Hi guys! In this video, I'm going to talk about metatarsal stress fractures.
We're going to look at which ones are seen as high-risk versus low-risk stress fractures,
basically due to healing times or whether they heal or not, we're going to look at how can you
tell if you've got a stress fracture, and also the most common causes, how you can prevent them,
and absolutely how you can treat them and get back to running again. So, for those of you who
don't know me, my name is Maryke. I'm one of the physiotherapists from sports-injury-physio.com,
where you can get online physiotherapy assessment as well as treatment for your injuries.
Have a look at the description of this video if you want a link to our website.
Okay, so if we think of the metatarsal bones, they are the little bones in your foot that
connect your toes to your mid-foot. And you have … When we talk about the metatarsal bones,
you'll often see people say, the first, the second, the third, fourth, and fifth;
it's basically just, your first one relates to your big toe, the fifth one is the one that
is for your little toe, and of course the three in the middle there. Now, when we look
at the metatarsal bones themselves, the portion closest to you, or closest to your ankle bone,
is seen as the base of the bone; then we have the shaft, which is the long, middle bit, and
then you've got the head of the metatarsal bone. Now, you can get a stress fracture in any part
of the bone, but there are certain ones that seem to be high risk, that they don't heal that well;
and it's a combination of how much pressure goes through that area in the foot when you walk or run
plus how well … how good the blood supply in that area is. Now, if something is a
low-risk stress fracture, it means they heal pretty easily; if you just offload them,
give them a bit of stability – not an issue. If it's a high-risk area, then it means that, uh-oh,
if you don't offload it dramatically and really look after it, they likely are not going to heal
well, and they may even require surgery. Now, if we look at the ones that’s seen as low risk,
it's any of the shafts of the middle three metatarsal bones; their shafts heal quite easily.
The fifth one is a little bit of a … Let's call him a little bugger. Any part of the fifth
metatarsal bone struggles to heal, and if you don't treat that quickly and you don't treat it
quite aggressively with offloading, then you may end up needing surgery. The other area that seems
to be a high-risk area that doesn't like healing that easily, is the base of the metatarsal bones;
they tend to be a little bit delayed in healing if you don't treat them well. And
the current recommendation is that you don't send somebody back to sport just because they don't
have symptoms there anymore; it's best to have a scan and just check, has it properly healed? So,
if we think of the causes of these stress fractures,
then overload is the number one cause of that. People like to dig into biomechanics:
“Oh, it's because you run in this way, your foot turns out in that way, that's the cause.”
But more often than not, it's just about overload. Now, what do I mean with overload? So,
if we think of, as you sit there today, your body has a base strength. So, your bones, your muscles,
your tendons, your ligaments, everything has a certain strength to them at that point. And
that strength is determined by what you've done in the last few weeks, last few months
up until this point. If you lie on a couch for four weeks, you'll lose some of that strength,
because you're not using the body. If you train, you'll build some strength in it. Now,
every time we do an exercise session or any activity that loads an area, we get micro-damage
in that area; and that's absolutely normal, that's what we want, because it's that micro-damage
that signals to the body that, “Uh-uh, you've got to rebuild me stronger, because this person
wants to do this activity.” Now, if we think of bones specifically: If we do impact activities
you get the micro- trauma. As you rest, the bone recovers and repairs the micro-trauma,
and then you're stronger than before. And if you train in this area where you've now got
stronger bones than before, you build on top of that and you get stronger over time. However,
if you train before you’ve fully recovered, then the micro-damage actually accumulates,
and then that's when you get overuse injuries like stress reactions in the bone or stress fractures
and even tendinopathies and stuff like that. Now, there are certain things that can predispose
you to this as well. So, if we think of … So, training loads that can predispose you to this
is if you have a sudden increase in the volume of training you do, or just the terrain changes,
so, there's a lot more downhill running or fast running sessions that you're doing.
If you don't recover well because your sleep is interrupted or you're not getting the nutrition
you should have. So, if we think of it, yeah, it's great that you give yourself enough recovery time,
but if you don't eat enough in calories and nutrients to replace what you've burned, you
just don't have the building blocks in your body, so, your body can't repair that. And it usually
decides on … It looks at what's most important for your survival. So, it will always look after
the more … the most important organs first, and then, if there's nothing left for the rest of you,
it just won't repair the rest. So, those two things are really important … or three things:
looking at training loads, looking at your recovery, and looking at what you eat.
