load due to the boot and/or compensations. The opposite hip often takes quite a beating in those who walk around in a boot for a long period.

    I'm thorough. And my tool bag includes a lot more than just manipulation. In fact, HVLA is often at the very bottom of the treatment protocol for a lot of conditions that I treat.

    My approach to nearly all patients is that of chiropractor, physical therapist, athletic trainer and teacher. I address the whole person. Mind you, my approach is not the norm in the chiro world. I enjoy sports and treating athletes and I have excellent results with this approach. The less I have to see a patient is my gauge of success.

    Any other questions?

    Oh, and edited to add:

    To address your opening statement of your last post. Manipulation of the spine can be both extremely helpful and in some cases the exact opposite of what a patient needs. There is a lot of literature to support HVLA for chronic low back pain. There is also a lot of literature that supports physical therapy. And some the supports medication and surgery. So what really works??? Additionally, whiplash injuries and or neck pain do quite well with some form of manipulation. Whether that form or manipulation is HVLA, gentle mobilization or soft tissue work depends on the stage, presentation and patient history and tolerance. Blanket statements about what any practitioner does, does very little to facilitate co-management of patients. I appreciate you asking for details of how I would treat a stress fracture. All that said, I'm more than happy to refer out when I feel as though I cannot help someone.

    Dr. Megan Zetter
    Ultra Chiropractic and Rehab
    Portland OR
  24. Lab Guy

    Lab Guy Well-Known Member

    QUOTE=DrZetter;321686]I do not think this is an appropriate treatment method for a stress fracture, however I do have a patient who was convinced by her DPM to give a round of cortisone a shot to treat a metatarsal stress fracture. I am a chiropractor so this sort of treatment is out of my scope, therefore it is not even an option for me, yet, I would never be inclined to refer a stress fracture case out for cortisone. Have a missed something in the recent years? I hate telling patients that the previous course of treatment was inappropriate, but I do find myself a bit dumbfounded by this approach from the DPM.

    Dr. Steve Arbes wrote, most foot surgeons give post-op injections using cortisone even after an osteotomy was performed (a surgically induced fracture). I agree with him as it is also my experience that post-op cortisone injection reduces inflammation and swelling within the tissues leading to a faster recovery rate and a decrease in pain.

    Cortisone comes in different levels of potency and duration among other things. I am sure Dr. Steve Arbes would agree that for a stress fracture, 1/2 ml (4mg/ml) of Dexamethasone sodium phosphate mixed with a long acting local anesthetic would be used. How much cortisone is that? 2mg.

    Why use Dexamethasone? It has low potency, rapid onset and a short duration as its crystal free so its not going to be hanging around long unlike Triamcinalone that is much more potent at 40mg/ml and would be contraindicated for the use for stress fractures or post-op injections after bone surgery.

    Injecting stress fractures with Dexamethasone together with local anesthetic serves to decrease the inflammation and break up the pain cycle. This is only one component of the treatment. A metatarsal pad/dome is then applied under the area of maximal tenderness that is palpated dorsally to decrease the dorsiflexing bending forces by shifting the ground reactive forces proximal to the metatarsal head. I will apply a strapping to support the foot and even cover it with an unna boot and wrap coban over it. I will dispense a stiff soled post-op shoe to negate the propulsive phase of gait and further reduce the bending forces. I Rx rest, ice, Motrin.

    Lastly, I educate the patient. I tell them that it is good that we caught it early because if we did not, they would have a displaced through and through fracture and they would need open reduction and internal fixation. I tell them this would lead to shortening of the bone which would lead to increased risk of stress fractures to the adjacent bones. By the time I am done educating them regarding the risks and consequences of returning to their sport prematurely, they always choose to be compliant.

    I have always chosen to do what I deemed was for the highest good for the patient, not the lawyers. I have given a zillion cortisone injections for stress fractures to immediately reduce pain as well as after reconstructive bone surgery and cannot recall one problem. I do not give cortisone injections when there is a great deal of osteoporosis or if an infection is present.

    To prevent reinjury, I use the Tissue Stress approach together with SALRE to ascertain why the lesser metatarsal developed the stress fracture in the first place and how best to reduce those forces while not creating another problem. I will do a biomechanical exam and gait analysis. During gait, I will see if they have a back issue (scoliosis) a pelvic tilt on one side (indicating a Leg length discrepancy), genu varum/valgum, et. We look at the mechanics of the entire body as function follows structure.

    In this case, I would not be surprised to find a foot that has low forefoot dorsiflexion stiffness so the medial longitudinal arch substantially lowers during early and late midstance. The large pronation moment at the ball of the foot is a result of a large moment arm from the medially deviated STJ axis (especially in the presence of contracture of the gastroc soleus complex) creating dorsiflexion of the forefoot on the rearfoot.

