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Jones fracture

Discussion in 'Biomechanics, Sports and Foot orthoses' started by jimmy, Aug 7, 2007.

  1. jimmy

    jimmy Member


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    Hello All,
    An elite athlete has presented to our clinic 8 weeks post Jones fracture.He was initially treated conservatively by his surgeon via non weightbearng cam walker. He presented symptom free. He has a relatively rigid foot type that supinates thro contact and midstance phases with no obvious forefoot valgus.

    I was wondering does anyone have any thoughts on orthotic management for these types of patients to help reduce risk of re-injury?

    I presume the standard modifications would include decreasing medial arch contour and adding some form of rearfoot valgus posting??? If a RF valgus post is applied, how far could you extend the post along the lateral border?And if it is extended to be underneath the actual site of the Jones fracture, could this predispose him to re-fracturing the bone?

    Do you avoid any form of forefoot valgus posting as this would imitate the mechanism of injury (i.e. a dorsiflexion force applied to the distal 1/3 of fifth metatarsal)?

    Any thoughts would be much appreciated.
     
  2. PodAus

    PodAus Active Member

    Hi Phantom,

    Risk Mx key - Review the incident and assoc. factors (movement, technique, surface, footwear type, etc.). Address as appropriate, considering modication of technique may be important, depending upon sport. Design orthotic Rx with consideration to above.

    Consider Lat posting using PPT from Cuboid to just prox 4/5th MTPJs (cannot comment on Orthotic Rx specifically to this athlete). Trial and monitor frequently, for tolerance during WB ex. and return to competition. Taping to assist with return to intensity also beneficial.


    [I sustained Spiral 5th met # with subsq displacement 2-3mm+. Return to elite competition with full contact within 6/52 employing interferential acupuncture and herbal medicine. Above PPT modification, 'proprioceptive' taping and minor technical change to WB technique most effective for full recovery].

    Cheers,

    Paul
     
  3. efuller

    efuller MVP

    What was the mechanism of injury? If you are going to prevent a re-occurrance then you have to know what caused it. From your post it appears that you are suggesting over supination. Does the patient have a laterally deviated STJ axis. Does the pateint have normal peroneal strength? Often people who are "over-supinators" will use their peroneal muscles to keep their foot plantigrade.

    If you are talking about putting the valgus posting under a rigid orthotic there should not be excessive pressure on the 5th metatarsal shaft or base. An extended post should be benificial in a foot with a laterally deviated STJ axis. If that is what your patient has.

    Regards,

    Eric
     
  4. Admin2

    Admin2 Administrator Staff Member

  5. jimmy

    jimmy Member

    Thanks Eric, for your advice on the RF posting position.

    The mechanism of injury was an inversion type sprain, where he went to change direction while running and "rolled" the ankle.

    And yes he does have a supinated foot type with a laterally deviated STJ axis.

    cheers
     
  6. PodAus

    PodAus Active Member

    Phantom,

    That's why you must review the incident specifically. The technical components of particular sports predispose different structural presentations to certain injury patterns. This is often grossly underconsidered when assessing mechanics (as often only done in context of normal gait).

    What is the sport and what motion/ movement was being attempted at time of injury (and i don't mean inversion / supination / etc. - i'm referring to e.g. right forehand / FF ground impact post footy mark / end range golf swing / etc.)? With this athlete, changing direction when running due to? Is this a movement frequently required in this sport? How does he perform the same movement now? How is rehab being formulated to retrain?

    Traumatic impact (from tackle / standing on opponents foot, etc.) or other accidental incident is part of sport. However now injury has occurred, explore in greater detail other weightbearing activities of the athlete (for example, even driving position ia a car can impact upon recovery), and what improvements can be made to Mx risk.

    You may find he has lingering symptoms post impact activity. Review your posting / taping method regularly to manage symptoms and confidence with WB rehab.

    All the best.

    Cheers,

    Paul
     
  7. Stanley

    Stanley Well-Known Member

    Phantom,

    I am a little confused as to what you are treating. :confused:

    There are three different types of fractures that occur in this area with three different areas, three different mechanisms of injury, and locations.
    First is the avulsion fracture (also called the Pseudo Jones fracture of Dancer’s fracture) It’s mechanism of injury is inversion. The fracture occurs on the styloid process.
    Then there is the Jones fracture that occurs in the body of the tuberosity of the fifth metatarsal and extends into the area of the fifth metatarsal cuboid joint. The mechanism is related to rotation with the foot plantar flexed.
    In the same location or distally at the diaphyseal-metaphyseal junction is the third fracture, the stress fracture of the fifth metatarsal. The mechanism is a repetitive motion injury which depending on what you read can be pure sagittal plane dorsiflexion moments to dorsal medial moments (with the foot slightly inverted).
    You stated "the mechanism of injury was an inversion type sprain" which is consistent with a Dancer's fracture. You also stated "he changed direction" which is consistent with a Jones fracture.
    Because of the acute onset, we are not dealing with a stress fracture, so we need to be clear as to whether this is a Jones or Dancer's fracture. Where exactly is the fracture located on the fifth metatarsal?

