Stress Fracture - Mid Shaft/2nd Metatarsal

Discussion in 'Ask the Docs' started by kagule, May 15, 2012.

  1. kagule

    kagule
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    Apologize in advance for the "setting of the stage":
    I’m a long time runner but I am relatively new to minimalist running who is apparently having some transition issues (former stable/orthotics shoe person who fixed her gait/form and heal strike issues in a pt/medical environment).
    Transitioned Jan/Feb - in March I had some mild top of foot pain which didn't hurt while running but did afterwards, no inflammation/bruising - expected it was tendonitis so I treated with ice and waited for no pain for a week and then started back running again. (Note: I was only up to about 5 miles in distance and ran about 3-5 times a week anywhere from 3-5 miles (trying to keep adding a bit more).
    About a week later I was on a 4.5 mile run and close to the end had pain/tightness in the opposite calf which remained for about a week (during which I iced, rolled, stretched).
    After about a week of no pain started to run again, and after a few days, the top of foot pain returned after a 4 mile run but it was much worse. Back to rest/icing - symptoms seemed to follow Extensor Tendonitis (vs. a stress fracture (comparing the symptoms of a SF I had a few years ago).
    Pain has reduced over the past 4 weeks, but still remains so I decided to get an x-ray to see if anything shows up. Primary Dr. just called to say indeed there are definite signs of a stress fracture in the mid-shaft around the 2nd toe/metatarsal (I don't have the report yet but this is what was stated on the phone). She recommends going to a specialist to see how they want to treat.
    At this point, assuming it's on its way healing and if I start wearing a "boot" am I good to go? Not discounting the specialist's expertise, just based on my first experience, not clear if there is any more that they would do other than confirm the diagnosis and tell me to wear a boot for x number of weeks...Am I missing anything? THANKS!!!
     
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  2. barnarddale

    barnarddale
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    I don't know anything for sure, but in my case, while I was healing a metatarsal stress fracture, I think that I rested my foot too much and lost some range of motion in my toes. When starting back, it was easy to hurt my toes (pain in top of toes where they meet the metatarsals) because it pushed them beyond their limited comfort zone. I had thought that the pain indicated that the fracture was reluctant to heal, but now I think that the pain was separate from the fracture. I recommend that you keep up the range of motion in your toes and ankles after a month or so of letting the stress fracture heal. It's been 7 months, and I'm still working on the range of motion in the toes, but running 3 miles or so. I bet that if I had started on range-of-motion exercises after a month, I would be all healed up long ago.
     
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  3. Barefoot TJ

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    Dr. Klein should be on the site this evening to answer pending questions.
     
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  4. Dr James Stoxen DC

    Dr James Stoxen DC
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    Stress Fracture - Mid Shaft/2nd Metatarsal - Regardless if you have a stress fracture or not, you have too much stress on the second metatarsal. That is why its called a stress fracture.

    That's why you have a stress fracture of the second metatarsal, if in fact you really have a stress fracture. That has not been determined yet.

    The key to this is not whether or not you have a stress fracture but why you have a stress fracture or too much stress in this area. That's what we have to figure out and eliminate so that you can go back to running barefoot for life.

    The body and specifically the foot has ingenious ways of absorbing or springing off stressful impacts. Stress is actually good for the body because stress allows the body to be stimulated to adapt to get stronger. It’s just when stress is abnormally applied to joints from poor form and technique or if joints are locked not allowing the impact to be absorbed into a movable joint or if the muscles that attach on this particular joint are not strong enough to absorb the negative impact loading from that impact landing.

    Just like a plane, the human body has a landing gear, spring-loaded shock absorbing mechanism built into the arch complex as well as the muscles that allow the dissent of the foot during impact like descending weights during a bench press or curl.

    The human foot has 33 joints that allow 26 bones to move freely during impacts such as walking and running and other activities. The reason why it has 33 joints is because when you impact with the earth that impact can be spread across these 33 joints lessening the overall impact on any one area.

    So why do you have more stress on the second metatarsal ban on the other 26 bones of your foot?

    If all joints are moving the way they should then like I said the stress will be distributed amongst the joints smoothly and you should be able to run without any problem. Obviously there's a problem with the distribution of stress otherwise you wouldn't have a stress fracture or too much stress on the area.

