How Can I Tell if My Foot is Broken?

Hi My Running Doc,

A couple of days ago I accidentally kicked the wall with my right foot. My foot still hurts and it is bruised.  I read on your website that bruising can be a sign of a metatarsal fracture. How can I tell if it is just bruised or if my foot is actually broken? I would love to have your expert opinion!

Thanks!

David, Houston, Texas.

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Hi David, 

Bruising is a Bad Sign

It is true that bruising is a bad sign when it comes to foot and ankle injury. When you actually fracture a bone, the bone cracks and bleeds quite a lot. That blood diffuses throughout the soft tissue under the skin. What you see is a bruise. That is part of the reason that a bruise can be so concerning for a fracture in the foot. 

In fact the sort of bruising pattern that the picture of your foot shows is often indicative of a fracture or broken bone in the foot. Given your pattern of bruising it is more likely that you have a metatarsal fracture or a fracture in one of the bones in the little toe such as the proximal phalanx phone.

Myths about Foot Fractures

1.  If you can walk on the foot, it can’t be broken.  FALSE!

This may be one of the most widely perpetuated myths about foot injury on the Internet. I have seen many patients with serious fractures that are walking on the foot. Some patients are limping and obviously in a tremendous amount of pain while other patients with fractures or broken bones barely feel any discomfort at all. This is not a reliable indicator of whether or not you have a broken bone in your foot.

2.  There is nothing you can do for a broken toe.  FALSE!

This is also absolutely not true. While it is true that most fractures in the toe will heal uneventfully, there are things you can do to speed healing and decrease your risk of complications. Fractures of the bones in the toe can move if not properly stabilized. Certain shoes will speed healing. Taping the toes to provide stability and immobilize the fracture will also help. But some toes should never be taped together. 

Without the proper treatment of a broken toe, the fracture can fail to heal leading to what physicians refer to as a nonunion. A fracture that never heals correctly can lead to pain, disability and interfere with your ability to run or even walk without pain.  Occasionally patients that take the approach that “nothing can be done for fractured toe” just end up in surgery later.  For the most part this is avoidable if the toe treated correctly.

Diagnosis and Treatment Options

If you are suspicious that there might be a broken bone in your foot (or in one of your toes) it is best to figure out whether or not it is actually broken.  The best option is to have an in-person evaluation by a sports medicine specialist such as a sports podiatrist.  The second option is to have a remote consultation with a sports podiatrist via webcam. A third option is an attempt at self-diagnosis. This video on YouTube can show you how to perform self-diagnosis of metatarsal stress fractures. This same video would apply in your case if the pain is located where you’re bruising is in the foot.

If you see a physician in person or via webcam or you perform your own self-diagnosis and think that you probably have a fracture then you should get x-rays. X-rays will not only confirm (or rule out) a broken bone in the foot but it will also give you an idea of the severity of the problem. There are some fractures that absolutely must be treated surgically. Others simply need a fracture walking boot in order to stabilize the fracture and allow it to heal. And occasionally it is necessary to use crutches. 

But not all fractures are the same. So if you have pain and bruising after this sort of injury and suspect that you have a fracture in your foot it is important to determine whether or not there actually is a broken bone, and treat it appropriately. As long as you treat the fracture correctly you should be able to heal and then get back to running.

Dr. Christopher Segler, D.P.M. is board certified, American Board of Podiatric Medicine. Because he is an active marathon runner and 10-time Ironman triathlon finisher, his practice focuses exclusively on helping runners get back to running as quickly as possible. He travels back and forth between San Francisco, Houston, and Hawaii so he can often to help Texas and California patients with running injuries.  He also provides web consultations via Skype for injured runners who who are too busy to drive to a podiatry office. If you are in San Francisco and have a question about a running injury, you can reach him directly at 415-308-0833. If you live in Houston and think you have a stress fracture, your can call him at 713-489-7674. Visit our Houston Doc On The Run Practice. Learn more about stress fractures here.

Can I Continue Running With This Blister?

We receivd an email inquiry from Julie who is currently training for a marathon. She recently injured on of her little toes and wants to resume her training.

She explains. "I have had this blister now for a week. I had also tripped over a bike rack which bruised my toe as well. I am on antibiotics and they took X-rays to confirm my toe was not broken. It was not broken but very infected. I was training for a marathon and want to know if I can continue running or do I need to wait longer for it to heal."

As a sports medicine podiatrist the primary concern with a blister is of course to help the blister heal as quickly as possible so that the patient can resume marathon training without any significant loss of fitness.

The basic tenets of blister treatment involve the following:

1. Provide mechanical protection of the blister. This means to use any combination of reduced activity, shoe modification, padding, etc. to stop rubbing and irritating the wound. If you continue to apply shear forces and friction, the blister will take much longer to heal, and could even get worse.

