Left Foot still hurts

Just one more thing, I've been putting my foot in a bucket of warm/hot water to promote circulation, blood flow in the area. Is this a good thing?

Hey Major,

Been tied up most of the day.

It sounds like you've made a lot of progress in your healing, and hopefully your doc has you doing the right things at this stage of your recovery so not to have a setback. I'd have probably kept you in the cast another 2 weeks just to give the fracture a little extra time to consolidate, to be on the safe side, but maybe it looked good enough at 4 weeks for him to feel you were ready. Without seeing your foot and your x-rays, I cannot say he was necessarily right or wrong. If running in place does not aggravate it, that's a pretty good sign that the fracture is well along in the healing.

I think one of the big things that has to be evaluated when you get to the point you're at is what was the actual reason or reasons that the 3rd metatarsal developed the stress fracture in the first place. This is not always that obvious. You may, or may not have been overtraining, but even if you were, that likely exposed an underlying weakness or vulnerability predisposing you to this injury. Determining the underlying cause(s) needs to be carefully evaluated and addressed to reduce the likelihood of a recurrence of this or another related injury as you get back into running. Things like footwear, vitamin D levels, bone density, foot structure and alignment, structural and functional asymmetries of the lower extremities, and training habits should all be given careful consideration. This would likely involve a comprehensive medical history, biomechanical workup by a sports physical therapist, and further studies such as bloodwork and bone density testing if thought warranted.

If your foot is still bothering you, that does not necessarily mean a cast is in order, but a very careful and complete evaluation has to be made, and this may require another MRI, to determine just exactly what it is, and what it is not, that is keeping it painful at this point in time, and then treat the issue(s) accordingly.

I've seen x-rays many years after-the-fact where the area of a fracture had healed but was subjected to an unstable healing environment (no immobilization), which resulted in a bulbous appearing enlargement of the bone. That does not automatically mean there will be permanent discomfort as a result, in fact, usually there is not any residual discomfort if that fracture has fully healed. If there is discomfort, however, it is likely either that the bone still isn't completely healed, or that it is applying pressure on an adjacent structure.

If excess bone formation was placing pain producing pressure on the adjacent muscle or nerve tissue, this bone could be surgically shaved away, which may do the trick (no guarantees in surgery, as scar tissue and chronic pressure on nerves can cause permanent damage in some cases). If that was going on in your case, it would be very obvious when looking at your x-ray. I mean, it would look really abnormal, and stick out like a sore thumb visually, so if your x-rays don't appear that way, ie, the bone contours of the 3rd metatarsal looks like those of the adjacent metatarsals, this is not what's happening. Also, if it were the case, you'd typically feel decent sized lump over the metatarsal at the fracture site.

Major_Jared wrote:

Just one more thing, I've been putting my foot in a bucket of warm/hot water to promote circulation, blood flow in the area. Is this a good thing?

Sure, nothing wrong with that. I'd actually take it one step further and then place the foot in a bucket of cool water for a few minutes to "flush out" the waste products. The alternating of hot and cold, known as "contrast bath therapy", would probably be more productive.

Hi, thank you so much for taking the time to provide assistance.

When I say running in place, I really mean walking in place. I haven't begun running yet.

My fracture was a result of overtraining. I was in basic training in the Singapore Army, and for my graduation, I had to march 16 miles carrying 45 pounds, with little sleep. After a couple days of that march, that's when I felt pain in my left foot. This was at the end of December 2015. I do have a high arch foot, that may be one of the causes of developing a stress fracture.

I believe the bone has healed, but the surrounding muscle or the nerves are still damaged, and that is causing the discomfort. How can I fix this? By complete immobilization? I'm still confused on whether I need to walk more or don't move my foot at all. I'm kind of in-between right now. I still definitely feel something is still "there" that is bothering me. I believe it is a nerve thing. I guess, taking an MRI will answer some of these questions?

Or I have a feeling that my fracture wasn't completely healed within the 4 weeks I was put in a cast. My foot is slightly better, but I can still feel some of the symptoms/pain/discomfort I did before I was put in a cast. Very similar feeling.

Is there a risk to be put in a cast again, this time 6-8 weeks?

Hi, I hope we can continue talking.

I went for physiotherapy, and I asked him if I could be put in a cast again, but he said that will make it worse, in a sense that my stress fractured area is weak so I need to continue to strengthen it by doing (his recommendation) single leg tip toes, forward/backward lunges. If I'm put in a cast again, the area will become weak again and will take long to come back 100%. He said it is unnecessary to put on cast again.