    Here's what I see happen over and over again clinically in my practice that can help you understand what might be happening. When the human body impacts the ground the entire human spring mechanism absorbs the impact through the floors of the entire body, the foot, the ankle, knee, hip, spine etc. Specifically the initial impact at the foot is absorbed through two mechanisms:

    The foot rolls from the outside to the inside. This is the rolling from supination to pronation. This rolling occurs as the force of the impact is gradually loaded into the foot along a particular path that loads it the safest. It obviously loads differently for all kinds of impacts. For instance if you're doing a side shuffle drill, zigzag runs, hops skips lunges etc. It cannot routinely roll out of the safe range because being in the safe range causes stress on muscles and joints.

    However, the foot has loading muscles, which are like loading the impact of the weight of the dumbbells as a negative in the bench press. The spring suspension system muscles, or what I call the landing muscles of the foot stretch and load the impact into them and win the foot hits the bottom point and goes into toe off they snap the foot back into its original position.

    This is what I call human spring. The ability to load this impact follows the laws of physics in particular Hookes law

    Certain activities can sabotage this event. For instance if you are holding a book and your hand with your arm in a 90° angle for 30 minutes (like a curl) the bicep muscle tightened stiffen and you will not be able to hold it very much longer perhaps because of the pain and stiffness in the joint of the elbow. You might have to do deep tissue work around the muscles of the elbow to get the elbow joint to free itself up again.

    Foot Lock (link) - The same thing happens to the spring suspension system muscles, the negative loading muscles of the foot spring suspension system. It might not find this lingo and books because I made it up to be able to explain this in easier terms for the public to understand. I explain it to you and my mechanics/medical terms you'd stop reading long time ago.

    So if you stand on your feet for a long period of time or on that particular foot for longer than you should any one of the muscles such as the tibialis posterior, anterior or peroneal muscles get tired, fatigued causing the complex to drop in the mid-arch complex to lock. What I have found clinically is it locks the majority of the time at the second metatarsal-cunieform joints and sometimes the third metatarsal-cunieform joints.

    [​IMG]


    To check for this we do what we call motion palpation of the joint play in that joint complex which is around your mid arch. A more fun way of describing it is called the wiggle test. Get a grip on your midfoot and a grip on your second metatarsal, the second long ball of your foot and wiggle those two back and forth to see if there's good joint play. What you might find is that it's stiff as if it's been in the freezer for a while similar to what it chicken feels like when you're pulling it out of the freezer the joints are its frozen. If you exceed the maximum amount of force that the spring mechanism can load its called failure strength and that’s how you got the stress fracture. (link)

    If we release as many joints in your foot as we can and we can spread the force out across all the other joints and keep the stress off your second metatarsal in the future. After you do that you can take your thumb and what the pad stick it into the ace of the second metatarsal joint at the soul of your foot and see if there's pain there. A stress fracture isn't a fracture that's broken through. So you can push on the bone and it won't fracture further. If you can run on it, that's about 300 pounds of force on the foot. You can't possibly develop the kind of force with your thumb print into that area. Also the doctor said it wasn't fractured through so I would not be afraid to do this.

    By applying the pressure to this muscle you can release the spasm that restricts the movement of that joint. If you start at the base of the heel and apply these deep tissue pressure points one thumbprint at a time to the knuckle of the second metatarsal you can release the muscle spasm that is restricting the second metatarsal cuneiform joint for moving.

    Deep Tissue Treatment Under The Big Toe And Second Toe
    Deep Tissue Treatment Above The Big Toe And Second Toe
    Stretching Great For Mortons Neuromas And Narrow Heels
    Scissor Stretching Of The Feet

    Throughout this entire rehab process you should be spending about a half hour to 40 minutes (or more) a day doing your own deep tissue on your foot, which includes your second metatarsal third metatarsal first metatarsal sub scale or joint ankle mortise and the tibialis posterior muscle.

    Check for Sub-Clinical Shin Splints too (link)
    Also the second metatarsal cuneiform joint is locked in your impacts are going to be more of a bang than a spring. That can cause shin splints. Check for shin splints! Like I said if that joint is locked then it can't flex two load the impact into the joint comfortably so that's why you have a stress fracture or stress, causing pain. So if you can't load the impact into that joint you might not be able to load the impact and to the entire land is the majority of the weight is held by the first and second metatarsal's. The third fourth and fifth just guide the foot while absorbing a minimal amount of impact force. In order for you to get this second and third metatarsal cunieform joint to be the least you really have to wiggle it pretty good. You may hear a click when the joint releases. Just keep it loose and wiggle it back and forth to wiggle it lose.

