Saturday, 24 March 2012

Story of A Broken Third Metatarsal or How to Drive a Runner Insane


Strictly speaking, this is meant to be a blog about archaeology and not my attempts at athletics.  However, as bones are involved in this story, I think I can just about justify publishing it here.  I also hope that anyone else trawling the internet for experiences of acute/trauma metatarsal fractures will at least have something to read about instead of a million stress fracture rehab stories!  It is NOT the same.  This is presented as a week by week experience of my recovery.  I warn you this is one long story and I’m not the most interesting of writers.

The Bone What I Broke, When and How
  •      11/12/11: Running my last cross country of 2011, I noticed my feet had become absolutely numb.  I have Raynaud’s Syndrome (poor circulation in my extremities), so this isn’t unusual on a cold day, but the almost entire loss of sensation in my feet was strange.  I was struggling because of this and further down the pack than usual.  At the beginning of the second lap and three km into the race I put my right foot to the floor and felt it give way beneath me with a crack/crunch sound.  My ankle didn’t go over and I didn’t trip but there may have been a stone under my running spike.  I tried to hobble for a few metres until my Dad and my friend yelled at me to stop and dragged me off the course.  At this point I knew that there was something wrong but didn’t realise the seriousness.  I pulled my shoe off and my foot looked normal, albeit completely pale and bloodless due to the lack of circulation.  Feeling a little ashamed that I’d dropped out I got my gear and went home.  As my circulation returned, my foot did feel painful, as it often does when the blood flows back into them.   It wasn’t until I got in the shower that I noticed the swelling on top of my foot.   Having never broken a bone, I told myself I’d damaged the extensor tendons on top of my foot which would explain the pain and location of the swelling.   I took some ibuprofen, iced my foot and carried on as normal.  THIS IS STUPID.  DO NOT DO THIS. What I should have done was go straight to minor injuries for an x-ray because if acute pain is accompanied by swelling and trouble weight bearing, you have probably damaged bone or ligament.  It is not just going to go away! It took me nearly 48 hours of limping and my foot turning black/blue to decide to go, and I was lucky more damage wasn’t caused by my idiocy.
  •      13/12/11: Diagnosis by X-Ray – the radiographer immediately told me it was broken in the x-ray room. The radiograph showed a mid-shaft oblique fracture of my third metatarsal.  It was misaligned and in two pieces (see below).  This fracture was an acute fracture rather than a stress fracture.  Acute fractures are caused by a large force suddenly applied to the bone.  Stress fractures appear over time.  In runners this is usually due to increase in mileage too quickly.   Stress fractures often take a while to appear on x-ray after the pain is first noticed and appear as thin hairline cracks in bone due to repetitive episodes of stress.  After x-ray, I was given crutches and an appointment at fracture clinic the next day.
  •      14/12/11: This was the day during which I learnt the NHS is not a big fan of injuries that occur whilst running.  I saw the consultant for all of three minutes in which he told me I had a fracture in my foot (Really?? Fancy that!), that it happened because I run too much (I run 15 miles a week and it was a trauma – acute not chronic pain!!).  I learnt that doctors don’t listen.  Especially when you try to ask questions (such as, should I be worrying about my bone density as osteoporosis runs in my family, and my foot broke pretty easily?!).   Oh and I was told I could have a fracture boot “if I wanted one” or stay in trainers.  Of course I wanted one!  Fracture boots are amazing.  They allow some weight bearing without hurting the bone, they give protection from careless members of the public and, best of all, they are removable at shower time and bedtime.  I left the hospital nicely equipped but with little advice on fracture rehab other than it would be six to eight weeks until I was healed.  No painkillers, no mention of physio.  Thus my rehab began.

       Weeks One to Four
This was possibly one of the most stressful periods of my life, made worse by simple tasks like getting to work each day (agency workers don’t get sick pay boo).  One very uncoordinated person in charge of crutches and fracture boot is not a good combination.  It involved escapades, which included falling over when the bus driver doesn’t wait for you to get off and starts driving (three times in one week), going to the work xmas do on crutches and waiting two hours for a taxi home and lastly getting three trains down to my grandparents for Christmas.  Luckily I had a nice housemate and some visitors to cheer me up.  Facing up to not being able to run for a very long time was not fun either.  However that concern soon paled in significance to the other problems encountered.
  •       Pain: It took three or four days for the nasty pain to kick in and this was mostly at night.  Every position I put my foot in was agony and strange stabbing pains would wake me from the deepest sleep.  I took the maximum dosage of painkillers for a week to get me through it and then stopped taking them.
  •       RICE: Following the mantra on icing and elevating as often as I could through the day.  My foot became a large swollen mass of fluid by the end of the day. 
  •       Mobility: By using the internet I learnt the crutch stair method, and the best way to shower (took me an hour).  You can’t carry things with crutches.  Thus you stand and drink your hot cup of tea on the side where you made it and when you spill your dinner over the floor you have to ring your mum and stepdad to come and clear it up for you.  Being helpless is definitely the most frustrating and humiliating thing about a disability, however temporary it is.
  •       Exercise: At week four I was lucky enough to start going to a personal trainer based at a physio and was able to do some simple core exercises with weight through the knees.  Swimming was still not an option so there was very little I could do.  I also looked up some foot rehab exercises on the net.  The most useful were these: http://www.sportsinjuryclinic.net/sport-injuries/foot-heel-pain/metatarsal-fracture/metatarsal-rehabilitation.  It is really important to keep doing them every day, starting with the non-weight bearing exercises first, because the lack of use causes the muscles and ligaments in the foot to quickly stiffen and atrophy. 

