2nd metatarsal break

(California)

Sept 13th 2013 I had a traumatic break in my 2nd metatarsal. It was non-displaced so they put it in a cast followed by a boot. They took X-rays after the boot came off to ensure it was healing and at that time released me to full work detail knowing I spend 80%+ of my day on my feet. Fast forward to September 20 2014 everything has been fine up till that point, not sure when it started exactly but over the past couple weeks I've developed stabbing pains in the area of the break. I'm waiting on my scheduled appointment to get X-rays but I'm guessing I have developed a stress fracture. My question is should The doctor have assigned me to physical therapy? Why or why not? After reading up on it the past couple of days it seems to me that they should have ensured I was performing adequate strengthening exercises to help support the weak bone. A bone which is prone to breaks in healthy adults who have never even broken their feet. If it is in fact broken I will now miss out on even more work time (I'm a building engineer and can't put on required safety equipment and therefore can't work) and I realize it's the least of my worries but hunting season is coming up in 3 weeks and I'll probably miss out on my favorite pastime this year.

RESPONSE

Hi Bryce,

I would think that if you did indeed break the second metatarsal bone again you could argue that there may be an inherent weakness in that portion of the bone, but the argument could also be made that there is a weakness in your foot relative to the shoes that you wear and the type of work that you perform.

I am guessing the latter here since you did go one year before you ran into the same problem again. If there was an inherent weakness in the specific bone, I think it would have been safe to say, you would have suffered another stress fracture a long time ago.

In regards to your question about physical therapy, I have never been a proponent of physical therapy for fractures simply because I do not think that it will actually strengthen the bone, the only thing physical therapy might do is speed up the healing process.

The standard of care in treating a stress fracture is to take a final x-ray and if it appears normal than the fracture is considered healed. That along with palpation of the area with no pain mentioned by the patient.

So the question becomes one of why did you sustain a stress fracture in the same spot? As stated earlier, my thought is that there is a problem that goes beyond the second metatarsal.

The first thought would be that you have an excessively long second metatarsal bone, relative to the others, this then creates more stress on that particular bone. This is then compounded with the fact that you are a building engineer and are probably called upon to do a lot of walking and perhaps at times walk on irregular surfaces such as in construction sites. All of this could add additional stress to the second metatarsal bone.

Your shoes now become the next thing that has to be looked at. I understand you have to wear safety shoes, but would be curious about these shoes in terms of their flexibility in the sole of the shoe. Shoes that are too flexible, could exacerbate the pressure on your second metatarsal bone.

You also need to consider external factors, such as if you are a smoker. Smoking decreases the amount of oxygen that gets down to a fracture site and could result in delayed healing or even non-healing of a fracture. Your age may also play a role. If you are overweight, that too could create problems in your foot.

Diabetes, people who are anemic, those on certain medications like non-steroidal anti-inflammatories, prednisone, statins will all show the propensity to slow bone healing (thus tendency to re-fracture).

So, assuming you have another stress fracture, I would have your doctor look at the architecture of your foot structure on the x-ray. This is best done by a podiatrist; I do not know what kind of doctor you have been seeing. If there is indeed a long second metatarsal, or even just a short first metatarsal (a podiatrist would know what I mean) then once the healing has occurred, an orthotic would be necessary to take pressure off the second metatarsal when you walk. This would go a long way to preventing further trouble with this particular problem.

Again, assuming there is a fracture, ask your doctor about using a bone stimulator. Unlike years ago, when you had to wait months in order for an insurance company to pay for a bone stimulator, now insurance companies will cover bone stimulators on fresh fractures.

A bone stimulator as the name implies will speed up the healing process and perhaps you will not have to wait as long for this new fracture to heal.

Marc Mitnick DPM
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