    I'm going to give you some more deep tissue techniques that you can use to release this complex of 33 joints so that your stress of the impacts can be absorbed more comfortably across these joints rather than the majority of it through that second metatarsal. Hopefully you will get back to running again without pain and this should help you with that.

    How to Self Adjust Your Toes
    Deep Tissue Treatment Of The Subtalar Joint Of The Ankle On The Inside
    Deep Tissue Treatment Of The Ankle (Subtalar Joint Outside)
    Deep Tissue Of The Ankle Mortise
    Stretching Of The Foot While Sitting At Your Chair
    A Stretch To Increase The Flexibility Of The Arch Of Your Foot
     
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  5. ladycheshire5

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    My problem is with my 3rd metatarsal. I had an injury maybe 8 months ago or more where I thought it was a stress fracture but X-ray didn't show anything. Dr. said metatarsalgia which is a fancy way of saying your metatarsal hurts. Back then I knew this was caused from doing too much too quickly. However, I just developed the same pain all over again. :( I've been BF running now for about a year and with the exception of a couple hiatus due to health issues I've been doing 2-3-4 miles. I was at about 3-4miles regular when one of my issues hit and put me out of commission for a few weeks after that I was regularly doing 2-2.5 for a while. Also, recently spent 17 days on vacation where I didn't get to do much running so when I returned I was making my way back up to the 3-4 miles. I spent one week doing anything between 1-2 miles flat. 2nd week was 2+ or anything under 3. 3rd week was 3-3.5. 4th week I was able to hit 4 miles and did that 4 days of that week. The following week was the same 4 miles with one 4.5 for 4 days of that week. Now this week, yesterday in my 3rd mile - ouch! The metatarsal pain. Felt like a charlie horse at first but I can barely walk on it. :( I don't feel like I'm doing more than I should/could so I'm left to wonder if my form is the problem? The above post talks about how to loosen the joints in the foot to allow for the proper distribution of impact, is that all we can do? I'm frustrated because I never had injury like this in a shoe. :( and of course whenever I get hurt like this the first thing people say to me is "maybe you should wear shoes". :-/
     
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  6. kagule

    kagule
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    Thanks for the follow-up on this thread. Strangely the alerts didn't alert me so I didn't think anyone responded to my entry and I happen to log in to take a look. :) My update... after I posted the question, I looked up on this site for a podiatrist in my area, which I went to. He looked at the xray and didn't buy in that it was a stress fracture, thought there was a stress situation going on but not convinced a fracture. He was more concerned with the tighness/fluid retention I have in my calves, ankles and feet which I have intermittenly (and had pretty badly around the time of the issue). He felt that was the more important area to focus on. This is something I've never known why it happens, just thought "it's just me". Over the last month, I had decided to help reduce the inflammation in the area (still assuming perhaps tendonititis) I decided to visit an acupuncturist that was recommended by a fellow runner. He recommended I get the MRI to have a final confirmation regarding the SF but also noted the fluid retention issue is caused by poor circulation (really, something else to deal with? :)). The acupuncture definitely helped reduce the build up in fluids and definitely helped the foot feel better (improvement of blood flow I expect). I did have the MRI which showed conclusively that I do have a 2nd M SF. So I'm at 12 weeks, pain has reduced but isn't completely gone, had still kept up with strength training, etc. (no running) in minimalist footwear. I will go back and take in the recommendations posted by Dr. Stoxen. Now I'm curious about the poor circulation with minimal/barefoot - I don't loose any feeling in my feet they just get big, I've read comments about poor circulation being a factor to consider when deciding on m/b running, is that only if you loose feeling due to the poor circulation? (perhaps I need to move the question to another post:)).
     
  7. ladycheshire5

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    It's good to hear you've found some decent answers. I don't know about the fluid problem. Hopefully someone else will have something to offer.

    X-ray didn't show a stress fx for me but MRI was suggested to confirm if it's suspected. I just need an order. The problem I have is viritually no one is very supportive in the medical field. They all think I'm bonkers for running bf and the doc who saw me last had to ask why I push myself so much... 4 miles is a lot! :-/ 4 miles was a nice little run for me before in shoes. No problem. Now it seems I can't do more than three for very long with out injury. I'm super frustrated. Tired of being layer up and not able to run I'm considering shoes again.
     
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