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Hello all.

Need some help with a case.

I have a 44 year old female who has presented with ongoing fractures to her 2nd and 3rd metatarsal neck/heads, these have occurred in both feet.

Her medical history - hypertension, iron deficient, hypercholesterolaemia

She is an office manager, overweight - BMI in the 25-30 bracket.

She does not exercise regularly (would like to) but is having significnat foot pain every 2-3 months with several fractures being diagnosed over the last 18 months.

When I saw her today, significant pain on palp of the right 3rd metatarsal head, with night pain - suspicious again of a fracture. Foot type is unremarkable.

Recent DEXA bone scan is normal.

Is someone able to nudge me into the right direction of why she would be getting sporadic stress fractures to her metatarsals. Im not sure where to look next.

Any help would be much appreciated.

Kind regards,
Dean

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Regards,
Dean

Hi Dean

There must be something going on with the bone for them to keep fracturing.

Whats going on biomechancially. Why is she getting increased bending moments at the metatarsal ?

You say unremarkable foot type but there must be something ?

ie tight triceps surea, FF Equnius etc.

What rehab is she having after the breaks ?

You might need to consider rocker bottom shoes such as MBT as part of the treatment plan as well.

Edit : Appart from the extreme overweight as a biomechanical cause of course, but not all big people get met fracture.

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Michael Weber

The most common thing about common sense is it´s not very common.

My location

dean,

you in mackay? if so, send her to ernie tyes next footwear clinic at MBH to get some rocker-sole action happening. might be enough to reduce the forces through the mets to below pathological levels?

if you're not in mackay, you'll have no idea who i am, but the advice might still be relevent!

phil (at community health)

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Phil Marshman
Mackay, Queensland Australia

A Dean does the patinet have a short 1st met ?

Heres some reading for you.

Attached Files

strain and loading of the 2nd met during heel lifts.pdf (1.55 MB, 12 views)

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Michael Weber

The most common thing about common sense is it´s not very common.

My location

Hi

What are her shoes like? If its anything like the UK, office managers tend to wear high heeled courts - could be an exacerbating factor. Pressure studies would be of benefit here.
David

I am assuming that you have seen some xrays ? if so how did the bones look? assume washed out.

Had a lady similar 2 years ago in Bundy spontaneous met fractures in both feet, bone density fine but her GP still put her on osteo medication and I stabilised the foot with a FFO with an extension of the front edge as described by Kevin Kirby in his treatment of plantar plate ruptures. Prior to the FFO she had been put in a BK immobilisation boot and consulted an ortho who told her to stop wearing the boot and "let pain be her guide" (I love this statement by the way).

At a 3 month review she was back playing bowls 3/week and active and pain free as long as she always wears her orthotics . I was speaking to an endro who mentioned that people can develop focal osteo in specific body areas although the bone scan indicates that all is normal.

It would be good to know how she goes

Cheers

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Mark Egan
Absolute Podiatry
331/33 North St
Spring Hill, Qld
4000

Dean:

As Mark mentioned, treating this lady successfully is not that difficult as long as you make the correct orthosis for her and she wears it consistently. Metatarsal stress fractures are caused by too much bending of the shaft of the metatarsals (excessive bending moments) and this bending can be reduced by supporting the metatarsal necks firmly with the orthosis so that the metatarsal heads have reduced ground reaction force (reduced the lever arm for ground reaction force to bend the metatarsal shafts).

Make the orthosis with anterior edge 5 mm thick with an abrupt dropoff (Kirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona, 1997) and accommodate the affected metatarsals as Mark suggested. Have her stretch her gastrocnemius and soleus muscles three times a day. Then have her wear a running shoe to work and get her on a serious weight loss program. She will likely think you are the most amazing healthcare professional that she knows once she figures out that you have cured her foot problem for her with these relatively simple treatments.

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Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

First she's obese@ 44. this observation tells us to rule out endocrine etiologies. Normal people don't continue to fracture even in heavy sport. Rule our parathyroidism and review its effect on CA& phosphorus metabolism. In that same vein kidney and urine studies to rule out abnormalities in electrolyte absorbtion and secretion. does this heavy woman have hair growth under her lip or hirsuit indicating an adrenogenital syndrome as a cause of metabolic mis metabolism? Are her periods normal as this may also give a clue to faulty metabolic state.

She's anemic. Is it chronic or due to menstration. If it's chronic what is the cause?
Is she black as sickling can cause bone infarction and fx. Is she mediteranian because Thalassemic anemias can do the same. What is her alkaline P'tase level.

She's hypercholesterolemic at 44. Family history? Subclinical hyperurecemia is commonly a comorbitdity. Occult malignancy can lead to fracture anywhere.
IS it the same foot that fx's or does it vary?

These are considerations to be ruled out before one glibly states" its too much bending" You can do this patient a big service. As a gate keeper you can pick up a systemic disease and make the proper referral. After these conditions are ruled in or out than you can jump to an arch support. robert bijak,dpm

Hi Robert thanks for DDx options.

Although "arch support" is not what I used in my cases.

cheers

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Mark Egan
Absolute Podiatry
331/33 North St
Spring Hill, Qld
4000