Rehabbing A Metatarsal Fracture With Displacement
A 60-year-old contacted me regarding a fracture that does not seem to be healing even at the seven-week mark. A hard bench had hit his foot when he slipped from the bench in the gym, causing the fracture. It is a midshaft metatarsal fracture with a bit of displacement of about 3 mm. A displacement of 3 mm will take awhile to heal, especially because it is at the midshaft, where the bone heals slower than at the ends.
Since the patient has experienced no pain with his foot in an Aircast since day one, is quite active at home and has an outing in which he needs to walk at least twice a week, his doctor asked him to wean off the Aircast slowly.
This advice would be the same for any weaning process. You give the patient between two and six weeks to go from boot to shoe. Have the patient starts with one hour the first day out of the boot, two hours the second day, etc. Emphasize to the patient that he or she should not have any more pain out of the cast than in the cast. The patient should be in the 0–2 pain environment on the Visual Analogue Scale and one cannot deviate from this. I love to have patients in a softer shoe with lacing that they can adjust and arch supports to spread out the weight. The pace should initially be slower out of the boot. Have the patient try using an ice pack for 10 minutes three times a day to control the inflammation for the first two weeks.
When the patient tries to walk on this fractured right foot, he tends to be compensating by walking flat-footedly. He is not putting his heel down first and pushing off from the front of the foot. In a way, he says he is limping.
It is probably okay to walk with the foot flat until the patient is out of the boot completely or at least for two weeks. You definitely want to avoid having the patient walking only on the outside of the foot. Ideally, you want the patient to try to gradually place all his weight down on the flat of the foot (the heel should take a lot of weight) like a slow march. The push-off will come but I think the patient has to be completely out of the boot for a week or so, and doing great before risking an active push-off.
The patient also says his foot swells up as soon as he has walked 10 to 15 steps. The pain level has been 0, 1 or 2. He says it is just slight soreness when he walks without the Aircast.
The swelling is the body's protection so pain will be this patient’s guide more on when to get off the foot. The patient should understand that he has to have the boot with him at all times in case he has to put it on. If he puts it on for relief, then he has to wait two hours before trying to go without it.
Standing is worse for the swelling. If the patient has swelling, see my video on contrast bathing (https://www.drblakeshealingsole.com/search/label/Contrast%20Bathing ) and start at one minute of warm water and one minute of cold water for 10 cycles. That is a 50 percent heat to ice ratio and this really gets the circulation going. If the patient is still swelling, he can try one hot cycle and three cold cycles for about 20 minutes. Patients need a big athletic shoe for this process because they want to wear inserts or at least compression socks for the swelling.
The patient is taking vitamin D, calcium and magnesium, and has just had a denosumab (Prolia, Amgen) injection. If the patient is taking Prolia, I assume he has some level of osteoporosis. This is going to take a while to heal a displaced, midshaft metatarsal fracture. Do not set time limits. The next period is to maintain the 0–2 pain levels and get out of the cast. The patient should walk slow and flatfooted so the heel can take some weight.
Maybe the patient will qualify for an Exogen bone stimulator (Bioventus) to help the healing. I would advise the patient to see about a Sole OTC arch support and a cushioned athletic shoe like the Brooks Ghost or the New Balance Fresh Foam 1080.
Editor’s note: This blog originally appeared at https://www.drblakeshealingsole.com/2017/01/metatarsal-fracture-with-displacement.html . It is reprinted with permission from the author.
