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Stress Fracture or Something totally different??

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Kerrie, May 10, 2013.

  1. Kerrie

    Kerrie Active Member

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    Hi All,
    Not posted for a while but definitely need some help with this patient!
    It's embarrassing to admit that in all the time that I have been practising (4 years) I have never really seen a stress fracture first hand, only the ones that have been diagnosed and had treatments put in place and we are following up on etc or who are coming back with a new complaint and it's in their medical hx.
    I had a gentleman attend my walk in clinic last week with severe pain in his right 3rd met, he has no hx of injury but does work long hours as a waiter, this pain has been going on for 4 weeks and is getting worse, he reports that his GP has been 'fobbing him off' with antibiotics and telling him that basically it is all in his head.
    On examination there is so me localised inflammation to the region of the 2nd and 3rd mets and pain can be ellicited on palpation of the shaft of the 3rd met just proximal to the MTPJ, HOWEVER, this pain is not there all the time, if I talk to him and distract him and push on the same area there is no pain but when he feels that pain should come he is in agony (hope that makes sense) He is not sensitive to the tuning fork as you may expect a fracture to be.
    He is limping (this could be a selective limp when he knows he's going to see a medical professional as he walked in with it but not out with it)
    We have not had the X-RAYS back yet but he wasn't x-rayed until I saw him in the 4th week of this injury.
    I need some help as he is basically a very angry man who feels he has been fobbed off and is on the breaking point of thinking he is going insane with this foot (trust me no exageration)
    Is this the typical presentation of a stress fracture or am I missing something blatantly obvious? Also how would you treat this?
    If you need any more info please just ask I'm sure I've missed something out, I saw him last week and he is due back today
    Thanks :drinks
  2. davidh

    davidh Podiatry Arena Veteran

    Hi Kerrie,

    This SOUNDS like a stress fracture, but you need an x-ray (or radio-active isotopes) to confirm. Callous formation around the fracture won't be really obvious until the fifth week.
    Don't depend on your local friendly Radiologist who may miss it if it is not obvious.
    I remember a case in Sunderland General years ago when Tim Faulkner (a mentor of mine) was Consultant Radiologist - his colleague had sent a child with a fractured skull back out onto the streets because he'd missed the fracture - don't ask!
    It happens.

    The stress fractures I've seen are always painful to light palpation over the fracture area.
    Could you be missing the spot?
    Let us know how you and patient progress.
  3. drdebrule

    drdebrule Active Member

    Thanks for sharing.

    This sounds like a stress fracture. I have found that applying tuning fork to the area to look for a pain response is helpful, but does not always give a response. If X-ray is negative and you really aren't sure, please consider diagnostic US, MRI, or bone scan. There was a study looking at US to diagnose stress fracture from Jnl of Rheumatology in 2009 looking at US to help diagnose stress fracture. I think the sensitivity was quite good like 80 something, so you may want to consider US (it is a lot cheaper than MRI here in the US).

    However, once your confidence and experience grows you may find yourself relying on the advanced imaging less and less. What do you do when advanced imaging and X-rays are all negative? Do you offload with CAM walker or crutches? Or do you turn to NSAIDs. This is something to think about as well.

    Also, please put your biomechanics hat on and look for something that may predispose this patient to stress fracture like a short limb, pronation, cavus, tibial influence etc. How about a new barefoot runner doing too much too soon?

    Keep us posted on the outcome and good luck to you!
  4. Kerrie:

    I haven't tried using a tuning fork to diagnose stress fractures for the last quarter century. They simply are useless for diagnosing most stress fractures.

    Rather, for metatarsal stress fractures or metatarsal stress reactions, I look for dorsal forefoot edema accompanied by induration and tenderness on the dorsal, dorsal-medial and/or dorsal-lateral metatarsal shaft with deep manual palpation from dorsally. Typically, metatarsal stress fractures/reactions will occur at the metatarsal neck, which is the most narrow area of the bone and, therefore, also will be the area of the metatarsal shaft which is subjected to the largest magnitude of bending stresses during weightbearing activities.

    For suspected stress fractures/reactions, putting the patient into a cam walker brace for one month and having them ice their foot dorsally 20 minutes twice a day will help considerably. Also, if you can, order an MRI scan to rule out stress fracture or stress reaction of the metatarsal since an MRI scan would be the best way to determine what exactly is going on with his foot. Custom foot orthoses with a thick anterior edge modifications work great at preventing future recurrences of the condition.

