The answers to all questions are at the end of the post.
Metatarsal Pain in a Hiker
History and Chief Complaint
- 62 year old hiker/walker trying to increase the amount walking per day and during the long weekend walks
- The patient’s goal is to walk the famous Camino de Santiago in Spain some year (500 mile adventure)
- Her left foot (pointing to the 3rd and 4th metatarsals) came sore the day after a long 8 mile walk
- That was 2 weeks ago, and the pain has not gotten better
- Day to day activities are fine, works at a desk all day
- No swelling, ecchymosis, or erythema noted
- There is some numbness and sharp pain at times
- Pain level with walking 5-6 out of 10
- The chief complaint is the patient feels she must of bruised the foot somehow
Question #1: With no swelling after 2 weeks, what is your initial diagnosis?
Gait Evaluation
- The patient had a slight limp due to the discomfort in the left foot
- The pain intensified with walking on the balls of her foot over flatfoot
- Moderate left foot supination pattern could have been from favoring
- Walking with the boots that she was wearing revealed great stability but too much of a shoe (too stiff and rigid for the type of walking she was doing)
Question #2: Hikers can come into the office with a great shoe for themselves, or one either too rigid or too flexible. What are some problems created by too rigid a shoe (in this case she was wearing an Alpine Hiking Boot even for her short street walking in an attempt to break them in.)
Physical Examination
- Obvious swelling over the lateral 3 metatarsals compared to the uninvolved right side
- Palpable pain 3rd, 4th, and 5th metatarsals
- Pain on side to side compression of the metatarsals
- Ankle Muscles tested in 4 directions appear fine
Question #3: This happens all the time where no swelling is reported on historical review, but found on physical examination. What metatarsal has the highest likelihood of being injured with this patient?
Cursory Biomechanical Examination and Asymmetry Noted
- Metatarsal Alignment showed plantarflexed first and 4th on left (involved side) and plantarflexed first and 5th on right
- Involved left side also had a tailor's bunion with slight hypermobility of the 5th ray
- Both feet with everted forefoot deformities left greater than right
- Very tight achilles tendons with left 0 and 13 and right 5 and 16 for gastroc and soleus respectively
- RCSP slightly inverted left and vertical right
Question #4: With an Inverted RCSP on the left, would the weight bearing be more medial or lateral in the forefoot standing?
Question #5: With a tight achilles tendon, do the metatarsals have more plantigrade or dorsal grade forces?
Question #6: With a plantarflexed 4th metatarsal, would GRF (ground reactive force) be more concentrated on the 4th or 5th metatarsals?
Tentative Working Diagnosis
- Sudden Metatarsal Pain in an overuse situation is a Metatarsal Stress fracture until proven otherwise
Question #7: What is the difference between a stress reaction and a stress fracture?
Common Differential Diagnosis (2ndary Working Diagnosis)
- Other occult fracture with distal swelling (like cuneiform or cuboid)
Question #8: Here the working diagnosis and the common differential diagnosis agree on the severity of the injury. Which fracture above (metatarsal vs. lesser tarsus) will probably need an MRI to visualize?
Occam’s Razor and Rule of 3
- Simplest Solution Cast Immobilization
- Rule of 3 works in the long term with achilles stretching (achilles tightness places overload on metatarsals), accommodative padding to off weight even in the removable boot (attempt to align metatarsals), check of Vitamin D level (in case there is poor bone health), and switch to a softer hiking boot for the level she is at (the rigidity and stiffness/hardness overloaded the metatarsals at heel lift)
Question #9: What are the 3 main types of hiking boots regarding activity levels and protection provided?
What Phase of Rehabilitation?
- Immobilization
Question #10: What are the general principles in deciding when you can stop immobilization and begin the Re-Strengthening Phase?
Should We Image?
- X Rays reveal through and through fourth metatarsal stress fracture without displacement
Question #11: What are the 2 types of stress fractures and how are they produced differently?
First Decision: How to Reduce Pain 0-2
- Removable Boot with Accommodation to float 4th metatarsal head and crutch
Question #12: With the injury being on the left side, what should be placed on the right side?
Question #13: As you progress from crutches to no crutches, what is an intermediary step that should never be used?
Second Decision: Inflammation Concerns
- Ice pack 10 minutes when aggravate
- Contrast Bathing 20 minutes 1-2 times per day for deep bone flush
Question #14: How do you progress the ice/heat program for contrast bathing from this point until there is no longer any swelling?
Third Decision: Any Nerve Component?
