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Freiberg’s advice-15 year old runner

Discussion in 'Biomechanics, Sports and Foot orthoses' started by 277podiatry, Aug 23, 2018.

  1. 277podiatry

    277podiatry Member


    Members do not see these Ads. Sign Up.
    could I please pick some brains.
    My 15 year old daughter has today seen an orthopaedic surgeon, having had an MRI to her right foot. She developed pain and some swelling to the r second met head about six weeks ago. She is a middle distance / cross country runner, and immediately stopped running after the first incident of pain. She has had no treatment to the injury other than restricting activity and use of a stiff soled shoe. Her consultant confirmed he is 90% certain she has Freiberg’s and recommends stopping running for six months with a review and re X-ray after 3 months. She had her foot initially Xrayed when it was first painful, but this showed, as far as I am aware, nothing significant. He has also suggested the use of orthoses with a met dome to offload the joint.
    Does anyone out there have an experiences of this they could share? Ie is conservative treatment generally successful? (Ie what proportion require surgery?). Is a six month rest fairly standard? Is physio of any use? Would any supplements be of help? Any other gems of wisdom?
    Many thanks
     
  2. efuller

    efuller MVP

    What did the MRI report say? (not the orthopedist, the radiologist) One would need to know this before offering advice on conservative therapy.
     
  3. Freiberg's infraction in a 15 y/o female runner may be treated with relative rest, ice and a full length custom foot orthoses with a forefoot extension to accommodate the 2nd metatarsal head and a soft metatarsal pad. I don't see a need to stop running for six months. Generally 4-6 weeks in a cam-walker boot is best followed by a gradual return to normal running activities. Your daughter need to see a sports podiatrist who regularly treats runners since Freiberg's infraction is not rare. In fact, many of the runners I have treated over the past 30+ years run without pain on healed Freiberg's infractions of their second metatarsal head.
     
  4. 277podiatry

    277podiatry Member

    Hi, Thank you for your response. The hospital has declined to pass the report to me, however they are in the process of sending the scan to me. The surgeon's letter states: "an MR scan has confirmed high signal in the 2nd metatarsal head with features consistent with early Freiberg's disease. X rays as yet show no bony changes yet to indicate Freiberg's." I hope this is of help.
    Many thanks
    John
     
  5. 277podiatry

    277podiatry Member

    Hi Kevin, thank you for your reply, it's greatly appreciated, particularly as it suggests a slightly more optimistic protocol for her treatment. I guess the use of spikes in middle/long distance events at her age seems possibly inappropriate, and not necessarily hugely beneficial to performance in comparison to the possible increase in injury, resulting from their use.
    Many thanks
    John
     
  6. Dieter Fellner

    Dieter Fellner Well-Known Member

  7. John:

    From the MRI scan report, this is possibly an early Freiberg's infraction, but without the radiographic changes to the metatarsal head, I would still treat it symptomatically. In other words, get her to a sports podiatrist who is an expert in foot orthosis therapy. Foot orthoses should be worn for both walking and running. For her middle/long distance races, an accommodative pad for the affected metatarsal head with a soft metatarsal pad attached to the shoe sockliner should suffice. However, I wouldn't allow her to continue running if any swelling is visible or there is significant pain during running. As far as spikes, I would remove any spike that is located under the affected metatarsal head and add the insole modification outlined above. Daily icing therapy will also likely be needed to continue running over the next few months.

    Hope this helps.
     
  8. efuller

    efuller MVP

    It's not all the spikes, it's just the one under the 2nd metatarsal head. I agree with Kevin's treatment plan. If you read the website that Dieter posted, you could see stage 1 with MRI findings of subchondral fracture only. Theorizing that this comes from high loads on the 2nd metarsal head, or the windlass of the 2nd ray, then Kevin's treatment plan of off weighting the 2nd met head makes perfect sense. As with any injury, the question is always can you reduce the load enough with environmental modifications (orthotic) to allow normal or high activity without worsening the injury. The only way to find out is to try the modification....and watch for that swelling or increased pain.
     