    During stance, the intrinsics are overworking and become weakened trying to decrease the pronation moment I would expect to see subluxed MPJs due to an imbalance of the extensor hood mechanism from the overworked interossei. Due to the decreased stiffness of the plantar ligaments and plantar fascia, the Medial longitudinal arch lowers further in the face of external pronation moment from the ground overpowering internal supination moments.

    In the propulsive gait, there will be an increased dorsiflexory moment under the lesser metatarsal head due to the loss of the help of the retrograde force from the base of the proximal phalanx to create a counter plantarflexory moment. The first metatarsal is dorsiflexed compared to the adjacent mets and patient may have a forefoot supinatus from the medial column being overloaded. Internal stress of the lesser metatarsal is unable to resist the GRF in late midstance and propulsion and thus a bending moment occurs that will lead to another stress fracture with overuse.

    For treatment, I will design an orthotic with the appropriate design kinetic variables to take stress off the affected anatomical area. I will also Rx stretching for those muscles that are tight. As a Podiatrist, I will do my best to ascertain the kinetics behind the injury so I will have the knowledge to best prevent a reinjury.

  25. DrZetter

    DrZetter Member


    Thank you for your thorough response. How would you treat a recalcitrant calcaneal sfx? One that is not overtly painful, but nagging, persistent, and limiting ADL's? Cortisone, so it was no longer on the pain radar?
  26. drsarbes

    drsarbes Well-Known Member

    Hi Dr Zetter

    Well, a proper treatment always begins with an accurate diagnosis.

    If I recall correctly from an earlier post, you have had a stress fracture of your os calcis which is of chronic duration, over two years.

    Unless you have recurrent stress fractures, your original fracture would be healed by now (assuming you are "healthy') thus either your original diagnosis was incorrect or you have concomitant pathology.

    As a specialist, we get a bit more specific with symptoms and treatments. To say you have "heel" pain after a year or two post stress fracture is really not enough information to base a treatment plan on. There are, as you know, many many structure/system/mechanical aspects of your ongoing symptoms that may be responsible. These need to be assessed first hand.
    Best Guess approach via Podiatry Arena may be entertaining, but I doubt it would be very productive in your case.

    I would seek out a foot/ankle specialist (perhaps one involved in sports medicine) to start from scratch and see if he/she can help you.

    Good luck

  27. DrZetter

    DrZetter Member

    Just to be clear this thread was not about me, but rather my patient, as I would not let anyone inject cortisone into a fracture. That said, regarding my own foot, which I have posted about in the past on this forum.

    Proper dx: Six radiographs over the past two years, the most recent being about five weeks ago. One MRI about six months ago. All confirm/visualize a fracture, zero soft tissue pathology. That said, the most recent radiograph did show signs of positive change, ie more trabeculae, less prominent callous.

    My health: labs: CBC, chem, thyroid, Vit D, blah, blah (I feel like a lab rat with all the needles that have been in my arm) are normal. Cycle: normal. Weight: normal. Nutrition: good etc, etc. I'm healthy.

    Bone density: 130% of normal

    Office visit last month with an orthopedist who works at a bone and fracture clinic and who specializes in feet and ankles, after seeing my work up, say my bone looks normal and that it should be healed by now. So then he throws out every possible reason for heel pain. So pretty much what any lay person would come up with via an internet search. The funniest thing about the visit is he commented on how tight my Achilles and gastrocsoleus were. I was thinking, yep, that is what happens when you wear a boot and or are unable to utilize a joint complex properly.

    Two visits to a DPM (same one). He actually offered a possible treatment: basically mirco fracture to the calcaneus. He said he only knows of one doctor who did that and that was during his residency. I read the article and patient was not suffering from a stress fracture, but rather a non-union that was obtained traumatically. If you are familiar with this procedure or have done it yourself I'd love to hear more.

    So why am I giving all this information and why am I not happy with trying to diminish pain in someone with a stress fracture, hence the cortisone questioning? Because of my own experience. Two+ years, the 23rd of this month will be 25 months since initial onset, is as you have said, and I fully agree, abnormal. However, my pain, which has never been pain, but rather an annoying sensation, has always been so low grade that had I not had any imaging (or a sfx seven years ago so I'm familiar with them) one might think they may just have something mildly wrong with their foot. That said, if said person partook in high impact activity, they would be in a world of hurt. So injecting this hypothetical person with an agent that reduces sensation, would surely make them worse. Less pain = more activity.