Then, other things like shoes is something to keep in mind. So, if you make a sudden change
in the type of shoe you wear, for instance. The two most common things that spring to
mind is if you go from cushioned shoes to minimalist shoes or even barefoot running;
because your metatarsals will then be used to a certain impact, but it's used to the cushioning.
So now, you take the cushioning away, and suddenly there's much higher forces on it. Now, if you do
it slowly over time and you ask it to run with the higher forces just for a few minutes a day
over several weeks and you slowly build that up, you'll give them enough time to rebuild themselves
stronger. However, if you just switch to those new shoes and you do your normal mileage in that,
the bones won't have enough time to rebuild in that period of time, and the load will be
too much, and you'll predispose yourself to stress fractures in those areas. Also,
if you suddenly use a shoe that just makes your foot supinate more – so, it rolls out more – that
will load the outside of your foot more and can lead to injuries to your fifth metatarsal.
I need to chat about the difference between fracture and stress fracture in a minute – I’ll
do that. Then, other things like Vitamin D deficiency; that's a big culprit, really,
especially for anybody who lives far away from the equator, who has long, extended winters
and who doesn't necessarily see the sun that much in the summertime. Vitamin D is extremely
important for bone health, because it's the only … you can only absorb your calcium in your diet
if you have enough Vitamin D. So, if you have a stress fracture, it's a good practice to get your
GP to just test your Vitamin D levels as well and see if you maybe needed topping up of that.
Then, there are other illnesses and other conditions that can cause bone mineral
deficiencies as well. So, if you have a history of osteoporosis in the family,
it may be worth checking that out, because if you can get that treated early on, it's much easier to
turn it around. Now, what does a stress fracture feel like? So, usually the pain builds up over a
period of time. So, it will feel a bit of achiness while you're running, be a bit sore after you've
run, but then it'll settle down, it'll be okay until the next run. But then, as it progresses
and gets more and more irritated and worse, you may even have pain with normal activities
like just walking or standing, or sometimes even at rest. And this is because initially,
you only get a bone stress reaction; so, you don't get a full-on fracture to start with.
If you looked at it on an MRI scan, you'll see there's a bit of swelling in the bone,
the bone just looks as if it's irritated. But if it continues to be irritated and overloaded,
then you can get a proper fracture line; but it's still not … it's still together,
it's not displaced. And then, a grade up, you can actually get that it displaces. Now, you can't see
the early stages of a stress fracture on X-ray; they're just not useful, they can't show you that;
it's only MRI scan that can show you that. But you don't necessarily need an MRI scan,
initially; if your clinician is skilled enough to listen to what you're telling them,
take into consideration how much training you've done, and do a proper examination ... So, usually
for any stress reaction in the bone, if you want to suspect that, the bone has to be tender to
press on. There are other things that can feel like a stress fracture in your metatarsal. So,
if we think of the ones over the metatarsal, the base of the metatarsals, then metatarsalgia, which
is an overuse injury where you get irritation of the soft tissue as well as the bones in that area,
it can feel very similar. Morton's neuroma is where the little nerves get irritated between
the toes or the metatarsals, and that can cause pain that can feel similar to a stress fracture.
If we think of the fifth metatarsal, then you have your peroneal tendons attaching into
this area. So, if you have a tendinopathy, it can give a very similar pain as a stress fracture,
because it can also be painful on the bone there. So, it's worth having an examination and then also
just confirming it with a scan if it's not reacting as you would expect it to react.
Now, treatment-wise: Treatment will very much depend on what type of stress fracture you have,
in what area it is, as well as how advanced it is. If it's just a stress reaction,
that there's no proper fracture line or anything yet, then you may just need to reduce the load
on that foot; you don't necessarily need a boot or anything like that. But it may mean that you
use some crutches for a while, if it's that bad, or you just don't walk or run on it;
you try to limit your time on feet. If it is a proper stress fracture, especially in the area
where it is high risk for not healing – so, the base of the metatarsals or on the fifth
metatarsal – you'll likely get stuck in a boot, because you want to immobilise that area as
best as you can to allow the bone to heal. Now, bones do well with being kept still for a while
to allow them to heal, but then they really want to be reloaded over a period of time. So,
when you come out of that boot or the pain settles enough that you can start weight-bearing on it,
your physio will usually help guide you, that you start a progressive loading program where
you slowly build up your time on feet and you do strength exercises that load that area over time.