  9. 277podiatry

    277podiatry Member

    Can I please just update and seek further opinion on this case. Since previous correspondence the patient wore a walking boot for about five weeks, and is gradually returning to running plus aquajogging. She can now jog 5k in 24 minutes, with mininmal pain. Faster running or hills causes increased pain levels. Walking now is generally pain free. Pain is now mainly apparaent to the dorsum of the joint when the toes is dorsiflexed to its end range. She has been using a pair of custom orthoses as suggested. I have just taken her to a chiropractor who was formerly a physio. I have gone down this route, not for treatment but as I wanted the foot re x rayed, to establish whether any bony changes were now visible to support or otherwise the diagnosis of Freiberg's. Having a chiropractor x ray the foot is for us the easiest way of doing this. Following the xray, It is his view that the joint looks completely normal, and that the chronic injury to the forefoot would be best resolved by chiropractic adjustments to the rear and mid foot joints, and mobilisation of the 2nd mtpj. Further to this the hip needed adjustment to address any imbalance there. His view was that this could only be done by a chiropractor or osteopath. To summarise he does not believe this is a Freiberg's.
    I therefore have two questions.
    Am I right in thinking that if the injury was Freiberg's, would the bony changes associated with it be showing on X ray by now (3 and a half months after first symptoms of injury)? And, is he correct in his view that abnormal ROM at the surrounding joints of the foot , are the primary cause of the residual pain she is left with? Many thanks
     
  10. Has she been seen by a sports podiatrist yet, as I originally suggested? If not, then that is your next best plan. I doubt having inadequate "range of motion" is the cause of her foot pain.
     
  11. efuller

    efuller MVP


    To recap what we know so far. 2nd met head hurts, no x-ray changes weeks ago, MRI with high signal in 2nd metatarsal head consistent with early Freiberg's. Weeks later it feels better after rest (Cam Walker) and an orthotic designed to reduce load on the 2nd metatarsal head. However, there is still pain at high loads.

    So what is Freiberg's and what causes it. My working theory is that it is a stress fracture of the 2nd metatarsal head caused by high loads. A stress fracture (or impending stress fracture) could show up on MRI before there are x-ray changes (no fracture). With rest the body heals and there is less pain up until the point there are high stresses on the metatarsal head. It should be theoretically possible for the stress reaction to completely heal.

    Some questions:

    How far has it healed? It sounds like it was a lot better than before. If the loads stay at the current level the pain may not increase. With a little more rest, there might be more healing and this level of activity may be tolerated without pain. There is no reason that early stage Freiberg's must progress to late stage Freiberg's
    Is the orthotic off weighting it enough? Look at the wear on the orthotic to see if there are still high loads on the 2nd met head. If there are you cold add some moleskin or other thin material to the off weight pads to increase the thickness.

    As for the chiro, the fact that there are no x-ray changes just tells you that the early stage Freiberg's seen on the MRI has not gotten worse. That is useful information. I am skeptical of the story that treating limitation of motion of other joints with chiro will help 2nd metatarsal pain.
     
  12. 277podiatry

    277podiatry Member

    Thanks for your replies. Yes she now has a pair of Paris made orthoses, polypro semi flexible shell with a combination of forefoot cushion and offloading to the second met head. I saw the new X ray today, which looks completely normal. The growth plate to the 2nd met is slightly more open than the other met heads. There is a significant improvement from 8 weeks ago, as she can now run on the flat for 20 mins plus, pain free, without any post run pain. Hill running does presently cause a 3/10 pain, so she is just pulling back from hills for the next couple of weeks. She has 11 weeks until her first x country race of the year (3.5km approx), so we are hopeful she will be able to be reasonably competitive by then, as long as it is not pushed too much too soon.
    The Chiro has suggested that the only way it will properly heal, is if he or an osteopath basically pulls on the toe to illicit a click, a few times a week for two weeks! Thanks Again.
     
  13. efuller

    efuller MVP

    Yeah, it always helps if the doctor pulls the patients leg once in awhile.
     
  14. Pod on sea

    Pod on sea Active Member

    Interested in this thread as I saw a 16 y/o male patient with 3rd met head Freiberg's today (early stage, no loose bodies, met head slightly flattened). usual sports are middle distance running and Parcour. Onset was 5 months ago and has avoided sport for past 3 months. He now has no swelling and no pain with normal activities, standing and walking, except for barefoot end range weight bearing dorsiflexion (i.e. heel raise). His orthopaedic consultant has said he must not do any impact sport for another 6 months and then have a new x-ray to check if growth plate has closed. This seemed very conservative to me, but I wondered if it's usual to restrict sports for this period of time in a teenager. I've provided an orthotic with met head cut out, given shoe advice etc. Any thoughts if the time scale is different due to growth plate? Thanks, Helen
     
  15. 277podiatry

    277podiatry Member

    Hi Helen
    It is also the case that the growth plate has not closed yet with my daughter. I guess if one is being super cautious the joint may be more stable once the plate has closed, but it would be a shame to not run if a sensible graduated return is now in fact possible. Having said that, it is difficult to contradict the advice of the orthopod, especially if they referred him to you. My daughter is now progressively training harder, when, if I had stuck to the orthopod’s advice, she would still be not running at all. So I would say yes it is a conservative approach, however, probably the approach one would expect from a surgeon. From the experience of my daughter, I would say that the most important aspect of the return to running is footwear. I have realised that the three types of running shoe she was using, made her vulnerable to the injury (track trainers, x country trainers and spikes). All of these lacked adequate forefoot cushioning and were very flexible accross the toes. These have now been ditched for more appropriate options. It may even be that this summer she will not race on the track wearing spikes to protect the foot, but use a race trainer instead. I would also suggest no Parcour for the foreseeable future, as I am sure that would put significant, uncontrolled forces on the joint.
     