- Yes, but it was believed to be related to the swelling or limping (irritating the low back)
Question #15: If the nerve pain/symptom does not quickly resolve, treatment must be started. What are 5 common treatments that can be started at the next visit for the nerve symptoms?
Fourth Decision: Initial Mechanical Changes
- Removable Boot with Accommodation Left
- Even Up for over the right shoe
- Crutches as needed to keep the pain down
Question #16: For the safety of the spine, either use two crutches or no crutches, never encourage a transition to one crutch. What physical examination finding must improve significantly before this patient can be casted for functional foot orthoses?
The patient has three mechanical concerns. The first is merely the appropriate immobilization needed to get this fracture to heal. The second is the bone health overall, which is suspect anytime I feel a patient really does not deserve the fracture, even in a case of overuse. Finally, the third is the treatment based around preventing this from reoccurring. This is tied into the bone health and the unique biomechanics that caused this in the first place. Let us review the metatarsal stress fracture checklist from Chapter 6 of Book 2. I have starred the two we have used so far.
Common Mechanical Changes for Metatarsal Stress Fractures (2 through 4)
- Cam Walker, Stiff Soled Shoes, Rocker Shoes, Bike Shoes with Embedded Cleats*
- Custom Orthotic Device with Metatarsal Support
- Metatarsal Padding for Support
- Forefoot Off Weighting of Affected Metatarsal*
- Circumferential Metatarsal Arch Taping
- Tubigrip for Support and Compression
- Metatarsal Doming
- Single Leg Balancing and Single Leg Poses
- Correction of Mechanical Faults Athletics
With this patient, Vitamin D was not low, but her bone density test was osteopenic. This changed the long term treatment since we had to protect her bones more. Hannaford style memory foam soft based orthotic devices have now been used for years protecting her. Ask your lab what they make that is equivalent. We definitely got her into softer shoes, strengthening exercises daily with metatarsal doming, and daily achilles stretching. Tubigrip for compression was needed for the Immobilization Phase to reduce the swelling, but circumferential KT arch taping for the Return to Activity Phase.
Question #17: What metatarsals are given more weight bearing in circumferential KT taping of the metatarsals?
Question #18: What subtalar joint motion do we not want to see in the softer shoes?
Question #19: Why is achilles tendon stretching so important for metatarsal problems post cast immobilization?
Answers to Questions
- Intermetatarsal Neuritis or Morton's Neuroma Syndrome
- Too rigid a shoe creates all the problems of weak achilles tendons. The ability to push off the ground is very hard, especially as she fatigues, abnormally stressing the metatarsal area, the arch, the plantar fascia, and the achilles. Imagine the achilles has to work so hard attempting to push off in a shoe that does not bend across the MTJs.
- If swelling occurs over 3 metatarsals, it would be the middle one most likely injured. In this case, the 4th metatarsal.
- Inverted heel should direct weight bearing laterally, opposite of what an everted heel does by overloading the medial column.
- Plantigrade
- 4th metatarsal
- Stress Reaction means that their is an injury to the bone without a break
- Subtle stress fractures to the tarsus or lesser tarsus normally require an MRI to see
- Hiking boots are commonly categorized into three groups — lightweight (street walking), midweight (trails and amount of support needed), and heavyweight (Alpine hiking)--and these are based on weight, stiffness, and overall protection to the foot
- Each injury has general rules on the amount of Immobilization needed, however this must be balanced with maintenance of 0-2 pain levels, amount of swelling in the tissues, how the patient feels out of the boot during the weaning off process, etc.
- There are stress related fractures caused by excessive loading (sagittal plane in this case),and those caused by excessive torque (typically pronatory twist of the bone in the frontal and transverse planes)
- With a CAM walker on the left place an EvenUp device on the right foot for balance and evenness of the spine.
- I am not a believer in using one crutch as it seems to always irritate the spine as the patient leans away from the injured side
- After 4 days of straight icing, you can start hot to cold contrast bathing. I love to start with 1 minute hot (100 F) and 1 minute cold (50-60 F) alternating for 20 minutes. Every 4th day you can attempt more heat by 1 minute until you are eventually at 4 minutes hot and 1 minute cold for 20 minutes.
- Topical Neuro-Eze or Neuro-One, Lidoderm patches, TENS units, Neural Flossing, and non-painful massage 3-4 times a day.
- The foot has to be devoid of swelling which would distort the shape of the foot when casting
- 1st and 5th
- Excessive supination leading to more lateral overload and the possibility of a re-injury
- If you did not have achilles tightness before being put in a cast, you probably will afterwards. A tight achilles places excessive plantigrade force at heel lift on the metatarsals to increase the chance of re-injury of the metatarsal fracture.
