3 Reasons to x-ray a stress fracture from running.

Dear MyRunningDoc, 

I have been ramping up my mileage as part of my marathon training. My foot has been sore and aching when I run. Someone told me that stress fractures don't normally show up on an x-ray until they start healing. If this is true, is there really any point to getting an x-ray if I think I did get a stress fracture from running too much?  

Adam J.

Houston, TX

Answer:

Great question!  This is a question I often hear from runners in San Francisco and Houston. Most runners are busy and don't wont to waste their time going to a podiatry office getting an x-ray of their foot unless they really think the x-ray will change what they need to do to get the foot to stop aching and  heal. (And of course, get back to running and training). But when you suspect a stress fracture, there are good reasons to get an xray.

3 reasons to get an x-ray of your foot if you think that you have a stress fracture.

The 1st reason to get an xray of your foot is to make sure that the metatarsal has not actually cracked all the way through the bone or broken into pieces. 

The 2nd reason is to confirm that the metatarsal, if it is broken, is still in a good position that will heal correctly. If the bone is moved out of place after it has broken that it will not heal correctly and will result in what doctors call a “malunion.” When the metatarsal bone heals in an abnormal position it will alter the way that forces are distributed across the ball of the foot. An unnatural distribution of forces across the ball of the foot will put other metatarsals at risk of problems later. It can also increase the chances of nerve compression that can lead to a neuroma. 

The 3rd reason to get an xray of your foot when you suspect you have a stress fracture is for peace of mind. Having an x-ray confirms that the bone is not actually broken and will not likely get worse if you are walking on the foot as it heals. A fracture walking boot is made to protect a stress fracture and allow you to walk while the bone heals.  if you have had an xray of the foot and confirmed that the bone is not completely broken, and you suspect that it is just a stress fracture, then you can treat it as such and feel confident you’re not going to make things significantly worse if you walk on the foot while protected in a fracture walking boot.

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.

What is this new pain in the ball of the foot? Question from a runner in San Francisco

Today I got a question from a runner in San Francisco. She says...

QUESTION:

"I wanted to get in touch about another issue (!) I'm having with my foot. Honestly, always thought it'd be knees that went...not my feet! Basically here is what happened:

*had been running again, but not heavy mileage...like 3-miles a few times a week along with perhaps some slower jogs (1 - 2 miles).

*but, then I participated in a TRX class where we did TONS of plyo stuff. squat jumps, etc. the next day, I noticed this pain.

*the pain is on the same foot as my tendonitis was. not sure if it's relevant. I decided to take a photo to show you where the pain is! hope that's not creepy ;) I did some research online, briefly, and thought maybe it's a bursitis?? I don't know, but the class was 3 weeks ago and I've been icing it, not running and the pain is not decreasing, if anything it's getting worse. I haven't been running, just doing the elliptical at the gym and cycling. Cycling does not exacerbate it at all, thankfully!

Also, do I need to get x-rays and stuff to rule out a stress fracture, etc.?

Anyway, thanks for your time!

Gretchen
San Francisco


MY RUNNING DOC's ANSWER:

Thanks for sending the pic and providing the description of the pain in the ball of your foot!

Based on your story and the location of the pain, it is most likely predislocation syndrome. Predislocation syndrome is capsulitis (inflammation of the joint capsule) in the ball of the foot, most often at the second metatarsal phalangeal joint (the joint at the base of the second toe). The capsulitis is what causes the pain, but the real issue is a strain or even tear in a reinforcing structure of the joint capsule called the plantar plate.

I actually see this all the time in active people who spending a lot of time on eliptical trainers. At the back stroke of the eliptical trainer, your heel comes up and the toes bend way up stressing the plantar plate. The plantar plate is a small ligament that reinforces the bottom of the metatarsal phalangeal joint capsule (the joint at the base of the toe in the ball of the foot).

To get it to calm down you have to avoid stressing the plantar plate. Avoid anything that causes you to bend the toes up, such as an eliptical trainer, running uphill, etc. You can also tape the toe down to decrease stress on the plantar plate. Ice, contrast baths and compression socks can decrease the inflammation.

This of course all assumes that your pain is caused by predislocation syndrome. The other common possibilities include a Morton's neuroma or a metatarsal stress fracture. It is pretty easy for any sports medicine podiatrist to tell on physical exam.

Given that 1) most stress fractures show nothing on x-ray until it has been at least 6 weeks, and 2) any sports medicine doctor who specializes in running injuries could tell you with relative certainly whether this is predislocation syndrome or not without an x-ray, I think a physician should just do a quick check and get you heading in the right direction.