I will make an appointment for an MRI soon, and if it shows an unhealing fracture, I'll have to be put in a cast, correct? I have to heal the fracture completely first before I can get back to 100%, which I am trying now.

Major_Jared wrote:

Or I have a feeling that my fracture wasn't completely healed within the 4 weeks I was put in a cast. My foot is slightly better, but I can still feel some of the symptoms/pain/discomfort I did before I was put in a cast. Very similar feeling.

Is there a risk to be put in a cast again, this time 6-8 weeks?

Typically no long term risk. I would get the MRI to confirm it's not healed, if possible, before subjecting yourself to that path, however. Also, I'd be pushing to get a bone stim on there. Insurance may not cover it if you don't have documentation of non-healing, which only MRI or CT would show if it looks OK on x-ray. If insurance doesn't cover those, a bone scan is an acceptable alternative, although it doesn't show any detail of the fracture like the other studies would. I gotta get to work but I'll get back on the other question later.

Sorry, easy 2nd question. Your P.T.'s logic is not sound, because if there is still incomplete healing to a significant enough degree, you risk increasing the damage by continuing to add stress from those exercises. Also, IF there is a biomechanical issue (high arch w/ long 3rd metatarsal) that he doesn't address with orthotics or something, you are just adding the same old excessive stresses to the 3rd metatarsal that contributed to forming the stress fracture in the first place (along with the long marches, of course).

Ok, I will get an MRI first before going on a cast (If it still shows a fracture). The problem is, scheduling an appointment for an MRI takes one or two months. I was wondering if I can be put in a cast for those couple months, then take an MRI to see if it is actually healed.

Is a bone stimulator a device I can ask when I visit a doctor or do I need to buy one? If I need to buy one, do you know any of the good ones?

This is complicated. My P.T. is assuming that my fracture is healed, that the reason I feel discomfort is because the muscle around my foot is weak, that it needs to be strengthened by doing those mentioned exercises.

The only exercise I can't perform now is single leg tip toes. I am able to do tip toes both feet but when it comes to a single leg, it is extremely difficult (feels a little both of stiffness/soreness with pain). I guess this shows the weakness I have in my foot. My left leg is sore from doing sets of single leg tip toes. I will see if this will help with my fracture.

I did a little research and tip toes train your tibialis posterior, gastrocnemius, and soleus. How are these muscles connected to my 3rd metatarsal bone?

Major_Jared wrote:

Ok, I will get an MRI first before going on a cast (If it still shows a fracture). The problem is, scheduling an appointment for an MRI takes one or two months. I was wondering if I can be put in a cast for those couple months, then take an MRI to see if it is actually healed.

Is a bone stimulator a device I can ask when I visit a doctor or do I need to buy one? If I need to buy one, do you know any of the good ones?

That's extremely unfortunate regarding the wait for MRI. My patients can get them within 3-5 days typically. Curious, do you live outside the U.S.? Anyhow, You certainly can be put in a cast, but "cast disease" takes a long time to reverse if you didn't need to be in one. Honestly, the vast majority of people with metatarsal stress fractures heal just fine with a TALL cam walker boot. This is much better physiologically than a cast. The key to knowing if you are going to heal in one is if it COMPLETELY eliminates the pain when you walk in it, at least after you've had it on for a few days. If the answer is no, then you need to be off the foot. This can still be in a cam walker, which has it's advantages, as it allows you to take it off and do non weightbearing range of motion exercises (strengthening) of your foot and lower leg muscles to keep them from atrophying as much,

A bone stimulator is something you should absolutely ask your doc to prescribe for a delayed healing stress fracture. The device is very expensive if not covered by insurance (over $1000 typically), but I'm sure you can get a used one on Ebay for a fraction of the cost. Exogen by Smith and Nephew is a great one, as it only needs to be applied for 20 minutes/day (most others must be on for an hour or even several hours).

Major_Jared wrote:

This is complicated. My P.T. is assuming that my fracture is healed, that the reason I feel discomfort is because the muscle around my foot is weak, that it needs to be strengthened by doing those mentioned exercises.

The only exercise I can't perform now is single leg tip toes. I am able to do tip toes both feet but when it comes to a single leg, it is extremely difficult (feels a little both of stiffness/soreness with pain). I guess this shows the weakness I have in my foot. My left leg is sore from doing sets of single leg tip toes. I will see if this will help with my fracture.