  16. drdachel

    drdachel Welcome New Poster

    It took me a while to find a article or thread like this that was sport specific to running. I have a 14 year old XC /Track athlete that just got out of her walking boot yesterday after being diagnosed with a stress fracture (via MRI) on 2nd metatarsal. The follow up with the podiatrist diagnosed Freiberg's disease. There were fractures on the bone which interrupted the blood supply causing avascular necrosis.

    She has a plan moving forward with limited return to cross training, followed by treadmill and then eventually running based on zero pain. They plan on getting an orthotic to take the stress off of the metatarsal. I appreciate the info on the spikes. If we get to that point we'll try and stay in racing flats and if spikes are warranted we'll remove that spike near 2nd metatarsal.

    Here's my question. What about type of shoes. Stiff forefoot? Ultra cushioning like a Hoka. Any recommendations along those lines. I found this article but it doesn't mention Freibergs, although I assume their recommendation re: forefoot issues is applicable. well.... I can't put a link but it was in podiatry today and was entitled emerging insights shoe recommendations patients.



    Thanks,
    Dan
     
  17. efuller

    efuller MVP

    I did an article on rocker tip shoes in JAPMA many years ago. I looked at the literature available at that time on reduction of pressure with various shoe modifications. Most of the research was on diabetics and walking (not running). A stiff shoe could reduce peak plantar pressures a small amount. My opinion is this is not a mechanical effect, but a behavioral effect. ( It's hard to push off the forefoot when the shoe doesn't bend.) The reduction in forefoot pressure with a rigid shoe was less than the reduction of pressure with a rocker tip shoe. Rocker tip shoes where the rocker started proximal to the metatarsal heads were the best at relieving forefoot pressure. I believe that rigid and rocker tip were better than just one or the other, but my recollection is a little hazy on that particular point. The old metatarsal bar can achieve some of this rocker effect. The Hokas have a rocker tip and quite a bit of soft midsole that would allow a prominent metatarsal to sink in to the cushioning. The Hokas are flexible, but you may not necessarily need the absolute best shoe, you just want one that is good enough to reduce pressure to allow the injury to heel. Those recommendations are good for generic anatomy. If there is some anatomical variation specific to the individual, modifications can be added to the generic stuff to accommodate further a specific problem.
     
  18. 277podiatry

    277podiatry Member

    Hi Dan
    Firstly to update regarding my daughter and her injury, which to summarise first occurred in July 2018. She is now back training as much as she needs to (5 days per week), and competing in cross country for her county. She is now pain free. It may be that her foot did not go through a complete Freibergs type process as it was caught early enough to prevent that.
    I changed all of her running shoes to options with greater stiffness to the forefoot, and used a variety of orthoses predominantly to increase the forefoot cushioning (3mm poron full length insole, with an additional 3mm forefoot pad, with cutout to second met head).
    The shoes she now uses are:
    Road/track - Asics Gel Noosa
    Off road- Addidas Terrex Agravic
    Spikes (both for track and x country - New Balance XC 7
    All of these are far more suitable for her compared to what she was previously using. I guess the Hokka would be very good therapeutically but might be a very unresponsive shoe for racing in.
     
  19. drdachel

    drdachel Welcome New Poster

    much obliged. Just to make sure I have this, best case scenario is to find a rocker tip shoe that has a rigid forefront. Thanks
     
  20. drdachel

    drdachel Welcome New Poster

    Glad to hear she's back in action. Today was day 1 back running. She got 10 minutes in on track in her normal shoes. She felt a bit of stiffness in the arches which I just assume is due to not planting and stretching the foot. I'll pass along the info on shoes. I know she's getting fitted for an orthotic soon. Going to do some major supplementing this outdoor season with elliptical and bike until we're very comfortable she's ok. Thanks
     
  21. efuller

    efuller MVP

    You don't have to have rigid and rocker. You just need good enough that the pain doesn't return with the desired activity. Some of the flexible rockers may be good enough.
     
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