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Recurrent stress fracture of 4th met shaft

Discussion in 'Biomechanics, Sports and Foot orthoses' started by wigs, Mar 25, 2013.

  1. wigs

    wigs Member

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    Hi all,
    Does anyone know if there are any specific ways of reducing bone stress of the 4th metatarsal shaft?

    Patient details:
    21 year old amateur aussie rules football player.
    MRI shows acute stress fracture of 4th metatarsal shaft, in same spot the patient had a stress fracture about 10 months ago. Back then he rested (no CAM WALKER) and returned to sport after 5-6 weeks, has had no pain until this recent incident.

    He's in a Moon Boot now.

    I haven't seen him in the clinic but he's obviously putting excess load through his 4th met shaft while playing football, resulting in the second fracture in the same area. The only thing I know about his feet is that he has a short 1st metatarsal.

    I understand that a short 1st met puts excess load onto the distal 2nd shaft, does it have a similar affect on the 4th met shaft too????
    Would a Morton's extension be worthwhile for such a patient? I'm obviously cautious of using a Morton's extension with its affect on Windlass.

    I will recommend a more supportive/robust footy boot as opposed to the light/flimsy almost minimalistic footy boot he told me he has been wearing

    Are there any specific orthotic modifications/characteristics that people use or know that decrease load through the 4th met shaft?

    I've heard of pods sending footy boots to boot makers to have them "reinforced" to reduce the amount of flex at the forefoot to reduce the load on the metatarsals during the propulsive phase of gait. Is this an effective addition?

    Any suggestions would be appreciated.

    Adelaide Podiatrist
  2. efuller

    efuller MVP

    There are two foot types that tend to put high load on the lateral forefoot and they have entirely different treatments. One foot type is the laterally positioned STJ axis foot (oversupinator). This foot usually, but not always, has additional range of motion in the direction of eversion. (Coleman block test). The other foot type is the partially compensated varus foot. This foot does not have any further range of motion in the direction of eversion and in stance you will be able to slide your fingers under the medial forefoot, but not the lateral forefoot.

  3. Ian Drakard

    Ian Drakard Active Member

    Might also be worth checking where the the stud positions sit relative to his foot. If there's one sitting under the 4th met head/shaft on a light boot it may be contributing?
  4. wigs

    wigs Member

    Thanks for your reply Eric and Ian.

    I won't be assessing the patinets feet until he can w/b pain free to get more accurate look at what his feet are doing, without any compensatory limp.

    Eric, from the two foot types you mentioned the one where the rearfoot has enough ROM in eversion and is correctable with the coleman test would I be right in saying that the orthotic should have a lateral skive in the heel cup to "push" the r/foot closer to neutral? The 1st ray would obviously have to be mobile for this to be successful. Would you suggest any wedging in the f/foot? My first thoughts would be a valgus f/foot wedge (thin under 1st met, thick under 4th and 5th) this may make the foot look better (closer to neutral) but would this f/foot wedge put more load on the lateral f/foot?

    In the second foot type you mentinoed - orthotic wise one would have to add a f/foot varus wedge (to bring the ground up to the foot) as there simply isn't enough ROM to correct the R/foot. Would you agree with this?

    Yes Ian I will assess his boots and stud position(s).

    Does reducing the flex of the forefoot of the shoe/boot put less stress through the lateral mets?
  5. efuller

    efuller MVP

    The reasoning that I would use the lateral skive is to increase pronation moment from the ground.

    The lateral skive and the forefoot wedge are both things that could be added. I really like making an orthotic with an intrinsic forefoot valgus post for met head problems as the forefoot valgus "wedge" is added proximal to the painful area.

    Yes. The forefoot wedge should be used because it works after heel off in gait, whereas rearfoot correction doesn't.

    I agree with this

    I don't have data on that, but it's plausable. There is data that a rigid shoe (full length rigid) will reduce pressure on the medial forefoot.

  6. wigs

    wigs Member

    Thanks again for your feedback Eric!

    Could I get clarification on your comment below?

    "The lateral skive and the forefoot wedge are both things that could be added. I really like making an orthotic with an intrinsic forefoot valgus post for met head problems as the forefoot valgus "wedge" is added proximal to the painful area."