    Back to myself: Last summer, May, up until July, I had resumed a fully active life. Hiking, running, no limitation in my activity. July 6th on a 6 mile run, I re-fractured it, but of course we all know that that was a slow build-up and it just happened be on that run that I finally re-injured it enough to produce pain. And ever since it's been a back and forth battle. Boot, feels better, start weight bearing, walking only (absolutely no running, biking, etc), and sure as sh*t a week later or often sooner, all symptoms return and gradually get worse if I don't get back in the damn boot. Treatment other than boot and rest have included bone stim 2x/d for 2 months (I no longer have the unit, a friend with the company loaned it to me and needed it for another patient) Class IV laser upwards of 5x/wk, microcurrent nightly, so 6-8 hours. What more can a person do? I'm not asking for advice or treatment options, that was a rhetorical question, but my experience clearly illustrates that the lack of pain does not indicate that the body is healed. What is my next course of action: more boot.

    Anyway, this thread morphed into something that was not intended.

    Thanks again for all the input. It was educational.
  28. drsarbes

    drsarbes Well-Known Member

    Dr Zetter

    I'm sorry about your continued pain and frustration. I can understand it.

    As a quick side-bar...may I say that MRI scans are not always conclusive or all-seeing. Very high percentages of significant injuries (such as linear tears of peroneal tendons) are missed on MRI. So just because "no soft tissue" pathology was visualized does not necessarily mean that there is none.

    Assuming, again, that these are true stress fractures and you have no underlying mechanical or physiological predisposition to them, I would suggest a bone stimulator. I have had great results with them in treating recalcitrant fractures, delayed healing, etc.....I have found the Exogen by Smith & Nephew to be the best that I've used (no, I don't get a kick back!)

    Otherwise, as I'm sure you can appreciate, it is very hard to give any productive and meaningful advice without an examination.

    Best of luck

  29. DrZetter

    DrZetter Member

    Yep, been down the Smith and Nephew road. My friend is a rep. Had the stim for two month. Used it twice a day AM and PM. Re: soft tissue. I'm 100% confident that it's bone. I have done zero activity to create a ST injury. Additionally the pain has always been the same (varying levels of discomfort) and in the same place. It's a stress fracture. Thanks for your thoughts.
  30. Lab Guy

    Lab Guy Well-Known Member

    As usual, Dr. Arbes provided excellent advice.

    In regards to your above question, cortisone is contraindicated for treatment of a recalcitrant stress fracture to keep the pain off the radar.

    I also emphasize with your prolonged ordeal. You really need to see a specialist that can really key in to why your developing the stress fracture in the first place. It appears to be from overuse, mechanical overloading from your marathons, but you need a complete biomechanical exam and gait analysis (includes running) to ascertain if faulty mechanics is contributing to the problem to come up with an appropriate treatment plan to prevent recurrence.

    You can research extracorporeal shock wave therapy as this may expedite the healing of your delayed/non union of your stress fracture. Here is one link:


    Have you ever considered Yoga?:dizzy:

  31. DrZetter

    DrZetter Member

    I've seen a specialist. And I cannot run, therefore a gait analysis is a moot point. My walking gait is even altered so there would be nothing gleaned from that. The contraction of the gastroc --- Achilles tractioning the bone is the main issue. A cam boot to the knee is superior in my case than a short one as it completely limits talocrual and Subtalar motion. As well as greatly minimizing muscle contraction. Over use is not an issue as I do nothing other that ADL's.

    I will research extra corporal.
  32. efuller

    efuller MVP

    Interesting discussion. I'll just throw out a couple of points.

    When a stress fracture hurts, where exactly is the inflamation? Is it inside the bone where you see increased marrow edema? Is it the callus formation on the outside of the bone. If it is on the inside of the bone how is an injection going to get the medication to the location of the inflamation? (Post op is a different beast because there will be a lot of soft tissue inflamation from the dissection of the surgery to get to the bone.)

    The mechanism of action in the reduction of inflamation of steroids is the inhibition of protien synthesis. If we want a fracture to heal, I would think that we would want protien synthesis to occur. However, I could see the argument that too much inflamation can impede repair.

    I can see both sides of the we should relieve pain versus pain is preventing this person from reinjuring their foot debate. Yes stress fractures should heel within 6 weeks if the person is not weight bearing. However, if everyday activity caused the injury in the first place then wouldn't be reasonable to expect the injury to re occur if the mechanics of everyday activities is not changed?
  33. Lab Guy

    Lab Guy Well-Known Member

    My fault, I was not clear in my last post. I meant that after your stress fracture is completely pain free, then be evaluated by a specialist with an interest in biomechanics. I know your not running now, I was referring to your marathon running in the past in regards to your injury that is now recalcitrant to healing.

    When your allowed to stretch your gastroc soleus complex, active isolated stretching is excellent which you are probably aware of already. http://www.amazon.com/Active-Isolated-Strengthening-Mattes-Method/dp/0965639630

    Tightness of both the achilles and the plantarfascia does pose a problem as you have two forces pulling on the calcaneus in different directions. Still, it is an enigma why you have not healed as you have rested it in an AK camwalker.

    Hope you make a full recovery,

  34. Paul Bowles

    Paul Bowles Well-Known Member

    If it looks like a duck and quacks like a duck.......

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