Thanks for the question!

Dr. Christopher Segler
Doc On The Run
Podiatry House Calls for Runners
San Francisco, Marin, East Bay

If you have a question about foot pain caused by running, you can email a picture (pointing to the painful area) directly to DrSegler@DocOnTheRun. Tell me how it happened and I will post a an explanation so you will know what is most likely ruining you run. Your name will be changed, and you will never be identified by your real name, so as to protect your identity and shield you from any possible accusations of making a preventable marathon training mistake. I will also never, ever share your email address with anyone.

Will orthotics help heel pain when running?

This morning I received an inquiry from a runner in Marin who is training for the Dispea. He asked a common question:

"I have severe left heel pain especially after a 5-8 mile run. I am training for the Dipsea. Advice? Should I consider orthotics?"

Answer:
Custom orthotics can certainly help to alleviate many forms of heel pain including the most common type which is plantar fasciitis. Custom orthotics in fact are one of the best ways to slow do pronation and decrease stress to the large ligament on the bottom of the heel called the plantar fascia. If you over-pronate and repeatedly tug on the plantar fascia as your arch height changes, you get inflammation of the plantar fascia... known as plantar fasciitis.

A long run can place a tremendous stress on the plantar fascia and the heel bone. Most people with plantar fascitis will have pain in the bottom of the heel on days following running. Usually the pain is worse with the first couple of steps when they get up out of bed. They can also get a sharp pain in the heel when they start walking after sitting at a desk for a while.

Custom orthotics are one of the best treatments for this type of running-related heel pain. But that doesn't necessarily mean that it is best to get custom orthotics and keep running. You must get an evaluation with a running focused podiatrist first.

The concern is that you might have something worse than plantar fasciitis. In this case, the runner reports heel pain that is "severe" following long runs. Plantar fasciitis would usually be worse (and more annoying) the day after a long run, but not necessarily severe. It would be important to get x-rays and take a look at the heel bone (calcaneus) to be certain that you are not at risk for stress fracture in the heel bone (calcaneal stress fracture).

It is also possible that there is a cyst in the heel bone that is causing the problem. In the simplest of terms, a calcaneal cyst is a hollow or fluid filled pocket that develops within the heel bone. When running, the walls of the cyst can flex slightly causing pain and inflammation in the heel bone itself. In some cases the heel bone can flex so much that it cracks or fractures. This is actually much worse than a calcaneal stress fracture.

With a quick set of x-rays and an exam by an experienced running podiatrist, heel pain can be effectively treated. With all of the conditions that effect the heel, the sooner the best treatment is chosen and starts, the faster you will finish your goal race, wether it is the Dipsea, the Vineman or the San Francisco Marathon.


Dr. Christopher Segler is an Award Winning Foot & Ankle Surgeon, 5-Time Ironman Finisher and a sports medicine podiatrist who makes house calls for busy runners, triathletes and active professionals in San Francisco, Marin, the East Bay and the Peninsula. If you have a question about running related heel pain, you can call him directly at (415) 308-0833. You can also learn more about custom running orthotics at AnkleCenter.com and DocOnTheRun.com.

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Do I Need X-Rays if I Sprained my Ankle?

San Francisco's Ankle Expert Explains When You Need X-Rays

If you are out trail running in Marin or Golden Gate Park and roll your ankle, your first thought is going to be whether or not you will be able to run with a sprained ankle. If the ankle is bruised and swollen, you will also probably wonder whether or not you need an ankle x-ray. This video explains how ankle surgeons and emergency room physicians decide whether or not you need to have x-rays after an ankle sprain.



Every single day thousands of people wait in line at the Emergency Room to get x-rays after they roll their ankles. After all that waiting, the ER doc will typically send you to an ankle specialist anyway. By seeing an ankle expert instead of going to the ER, you can be sure to get the best treatment for your ankle sprain. If you sprained your ankle, see an ankle expert today!

Dr. Christopher Segler is a sports medicine podiatrist who specializes in the diagnosis of sprains and fractures of the foot and ankle. Has has won multiple awards from the American College of Foot and Ankle Surgeons for his research on fractures of the foot and ankle that are often misdiagnosed as sprains. As a runner and triathlete himself, he believes that non-surgical treatment is best whenever possible. You can learn more about ankle sprains at the Bay Area's best ankle sprain info site. YOu can also learn more about ankle sprains and x-rays here. You can reach Dr. Segler at 415-308-0833.