    The patient in this instance has the fracture in shaft of the 4th met, not at the met head. So I'm mindful not to have added pressure along the met shaft. Would an intrinsic f/foot post actually increase forces through the met shaft as the orthotic shell would be "pushing up" on the met 4th met shaft?

    Is laterally posting or laterally skiving the mobile r/foot the best way to shift load from later f/foot to the medial f/foot? Or are there other orthotic features I should b considering? As ultimately what I want to achieve with the orthotic is to reduce he stress through the 4th met shaft and try prevent a 3rd fracture in the same spot for the patient.

    Bearing in mind the patient has a short 1st Met - would a morton's extension help achieve this?

    Thanks again!
  7. efuller

    efuller MVP

  8. toomoon

    toomoon Well-Known Member

    it might be worth thinking about a boot on more of a running platform. There are a few out there that are specifically for Aussie rules, but they have more overt midsole, and will definitely be a bit more robust.
    interesting problem though.. do you know what boot he was wearing? lot of reports, including a few in the literature now of MT4 stress# from minimalist running. i would also want to know more about his training. Years ago there was an amateur league coach in Adelaide who insisted his players do 10km runs in their footy boots. That bloke paid my house mortgage for an entire winter... until he got sacked!
  9. toomoon

    toomoon Well-Known Member

    this one from Sharon Dixon.. but relating more to the effect of high cut boot. I do wonder about the merit of "stiffening the boot up though.. I have no evidence, but I think this might be counter productive. Cushioning may be more important.

    The effects of standard issue Royal Marine recruit footwear on risk factors associated with third metatarsal stress fractures
    Nunns, M. , Stiles, V., Dixon, S.
    Footwear Science
    Volume 4, Issue 1, 2012, Pages 59-70

    Purpose: The relatively high incidence rate of third metatarsal (MT3) stress fractures in Royal Marine (RM) recruits may be linked to the footwear worn during training. The present study investigated the effect of standard issue RM recruit footwear on biomechanical variables linked with MT3 stress fracture risk. Methods: Seven male volunteers (age 18.3±0.4 years, mass 81.1±8.2 kg) ran at 3.6ms -1 in a laboratory while wearing a combat assault boot (CAB) and a neutral gym trainer (GT). In-shoe plantar pressure was assessed using pressure insoles (RSScan, 500 Hz). Two-dimensional ankle kinematics and kinetics were assessed at 120 Hz (Peak Motus). Horizontal ground reaction force characteristics were investigated using an AMTI force plate (960 Hz). Results: Peak plantar pressure, impulse and loading rate were significantly greater at the MT3 head in the CAB (P<0.05). Further significant differences with the CAB were a smaller and earlier peak ankle dorsiflexion, a later heel-off, and greater magnitudes of peak plantarflexion moment and ankle joint stiffness (P<0.05). At the instant of peak horizontal braking force, the resultant horizontal force vector was applied significantly more laterally in the CAB than the GT. Conclusions: The higher magnitude for several risk factors for MT3 stress fracture when wearing the CAB compared with the GT suggests that wearing the CAB contributes to the high incidence of MT3 stress fracture in RM recruits. Increased ankle stiffness was attributed to above-ankle support and increased eccentric muscular control in the CAB, contributing to the higher plantar loading at the MT3 head. The higher plantarflexion moment and associated increased muscular demand in the CAB may have implications for fatigue-related MT3 stress fracture mechanisms, although further research is required to support this
  10. toomoon

    toomoon Well-Known Member

    this is also quite interesting:

    Journal of Mechanics in Medicine and Biology
    Volume 12, Issue 4, September 2012,
    Mechanical properties of the human metatarsal bones
    Danesi, V. , Cristofolini, L., Juszczyk, M.M., Erani, P., Viceconti, M.