    Regards,

    Stanley
     
  8. efuller

    efuller MVP

    I was thinking further on this. A forefoot valgus wedge won't put to much pressure under the 5th met shaft if the the wedge does not try to evert the foot farther than it can go. Some feet when the subject is asked to evert their foot will have zero lift, others have as much as an inch and a half of range of motion to evert their lateral forefoot off of the ground. In classical terms this is range of motion of the midtarsal joint as well as the STJ. I have seen patients that do get excessive lateral load with too much wedge.

    Cheers,

    Eric
     
  9. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    Stanley

    (The) Phantom has already told you - re-read the initial post. This is a Jones fracture we are dealing with.

    Bottom line is: was this bad luck? - most Jones factures seem to be a one off event. Or, are there enough significant biomechanical issues at play to be wary of another of these injuries in the future. This is an elite athlete.

    Since we have been told that he has a laterally deviate ST axis and sounds like a typical cavo-varus foot type, then appropriate orthotic Rx should deal with this as the other posters have suggested.

    If conservative measures were to fail and other lateral column symptoms developed, one could consider the results of a Coleman block test - as to wether a dorsiflexion wedge osteotomy (DFWO) might be prudent to reduce the forefoot deformity and allow the talus to come back down and adduct - shifting CoP medially.

    Just a thought.

    LL
     
  10. Stanley

    Stanley Well-Known Member

    Lucky,
    Thanks for clearing this up. :)
    So could you please explain to me how the appropriate orthosis will negate the force that causes the Jones fracture (That is, rotation with the heel off the ground {in other words twisting}). :confused:

    Regards,

    Stanley
     
  11. Nat

    Nat Active Member

    I was thinking along the same lines. In a textbook Jones fracture, the patient is on the ball of the foot, with the heel off the ground at the moment of injury. The orthotic is not functioning in any way at this point, is it? It's just "along for the ride" inside the shoe.

    Nat
     
  12. Stanley

    Stanley Well-Known Member

    Nat, It all depends on whether the material is under the metatarsal heads.
    So far all the posts have discussed posting proximal to the metatarsal head, so I tend to agree with you.

    Regards,

    Stanley
     
  13. Nat

    Nat Active Member

    Do you guys make orthotics with semi-rigid or rigid shell material under the metheads? I tried it a few times with eva posting to the sulcus with less than happy patients.

    I may use a full-length shell in cycling-specific devices now, but not in anything requiring normal walking.
     
  14. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Typically I will use a Fettig modification (ie proximal to 5th MT head), or extrinsic FF valgus post. Never extending out under the MT head or MTPJ.

    In response to the issue of foot position and mechanism of injury with Jones fractures - there needs to be some axial and lateral stress on the MT to produce the fracture. Whilst an orthotic is not the complete answer when the heel is off the ground, enough shift in CoP across the MT heads towards medial may be of help...Hence my suggestions above. Naturally, landing badly after going up for a jump with basketball is always going to be a problem, but this approach may help those that simply do a lateral ankle 'sprain' with a simple mis-step sue to uneven surfaces.

    I agree it is a difficult area. But in an elite athlete with a cavo-varus foot type, I think it would pay to try and do what you can to proxide a pronation moment across the STJ.

    LL
     
  15. Stanley

    Stanley Well-Known Member

    Nat,

    That is very insightful of you. :cool: You cannot make non flexible materials end past the MPJ's as they act as splints/ :eek: You can use flexible extensions (top covers with flexible materials underneath).

    20 years ago I rode, and made myself a full length plastic device orthosis (to increase stiffness). A little trick I also added was using a met pad, so there would be increased efficiency in the pull back part of the stroke (the foot to the shoe) :) Remember the bottom of the counter is the stiffest, and if you pull against this rather than the top of the counter, you will be more efficient. The met pad doesn't allow the foot to slide back on the orthosis, so the orthosis gets pulled back also, and this is resisted by the bottom of the counter.

    Regards,

    Stanley
     
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