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No stress fractures, any ideas?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Duncan Burnside, Apr 30, 2008.

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    Hi folks, help on this much appreciated.
    30yr old male.
    2wk H/O, acute left lateral FFoot pain.
    Former pro ice hockey player.
    300lbs in weight.
    no H/O direct trauma.
    Cavo varus foot, almost no calcaneal eversion, active or passive.
    severe pain on direct plantar palpation of distal 1/3 of both 4/5 met shafts and compression of Ffoot, pain very specific to this area.

    Suspected stress fracture due to extreme lateral loading and body weight, however W/B D/P and M/L X-rays normal, muscle testing was normal other than resisted eversion but pain seemed to be elicited due to lateral pressure on the 5th met, not the peroneals.

    Any bright ideas???
  2. Dunks (do you have another name?):

    This is either a metatarsal stress reaction (i.e. pre-stress fracture) or a metatarsal stress fracture. A bone scan will be positive in the latter but may not be positive in the former. MRI scan will be the only way to specifically diagnose a metatarsal stress reaction and will show bone marrow edema with no fracture line. In metatarsal stress fracture, MRI will show bone marrow edema and a fracture line. This article talks about the use of MRI in preventing metatarsal injuries in basketball players. The patient likely has a laterally deviated STJ axis, increased laterally directed ground reaction force at the forefoot as a result of the laterally deviated STJ axis, and increased dorsiflexion bending moments on the lateral metatarsal shafts that has caused the pain and the pathology.

    Try a valgus rearfoot and forefoot valgus wedge and/or orthosis to reduce the pathological forces that are causing the injury. Another possible treatment (if he is still playing hockey) is to have the ice skating blade shifted 2-3 mm laterally on the skate bottom to increase the STJ pronation moment from the ice-reaction force. Neil Humble, DPM, wrote a nice paper on these concepts using STJ axis location theory (Kirby KA: Subtalar joint axis location and rotational equilibrium theory of foot function. JAPMA, 91:465-488, 2001) to guide the treatment of ice skaters . I have attached the article below.

    Hope this helps.
    Last edited: Apr 30, 2008
  3. efuller

    efuller MVP

    I'd agree with Kevin's diagnosis and with the possibility that he mentioned. There is one other possibility and that is an average STJ axis and the classic Rearfoot varus described by Root et al. Have patient stand in angle and base of gait and assess the relative force on medial and lateral forefoot. (John Weed described putting fingers under the foot. 300lbs maybe not.) If the medial forefoot is bearing little weight a forefoot varus wedge could be very helpful. However, if he has a rearfoot varus and a laterally deviated STJ axis a forefoot varus wedge could make things worse. Another test, I call the maximum eversion height test is to ask the patient to evert their foot when they stand in angle and base of gait. A classic rearfoot varus foot will not be able to lift the lateral column off of the ground with out moving the knee medially relative to the foot. If he can't lift the lateral forefoot off of the ground try a forefoot varus wedge.


  4. Just spent 2hrs trying to make an informed response to you both and managed to loose everything.
    Duncan Burnside is my full name Kevin, and am feeling rather silly right now.
    Thank you both very much. Will respond fully after a few hours sleep.
    Apologies and appreciation
  5. would you believe, after all this time, our health service has confirmed, gout. Other factors should have been factored in to the equation all along. thanks for all assistance gents. regards Duncan

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