    Hope this helps.:drinks

    By the way.....tuning forks are more suitable for tuning musical instruments.... not attempting to diagnose stress fractures.:cool:
  5. SjjDavs

    SjjDavs Member

    Hi Kerrie.

    Yeah it does sound like a stress fracture. Like Kevin said, getting the patient into a CAM walker is a great idea. Just also make sure to check what his workplace allows him to wear as well. If he is a full time waiter, wearing the CAM walker may not be allowed under OH&S.
    I had a similar patient recently who was a roof tiler by trade. We advised him to wear his CAM walker as much as possible but due to OH&S he was not able to do so at work.
    By getting the Patient to purchase a good supportive cross-trainer and placing a carbon fibre plate inside, we attempted to mimic the function of the CAM walker, while also allowing the patient to work. Not as good as a CAM walker but at least allowed some measure of immobolization.

    All the best with this case.
    Kind Regards
  6. Fraoch

    Fraoch Active Member

    Nice post Kevin, thanks.

    I'm not sure i understand what you refer to as "a thick anterior edge modification". When you have time I would really appreciate it.


  7. drdebrule

    drdebrule Active Member


    All foot orthotic labs have a protocol for tapering or angling down the anterior edge of the orthotic so it transitions smoothly to the shoe interface. I have used this technique in my lab before. You have to instruct your lab to skip this protocol and it will act similar to metatarsal bar elevating the metatarsals from the ground.
  8. Fraoch:

    I first learned about the concept of thicker anterior edges on orthoses from Dr. John Weed during my Biomechanics Fellowship in 1984-85 when he told me he often ordered 6 mm thick Rohadur orthoses for patients with metatarsalgia since this would act as somewhat of an "internal metatarsal bar" inside the shoe. Since that time, I have written about this concept in my Precision Intricast newsletter books a few times.

    Basically, I have the orthotic lab do more of a vertical grind (and less of a horizontal grind) on the dorsal aspect of the anterior orthosis edge so there is more of a vertical "drop-off" in the orthosis anterior edge with less of a distal tapering effect. Secondly, I tell the orthosis lab not to grind the anterior edge from plantar or "leave anterior orthosis edge full thickness". This may be also combined with having the lab make the orthoses 2-3 mm longer than normal so that the orthosis ends exactly at the distal orthosis necks. The thicker the orthosis plate, the thicker the "internal metatarsal bar" effect from the orthosis using this modification.

    This modification works well (along with other orthosis modifications) for the treatment of metatarsal stress fractures, metatarsalgia, MPJ plantar plate tears, and neuromas. Specifically, in regards to metatarsal stress fractures/stress reactions, this "leave anterior orthosis edge full thickness" modification increases the plantar compression force on the distal metatarsal shaft and reduces the plantar compression force on the metatarsal head which, in turn, reduces the metatarsal bending moment at the metatarsal neck which is the cause of the majority of stress fractures/stress reactions in the metatarsals.

    Hope this helps.:drinks
  9. Here is an illustration that I made for my October 1987 Precision Intricast Newsletter titled "Orthosis Modifications for Metatarsalgia" (Kirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona, 1997, p. 149).

    The shaded portion at the distal plantar orthosis edge would be left on the orthosis for the "anterior edge full thickness" modification and ground off in most orthoses to allow better shoe fit.
  10. Fraoch

    Fraoch Active Member

    Thank you very much for that Kevin. I do feel a bit of an eejit for asking though; I had "Letters II and III" on my desk here at work but not Letters I which is at home for me to read whilst trying to put Mini-Me to bed. I will also admit I've not gotten as far as October yet as Mini-Me cannot switch off her brain in the evenings. I need Super Nanny. And tranquilizers (for me, not the child).

  11. Leah Claydon

    Leah Claydon Active Member

    Just a thought. I had a similar patient last October who came in wearing a cam-walker - presented with dorsal oedema over 4th met. X-ray, MRI revealed no stress # but increased distal cortical thickening and erosion of met head. 3 months of cam-walker alleviated symptoms but when she came out the symptoms returned. I noticed she had very little calc inversion/eversion on affected foot and supinated forefoot. Pressure scans revealed overloading of lateral aspect of forefoot. Further examination of MRI scans showed missed calcaneo-navicular bar. She was a slim 57 year old previously very sporty/active person. We ran bloods and found her to have sero-negative arthritis. Made orthosis with met balance bar and offloaded 4th and 5th. Now symptoms have settled in foot but now arthritis is flaring up in metacarpels. Basically, mechanical factors were involved in initial flare up of arthritis - herald symptom. Might be worth checking for Rh, sero-neg, ESR etc in your patient.

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