    Despite the incidence of metatarsal fractures and the associated risk of significant disability, little is known about the biomechanical properties (strength and stiffness) of metatarsal bones. In most cases a single metatarsal bone (first, second and fifth) has been investigated. An extensive investigation of the biomechanical properties of the metatarsal bones is essential in the understanding and prevention of metatarsal injuries. Entire sets of metatarsal bones from four feet were tested. The first foot was used to fine-tune the testing set-ups. To measure the stiffness, each metatarsal bone was subjected to non-destructive four-point-bending in the sagittal and transverse planes, axial compression and torsion. Strain was measured at two locations. To measure the strength, each metatarsal bone was tested to failure in torsion. Significant differences (p < 0.0001) existed among the stiffness of the five metatarsal bones: (i) in torsion the first metatarsal bone was 23 times stiffer than the others; (ii) in four-point-bending and axial compression this difference was less pronounced than in torsion; (iii) differences were smaller among the other metatarsal bones; (iv) the second metatarsal bone was less stiff than the third and fourth in bending. The second, third and fourth metatarsal bones were stiffer in the sagittal than in the transverse plane (p < 0.0001). Conversely, there was no significant difference between the two planes of bending for the first and fifth bones. During destructive testing, all metatarsal bones exhibited a linear elastic behavior and brittle failure. The torsional strength at failure ranged between 1.9 Nm and 6.9 Nm. The first metatarsal bone was stronger than all the others. Stiffness in different loading conditions and failure were measured and compared for all metatarsal bones. These data corroborate previous biomechanical studies concerning the role and load sharing of the different metatarsal bones
  11. wigs

    wigs Member

    Thanks TooMoon, they were interesting reads and I'm sure if I dug around I could find some papers on MT4# and minimalistic running.

    He was wearing Puma Kings Footy Boots at the time of the incident. I have already suggested he gets Asic Gel-Lethal Ultimate Footy Boots upon his return to training and playing. These are more robust, have a built in heel elevation similar to runners, have a wider base and more cushioned midsole at the forefoot (more of long distance runners shoe platform as you mentioned). The Puma Kings are very narrow, have a very thin base/platform and have no heel raise component. The hard oval this time of year in Adelaide would've also played a factor.

    I'm actually this players coach (and now pod) and our club is in the adelaide amateur footy league too. You can be assured I didn't make the players to 10km runs in their footy boots! Training methods have certainly changed, all about repeat efforts these days. The famous 2.2km uni loop was the longest distance I got them to run this preseason. One players BP was 6min 36sec - rivals any AFL midfielders!

    Once I assess the players foot (when he can w/b pain free without the moon boot) I'll have a better idea of his foot type etc which will influence what features I use in the orthotic.

    I agree with your statement below:

    "My sense is that stress fractures are usually from loading at the metatarsal head. This load will cause a bending stress from the upward ground reaction force and the downward force of body weight."

    As the # is mid shaft this makes sense. Although I'm also conscious that once the heel lifts only the distal forefoot component of the orthotic will have any great influence of weight/stress distribution on the mets..........

    Another pod suggested a tarsal coalition may be contributing to excess forces through the 4th met shaft. Stiffness at tarsals = excess force through the met shaft - makes sense.
  12. toomoon

    toomoon Well-Known Member

    wigs.. do you mind if I ask your name and which footy club you coach?
    Simon Bartold
  13. wigs

    wigs Member

    Hi Simon,

    Tom Wigley - have a pod clinic in St Peters.
    Coach Rostrevor Old Collegians (ROCS).

    Hope I was on the money re: ASIC footy boot?
  14. toomoon

    toomoon Well-Known Member

    Hi Tom! My son plays for SPOC so I will look out for you on the field of battle this winter!
  15. Admin2

    Admin2 Administrator Staff Member

  16. Trevor Prior

    Trevor Prior Active Member

    No issues with any of the comments to date but my question would be why the 4th and not the 5th? Obviously, there can be a structural variation and a number of mechanical factors that will predispose to increased lateral load.

    A number of years ago, I had an international front row forward (rugby) who had fractured his 4th met 4 times, including the plate someone inserted.

    These guys are big and he had a broad foot. As a result, he got his boots 3 sizes to big and the 5th met still hung off the edge of the boot. In the scrum boots, there are 3 lateral studs and as a result of the length / width, his 4th met head was over the most proximal of the lateral studs.

    We performed some inshoe analysis and demonstrated the loading here - it looked like it was udner the 5th but it was the 4th because the 5th hung off the side of the stud plate.

