Troy Bannister a 28 year old long-distance runner. He has been running for years having finished both several half and full marathons. Approximately 5 weeks ago he noted some pain in his left foot. He had a 10km race the following day and ran through the pain in the foot. Afterwards he sought treatment with his chiropractor, who performed several manipulations. He started noticing his pain worsening and subsequently 3 weeks ago withdrew from his next race while stopping running altogether. He now presents to your clinic for assessment.
Interval training 5-7km 1/week
PMHx: No prior medical conditions, no prior surgeries
Medications: None, not taking any supplements.
Allergies: No known drug allergies
Tall slender male. Non-antalgic gait.
No evidence of arch abnormalities.
Achilles was noted to be normal.
Some blistering of right heel seen.
Subungal ecchymosis of lateral digits of left foot.
Swelling on the dorsum of his left foot.
Tender over Metatarsals, 3,4, and 5.
Non tender navicular, cuboid, base of 5th MT.
Full ROM of metatarsalphalangeal joints, however some pain with flexion of lateral digits 3 and 4.
Neurovascular exam normal.
Report: D3 mid-shaft metatarsal periosteal reaction – consistent with healing stress fracture.
Assessment: Stress fracture of Metatarsal number 3
1. May start cross-training (e.g., water running, swimming, stationary cycling) immediately as tolerated. (Aircast walking boot if antalgic).
2. When athlete is pain-free without any observed antalgia, gradually resume running load. Commence with short test run or equivalent, every other day, “easy run” paced. If successful (i.e., pain free 24h post-test run), increase running duration (with unchanged intensity – “easy run” pace). Ensure injured athlete can tolerate at least 20-30 minutes continuous easy-paced running, symptom-free, prior to augmenting intensity.
3. Vitamin D and calcium
4. Consider low-intensity pulsed ultrasound bone stimulator in special circumstances
Dr. Mark Leung (July 10, 2014 PR ND)