Courtesy of myfootshop.com

Bone is a phenomenal tissue that has the ability to change, grow and restructure itself based upon the loads we apply to it. Bone gives our bodies support and structure, it protects our many vital organs and it acts as a reservoir for the important minerals we need every day.

Think of the bone structure of your feet as shock absorbers, in fact they act much as do the shock absorbers on your car. We expect our cars to have a smooth consistent ride regardless of loads that we put in the car like groceries or people. Those loads are constantly being added or removed from our cars, yet the shock absorbers provide a smooth consistency over their functional lifespan. Our bones work in much the same fashion and yet are a much more dynamic structure, able to change when we change.

Let's say we start to work out at the gym. We plan to get big muscles to impress our significant other. What supports those muscles? That's right, bone. Our new fitness plan increases loads applied to bone causing it to grow to be able to accept those new loads. The opposite holds true also, decrease your activity and your bone mass will decrease. That's why it's so important for seniors to maintain regular physical activity.

The bones of the foot are a very complex set of structures designed to carry load. Each foot consists of 26 different bones and 114 ligaments. That number is complex enough but when we bear weight and begin to walk, all of these bones move and change. The interesting part of my job is that the bones of the foot are constantly changing. For instance, when I exam a patient in my office, even though they are sitting in a treatment chair, I am visualizing what the foot and all the bones are doing while that patient is walking

A fractured bone simply is a broken bone. There are many sub-definitions of the term fracture. For instance, a compound fracture is an irregular fracture that has broken through the skin. A comminuted fracture is one that is in many pieces. There are any number of different varieties of fractures that we see in the foot.

Fractures can occur for many different reason. We tend to think mostly of trauma causing fractures but there may be other contributing factors. Most of us are familiar with the term osteoporosis. Osteoporosis means that the density of the bone, the mineral content so to speak, has been reduced. Patients with advanced osteoporosis are subsequently more susceptible to fracture. Bone tumors may also contribute to fractures by weakening the bone. And lastly, many other systemic or metabolic diseases may contribute to change in bone that may result in a fracture.

Stress fractures are quite common to the foot. We mentioned before that bone carries load. A stress fracture simply implies that the load applied to the foot was greater than what the bone could tolerate, so it breaks. The most common stress fracture that occurs in the foot is in the metatarsal bones. These fractures are also referred to as march fractures. The name came about as the result of forcing young, sedentary army recruits to march 20 miles with a full backpack. Their transition from civilian to soldier was too abrupt resulting in a load that was greater than what the metatarsal bone could tolerate.

The onset of a metatarsal stress fracture is somewhat subtle. Let's look at a few case examples.

Case 1. Bob, 32 years old, was on a business trip in the Atlanta Airport and was late for his plane. He had to go from concourse A to concourse Z carrying his luggage. When he finally got on the plane and sat down, he felt a dull ache in the forefoot that just wouldn't go away. After a week of limping around he contacted us.

Case 2. Ethel was a retired housewife who lived on a rural farm. Her husband had sustained a severe heart attack and was at home but was required to stay in bed. Therefore, Ethel was obligated to do a lot of the chores that here husband had done in the past. Ethel mowed her large yard with a push mower, and while mowing she noticed a dull ache of the left forefoot. The pain did not resolve over the next few days and she made a call to come see us.

You can see Bob and Ethel represent two very different people but the onset of the stress fracture is very similar. Each presented dull achy pain just behind the toes. It hurt to bear weight on the foot. The more they were on their feet, the more swelling they would see on the top of the foot. Getting a shoe on, and keeping it on was tough.

X-rays are necessary but aren't always so helpful with metatarsal stress fractures. In most cases, metatarsal stress fractures can only be seen on x-ray three to four weeks after they occur. X-ray findings of metatarsal stress fractures are very subtle in nature. We don't actually see the fracture, but we see the deposition of calcium surrounding the fracture as the bone heals. This finding is referred to as bone callus and is the body's own internal cast, so to speak.

Other stress fractures of the foot include the calcaneus and navicular bones. These are bones of the rearfoot that support the loads applied to the foot during standing or jumping. These fractures are difficult to diagnose and are often treated as arthritis or other inflammatory condition. An MRI will aid in the diagnosis of calcaneal and navicular stress fractures. Treatment for calcaneal or navicular stress fractures depends upon the location and severity of the fracture.

The technique of treating fractures varies on a fracture by fracture basis but the fundamental principles are the same. The first thing we have to do is to confirmed on X-ray that the fracture is stable, it's well aligned and that the ends of the fracture appose each other. Once we've done that, we find ways to help the bone heal. In most cases this is a variation of rest. It could be bed rest, a cast, a fracture shoe or just decreasing activity. As you can see, each of these methods of treatment is a variation of rest. Most stress fractures of the foot will heal over time with just a little help. Patients are usually surprised to find out that a stress fracture takes 8-12 weeks to heal.

Bone callus - describes the increased area of initial fibrous tissue, and finally calcified tissue surrounding a fracture. Bone callus helps to stabilize the fracture acting as an internal cast.

March fracture - a term used to describe a stress fracture that results from marching in the armed services.

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Symptoms of stress fractures may vary. Symptoms may include localized swelling (edema) and pain that increases with the duration of time spent on the feet.

The differential diagnosis for this condition should include;

Morton's neuroma

soft tissue tumor

This article was written by Jeffrey A. Oster, DPM, C.Ped and last updated 3/24/05.

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