I did a little research and tip toes train your tibialis posterior, gastrocnemius, and soleus. How are these muscles connected to my 3rd metatarsal bone?

Your P.T. may be right that your fracture is healed, but what's his criteria for this assumption? This is a critical question.

Your research is correct. Those muscles are not connected to your 3rd metatarsal bone. Why do you ask?

Yes, I live outside the U.S. (in Singapore). Before the cast, I was put in a cam walker boot for a couple months, but this had no effect on me. It is only after I had the cast on in which my foot improved.

Were you on crutches w/ the cast, or putting some weight on it?

Well, my doctor and my P.T. is separate. After taking off the cast, he's assuming the fracture is healed.

Anyway, after doing those tip toes exercises, my foot feels much better now (although very sore, I'm guessing because I haven't worked those muscles in a very long time). Those muscles aren't connected, but I can feel it is helping me.

I will continue those exercises until my next doctor's appointment next Thursday.

Looking at it now, I believe I should stay off the cast for the moment. I will continue these exercises for a couple more weeks to see how my foot feels.

I was on crutches. I stayed home the entire 4 weeks. Did not put any weight on.

Major_Jared wrote:

Well, my doctor and my P.T. is separate. After taking off the cast, he's assuming the fracture is healed.

Anyway, after doing those tip toes exercises, my foot feels much better now (although very sore, I'm guessing because I haven't worked those muscles in a very long time). Those muscles aren't connected, but I can feel it is helping me.

I will continue those exercises until my next doctor's appointment next Thursday.

Looking at it now, I believe I should stay off the cast for the moment. I will continue these exercises for a couple more weeks to see how my foot feels.

Sounds good. Glad to hear that your foot is responding well to the exercises. Being in a non-weightbearing cast is a much bigger deal than being in a walking boot as far as muscular and bone "weakening", so as long as things are improving, definitely don't subject yourself to that unless there is a clear reason to do so. Hopefully the doc will help determine the answer to that for you next week.

I am reading an account of YOUR OPINION but what is the doctor's opinion?

Specifically what is the doctor's opinion regarding the healing of your fracture? When was your last X-ray? An X-ray will confirm if your bone has in fact healed and just as importantly has it healed with proper alignment.

Metatarsal stress fractures can be very difficult to recover from and your current complaints are not rare.

The root of your problem is that you developed pain in December and obviously continued to train and run for 9 months!! Pain is a signal that you have an injury "playing through the pain like a man" is nonsense that is left for the movies it is not something a child (yes you are still a child) should be doing. You are now paying the price for your bravado and the stupidity of your coach and parents for allowing you to run when you were injured.

you mentioned your first doctor told you that it was alright to walk and it would heal itself. What did he say about running? If you ran when he told you to walk the problem rests with you not your doctor.

Nerve pain is extremely difficult to diagnose and treat because it is entirely subjective. Nerve conduction studies are of no assistance in your case. Is your pain similar to a tooth ache (ie. throbbing)? Or is it a dull ache or discomfort?

At the end of the day you are only going to recover by resting your foot. Without seeing your X-ray I can not give an opinion the necessity of the boot.

I've taken many X-Rays before I was put in a cast, but the results say "No definite fracture or dislocation is detected," " The bony cortex and trabecular patterns are preserved. There is no periosteal reaction."

This above X - Ray findings were performed BEFORE I was put in a cast last December where I genuinely felt pain on my left foot whenever I put significant weight on.

I did take another X - Ray after I took off the cast (mid-January) but, again it does not show anything wrong with my foot.

Although slowly improving, I can still feel something is still bothering me. I'm guessing is a nerve damage, but I don't know what solution there is to fix it. I just hope this is not a permanent thing. My second doctor has told me that surgery is not necessary.

It feels like a dull ache, like a muscle ache. Before the cast, whenever I push my third metatarsal bone with my finger down, I felt pain. However, I do not feel that pain anymore. But I do still feel an ache, which I don't know what is causing it, which is why I will getting another MRI.

Yes, my first doctor said I shouldn't run. And I didn't. I just continued to walk, trying to avoid putting pressure on that area of my foot. But I am still puzzled why I wasn't put in a cast at the very beginning.

Currently, I have began to walk normally, but at times I can still feel the discomfort in that particular area.