What My Patient Has In Common With Soldiers

 

Picture from statpearls.com

I wrote last week that Byron had an interesting case. A patient with a foot condition that the doctor may have missed. This patient started having dull, aching foot pain 6 weeks ago after a game of tennis.

He had been playing tennis more frequently at a higher intensity, besides running and cycling. Since the pain started, he had stopped all exercise. He consulted a doctor a month ago and was diagnosed with 'inflammation in the tendon of the 2nd toe'.

Upon assessment, the patient could perform all functional tests like heel raises, toe raises and single leg hops with no pain. There was just a slight difference in muscle strength in the patient's painful foot. No pain at all during muscle strength testing, which is common during tendon injuries.

Picture from Merck manuals

The patient's pain was immediately reproduced upon specific palpation of his 2nd toe, along the shaft of the metatarsal, suggesting that he had an almost recovered "March" fracture.

March fractures (or metatarsal stress fractures) were first described in literature in 1855 in Prussian soldiers after they experienced pain and swelling in their feet after long marches. They are usually caused by repetitive stress and extrinsic environmental risk factors. If a patient is nutritionally deficient in Vitamin D or calcium, the risk of these fractures occurring are increased.

March fractures occur most commonly in the second or third metatarsals when they are unable to withstand the load from excessive forces/ loads. The second toe is less flexible and is prone to more torsional forces due to its attachments to the cuneiform bones.

Diagnosis is based on physical examination followed by confirmation by x-ray imaging.

We did not suggest that the patient go for an x-ray since it's been 6 weeks since the pain first occurred (stress fractures take approximately 6 weeks to heal). We advised him to gradually resume his exercise routine after treating him.

Reference

Warden SL, WB Edwards and RW Willy (2021). Optimal Loading For Managing Low-risk Tibial And Metatarsal Bone Stress Injuries in Runners: The Science Behind Clinical Reasoning. JOSPT. 51(7): 322-330. DOI: 10.2519/jospt.2021.9982