But it's best to just make peace with it that it will likely take you about three months to get
back to running. And if you try to rush it, you'll likely just end up overloading again and having to
start the progress from scratch again. But, it doesn't mean you have to do total rest; you can
do anything that doesn't load that area. So, if we think of stuff like that: cardiovascular exercise,
swimming – brilliant option. Later stages, if it starts accepting load in the water,
you can do some jogging in the water. You may be able to do some cycling, depending on what
stage you're in and how much pressure goes through that part of the foot if it allows you to do that.
Rowing could be another option. Sometimes, you just need to adjust how your foot is on the pedal
to offload that area. Also, there's nothing wrong with the upper body or the core muscles. So, you
can start doing exercises for those, keep yourself fit and strong. Again, just take note of how much
pressure do I put through my foot; is it through the injured area? Because you don't necessarily
want that at the beginning. But as you grow stronger, you do want to load it a little bit.
But it's all according to pain, that you don't want to stir up the pain as you reload it. Now,
I often get asked, “How do I know I'm ready to go back to running after I've had a stress fracture?”
Well, there's no magic "Ping! Now you know you can go back.” It's about building up slowly towards
it. So, when I want to … When I decide whether you're ready to go back to it or not, I'll be
looking at, what have you done in the last week or two? How much walking have you been able to do? If
you've not been able to brisk walk yet, there's no ways you can run. So, we've got to build up
the walking and your speed in walking before we can get to run-walking, for instance.
We want to look at your heel raises, for instance. If you can't go up on your toes, up-and-down with
a bit of extra weight in your back, and that still irritates your foot, no ways you can run,
because when you run, it's forces of between – well, depending on what research you read – three
to six times your body weight just through your Achilles tendon and your calf. So, it's very
similar to that that goes through the foot. So, you want to be able to tick those boxes, that you
can do certain exercises without aggravating it before you transition back to the running.
Now, often people feel that there must be something wrong with how they move, or their body,
and that's the reason they got the stress fracture.
Now, in a very small proportion or portion of people, there may be some biomechanical
factors that could help if you changed it. But I want you to really clearly understand that
there is no perfect running form; there is no, “You have to run like this if you want
to be injury-free.” Our bodies can adapt and grow strong in any position of running,
as long as you don't load it too quickly, as long as you allow it that time to adapt to it.
So, biomechanics is not the first thing to try and change. Especially if you've run for years
and years and years without an issue, then it's not biomechanics that's your issue.
So, before you start worrying about biomechanics, just get yourself strong top to bottom in your
normal positions and movement patterns that you have, and then look at your load management going
back, that you don't overload too quickly, that you look at your training load and make
sure you've got enough time to adapt, and look at your nutrition, that you've got that sorted.
If it still remains a problem, then you can start looking towards biomechanics. And you may benefit
from seeing a podiatrist if you really supinate dramatically, because it could be as easy as just
choosing the correct shoe that doesn't allow that much supination or getting an orthotic
with a little bit of a wedge on the outside that just stops it from rolling quite so much.
So yeah, definitely for me, the first thing is, get your load management with training right,
make sure all your muscles are strong, get your nutrition right, and then you can consider whether
you still need to change anything in biomechanics. But it's not the first thing to do. Ah!
Note to self; I nearly forgot. The big difference ... You can get an acute fracture in this area as
well – not a stress fracture – by rolling your foot suddenly. So, just something to point out.
I should have said this under “How does it feel when you've got a stress fracture.”
If you've turned your ankle and you suddenly have pain in this area,
have it checked out. X-ray could even be useful, because it's much more likely that
you may end up having a fracture rather than a stress reaction if your pain came on suddenly
after you've twisted your ankle or something like that. So, that's just something to keep in mind.
Very well! I think I've said everything that I've meant to say. Let me know if you've got
any questions. And remember, if you need more help with an injury, you're welcome
to consult one of us via video call. The link to the website is in the description of this video.