2. Optimize a moist environment of the wound to facilitate healing. This means that you want to keep the wound properly hydrated. The wound has to be moist, but not too moist. If a blister is actively draining, the dressing should absorb the exudate to prevent the excess moisture form breaking the tissue down further. If the wound is too dry, then a dressing should be used that will add moisture sufficent to promote healing.

3. Reduce the bioburden of the wound. "Bioburden" is a term used by wound care specialists that refers to the well-know negative effects of bacteria colonizing a wound, or worse yet, infecting a wound. Your skin is covered in bacteria. This not a comment on hygiene; it is a natural state. Any open wound will quickly become colonized with bacteria as well. If there is an excessive amount of bacteria feeding in the wound, the wound healing process slows. Many wound care products are designed to impede the growth of bacteria or wash the bacteria away. But not all are created equal. Some commonly used wound-cleansing substances such as dilute bleach, hydrogen peroxide and povidone-iodine kill off bacteria, but unfortunately are also toxic to the cells trying to heal the wound at the base and edges of the blister.

Much worse than a "colonized wound" is an "infected wound." The difference is that an infected wound is one where the bacteria is actually directly damaging the tissue. This is the case described above.

It appears from the picture and description provided that this runner's toe has not been caused by the exceeding common friction from running shoes, but is in fact a traumatic injury, more likely causes by a direct blow when tripping over a bike rack.

When this kind of injury occurs two things can happen.
1. The toe (or at least on of the phalanx bones within the toe) can easily break.
2. The nail plate can become separated from the nail bed leading to a nasty infection.

This type of injury has to be treated much differently than a standard friction blister.

The first concern is to treat the infection. This might be accomplished through the administration of prescription oral antibiotics, drainage of the blister and removal of pus in a podiatrist's office, and perhaps, even remove of the nail plate. Deciding which of these are appropriate would require an in-person evaluation with a podiatrist.

The second concern is the possibility of fracture. Little toes get broken all the time with the kind of injury described. The reason this is so worrisome is that if one of the bones in the toe is broken, the infection in the skin and surrounding soft tissue could easily spread to the bone resulting in osteomyelitis- also known as a bone infection. Bone infections are serious and are the primary cause of amputation of toes.

Before returning to running this runner (and her doctor) would have to be certain that the toes wasn't broken and the infection was well on its way to healing. Once that has been accomplished, it would be necessary to have a podiatrist who treats runners often evaluate the runner's shoes and determine the best way to offload the toe so that it could continue to heal with any irritation. She should then be able to get back to training for her marathon.

Dr. Christopher Segler is sports medicine podiatrist who practices in San Francisco. He is an active runner and triathlete who is competing in 1 marathon and 4 Ironman triathlons in 2012. His practice is limited to active runners and triathletes. You can learn more about running injuries at www.DocOnTheRun.com and www.AnkleCenter.com

When is Surgery Needed for a Ganglion Cyst in the Foot by San Francisco Running Foot Surgeon

A runner with a ganglion cyst called from San Francisco and had the simple question. "When should a runner consider ganglion surgery?" Here is the answer....

Whenever a patient has a big squishy lump on the top of the foot, big toe joint or the ankle joint, they want to know what will make it go away. The most common soft tissue mass in the foot is a ganglion cyst. Sometimes ganglion cysts will go away on their own. Sometimes the ganglion cyst needs to be drained. But sometimes a ganglion cyst in the foot needs surgery.

There are really 3 reasons that a ganglion cyst in the foot or ankle will need surgery

1. The ganglion cyst is painful.

2. The ganglion cyst is pushing directly on a nerve and can cause nerve damage.

3. The ganglion cyst is so big that it makes it difficult to wear shoes.

Unfortunately, many times ganglion cyst happen to develop in locations that are positioned close to nerves. This is really the best reason for a runner to think about ganglion surgery.

The tingling and burning pain that is often associated with a ganglion cyst is usually because the soft tissue mass is pushing against a nerve and causing the nerve to become irritated. If this continues for a long period of time, you can develop chronic pain or permanent nerve damage. The skin on the top of the foot is very thin and when a soft tissue mass develops the mass gets squished between the shoe and the bones that are close to the skin. The nerves that are located in that area can then get caught in the middle and cause pain. For this reason midfoot ganglion cysts often have to be removed surgically.

Dr. Christopher Segler is a runner, 6-Time Ironman finisher and a nationally recognized foot surgeon and sports medicine podiatrist who focuses on rapid recovery from running injuries. He is an internationally recognized expert in the treatment soft tissue masses that may appear to be ganglion cysts. His research and theories on PVNS (a dangerous soft tissue mass that is often mis-daignosed as a ganglion in young adults) have been published in the medically journals and were used as the basis for new treatment methods of these soft tissue masses. He practices podiatry, sports medicine and surgery in San Francisco.

You can learn more about the best treatment for ganglion cysts in the foot at www.AnkleCenter.com and www.DocOnTheRun.com. If you live out-of-state or abroad, you can arrange a remote consultation with a true running expert through www.RunnerSecondOpinion.com