Weeks Five to Eight
These were the weeks in which I expected a dramatic transformation to occur. By week eight I would be cured and ready to run again!  Instead I learnt that recovery is usually even longer than the slowest prediction.  I saw the consultant again after four weeks in the boot, for another long slot of five minutes.  Firstly, he asked me why I hadn’t brought my trainers to which I replied, rather stunned, “You told me six to eight weeks?! It’s been four!”.  Then he got me to take my boot off and put weight through me broken foot, which to be fair didn’t hurt when I did it for two seconds.  Then he discharged me.  No follow-up x-ray, no physio, no advice on rehab...just a wave of the hand and a command to go off and walk around in trainers.
  • Mobility: Now I don’t have a medical degree, but it occurred to me that I probably couldn’t just put my foot in a trainer straight off and go merrily on my way moving as much as I had before my fracture. I started off my walking round my house gingerly in trainers and started using my crutches less and just my boot when out and about.  Several attempts at going outside in trainers were unsuccessful at this point as my foot was still painful and uncomfortable.   By seven weeks I went to my GP and asked for an x-ray, as I was so concerned at my lack of improvement.  People had begun to comment that my recovery was slow but I had to wait two weeks for my x-ray results.  By the end of week eight I stopped wearing the boot completely but was walking with a strange rocking limp and having to take the bus to and from work (usually a 20 min walk). 
  • Exercise: I gained enough movement by week seven to walk from changing room to swimming pool and start swimming.  I desperately tried to get my heart rate up and avoid being kicked by other swimmers. 

Overall I did move from being in the fracture boot to trainers but very slowly and still with discomfort.

Weeks Nine to Twelve
By this point I was going a little bit mental – recovery was taking much longer than anticipated and I was seeing runners everywhere.   Meanwhile my list of foot rehab exercises on my wall was ever growing as I fought to regain the strength and flexibility in my forefoot.  My ultimate goal was to be able to walk on tiptoes, which seemed a far off dream. 

I received my x-ray results which showed a healing fracture with “slight misalignment” perhaps due to walking on the foot for two days before diagnosis!  Good news, but it didn’t explain why I was still struggling.  At one point in week ten I was limping fairly badly and worried that there was a serious problem with the foot.  However in another week my walking became a lot smoother and I could manage a fairly brisk walk to work.  By week twelve I was walking to work and back at a steady pace.  My only worries were that my foot was still swollen over the forefoot and that the lateral side of my foot was sore and inflexible when walking.  It was also very sore when touched. 
Follow-up x-ray showing healing fracture with bone callous formation.  


Received wisdom for a healing fracture is six weeks for fibrous union and another six weeks for bony union, when running should be safe.  But at twelve weeks I knew my foot was still not ready to run. 

Weeks Thirteen to Fifteen: Towards Running Again...
My foot suddenly became a lot stronger and I was able to walk on my tiptoes!  My two tests for foot strength was walking for an hour without discomfort and very little swelling and being able to hop on the injured foot without pain.  I then waited a week and tried running for 1min, walk for 1min a few times on grass - the first time in fourteen weeks! Afterwards and the next day my foot was sore and swollen but the discomfort was muscular rather than worrying.  I am now starting a gradual schedule to increase mileage carefully without re-injuring the foot by Pete Pfitzinger: http://pfitzinger.com/labreports/stressfracture.shtml.

Why did I experience an acute fracture in the first place? It's very odd that I fractured my foot without a fall and without high mileage in training.  The doctors were not interested in answering this question, even though my first thoughts were worry about my bone density when my foot seemed to have broken so easily.  I think, however, it was actually my Reynaud's that was to blame.  I suffer with poor circulation to my extremities (which might also explain why my foot took longer than average to heal).  My feet had become so cold and numb during the race that my muscles and ligaments had 'frozen' and instead of soft tissue taking the strain of impact, my third metatarsal did.  Hence why it broke.  A very unlucky accident!

Touch wood I can avoid re-injury!


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