    We removed the stud, repeated the inshoe analysis and hey presto.

    So, I would check the width/ length (similar issues can happen with boots that are too short) as part of the issue and be very specific to where the studs lie in relation to the foot as has been suggested.

  17. efuller

    efuller MVP

    The coalition only makes sense if the coalition is "fused" in varus. A coalition could look just like a partially compensated varus foot that does not have range of motion to fully load the medial forefoot until after heel off.

  18. docbourke

    docbourke Active Member

    Stress fractures of the lateral metatarsals are associated with a varus hindfoot in particular a varus calcaneus. Look at training methods, ie how much running etc he is doing and by all means change to a more padded boot but if all else fails and this becomes a recurrent problem he may need a calcaneus osteotomy. I have had several players with recurrent 5th stress fractures who have required this. Just something to keep in mind if the problem won't go away. An in shoe pedobarograph is also helpful here so if you have access to one it will show the pressures under the lateral forefoot in various boots with and without different variations of the orthotics.
    Good luck.
    Gerard Bourke
  19. efuller

    efuller MVP

    What kind of calcaneal osteotomy are you recommending for 4th met stress fractures?

  20. My guess would be a lateral displacement osteotomy of the posterior calcaneus, the exact opposite type of calcaneal slide osteotomy typically done for posterior tibial tendon dysfunction.
  21. efuller

    efuller MVP

    Yeah, but that wouldn't work for a partially compensated varus foot type. Of course you would do the Coleman block test first to make sure that you had range of motion.

  22. Eric:

    A lateral displacement osteotomy of the calcaneus would probably still help a patient with a "partially compensated varus foot type" by increasing the STJ pronation moments from the Achilles tendon and ground reaction force on the plantar calcaneus. For an athlete, having less of a supination moment arm for the gastroc-soleus complex would probably help significantly in reducing the ground reaction force plantar to the 4th metatarsal head.
  23. docbourke

    docbourke Active Member

    If Coleman Block test is positive it means the hindfoot varus is correctable and driven by the plantar flexed first ray. A dorsiflexion osteotomy of the first ray is indicated. If the hindfoot is fixed then the block test is negative. Usually in an athlete the first ray is mobile as is the hindfoot which is in relative varus placing more stress through the lateral forefoot rays. With repetitive activity a stress fracture occurrs. By correcting the hindfoot the forefoot also corrects as long as it is mobile to allow more even weight bearing.

  24. efuller

    efuller MVP

    I would agree that a lateral displacement osteotomy will increase pronation moment and would be helpful for feet that have additional range of motion. However, if the problem is caused by lack of eversion available, no matter how much you increase the pronation moment, you won't get any more pronation motion.

  25. efuller

    efuller MVP

    A dorsiflexion osteotomy of the first works on the same principle as a lateral slide calcaneal osteotomy. They will both tend to shift the center of pressure under the foot more laterally. If the 1st met was plantar flexed relative to the other mets, then you could choose that procedure, then if not you could choose the other.

    I'm not sure I follow your last two sentences.

  26. docbourke

    docbourke Active Member

    Dorsiflexion osteotomy only is needed if the first ray is rigid in plantarflexion otherwise the mobile ray dorsiflexes on it's own. If the midfoot is fixed eg in pronation then osteotmy of the hind foot is not going to work and could worsen the situatiuon. A functioning athlete will rarely have a fixed mid or forefoot, these are usually seen in very longstanding deformities and neuromuscular problems.

    The forefoot is a slave to the hindfoot if it is mobile and will do it's best to put all met heads on the ground if it can. If the hindfoot is in marked varus then the lateral met heads take the brunt of the force. If the hindfoot is brought into neutral or valgus the forefoot can land in a more even position and the medial rays take more of the weight.
    I hope this helps.

  27. seems a massive over kill the osteotomy but anyway

    what are people´s views on forefoot posting under the stud plate rather than in shoe ?
  28. Or even just differential variation in the length of the studs...
  29. was thinking about this sort of today I have an long jumper coming in on Thursday with a stress fracture of the 5th , one of the things on my list to look at in spike length :cool:

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