Fractured 3 rd metatarsal at base/lis franc

by Giselle
(Trenton, NJ, USA)

I suffered a fracture at the base of my 3rd metatarsal 9 wks ago. At the Er I was put in a boot. I saw a PA at an orthopedic office and was put in a hard cast for 3 wks and then put in a walking boot and told to bear weight as tolerated. The pain became severe and I ended up consulting a podiatrist. I was told I needed to be put back in a hard cast and no weight bearing. I had the cast for 3 wks and then put back in the boot. After two weeks I was told the bone was healing and I could ditch the boot and bear weight fully. I was also referred to PT. The pain has been horrible at the fracture site as well as around my ankle. There is swelling as well. I have had two PT sessions but due to the pain and swelling they are limited in what they can do. They had me doing ROM exercises. Is it normal to have this much pain this far out?

RESPONSE

Hi Giselle,

In theory, at least, at nine weeks you should be virtually healed. There can be a any number of reasons you are still having pain and I will go through a few of them.
The first place to examine would be the actual site of injury. I assume follow up x-rays have been compared to the original x-rays. I ask, because there is always the possibility there was further displacement of the original fracture, particularly if you were weight bearing at any time during the initial healing.
Secondly, has the fractured actually healed? The area around the base of the third metatarsal has many small bones surrounding it and at times can be difficult to really see the extent of the fracture from an x-ray alone. That then raises the question of whether or not you have had an MRI or CT scan at any point which would give better visualization of that part of the foot and better detail of any fracture that may be present.
I would think the fact that you are at the nine week mark, an MRI or CT scan would be indicated simply because you are in so much pain. If the x-ray reveals the fracture is "healing" but is still open, I am willing to bet an MRI or CT scan will find a greater degree of open fracture.
Additionally, these tests would rule out soft tissue damage such as a torn ligament, which would not be evident on x-ray.
Once the trauma site has been properly evaluated and nothing additional is found compared to the state of the foot after the initial trauma, then your overall health status has to be evaluated.
I know nothing about you, but factors such as excess weight, low estrogen levels, excess osteoporosis and tobacco use will delay fracture healing. If any of these apply to you, then they must be addressed.
Physical therapy, per se, does not help a fracture to heal, but rather returns the foot to normal function (if the fracture is actually healed). So, if there is any degree of open fracture then range of motion exercises would probably aggravate the problem rather then help.
At nine weeks, if the fracture is still open as verified by x-ray or MRI or CT scan, I would consider the use of a bone stimulator to help facilitate closure of the fracture. Ask your doctor if a bone stimulator is a good option for you.
Once the fracture is completely closed, you could then return to physical therapy. If however, you are going to continue with physical therapy, then you might ask the therapist to stop the range of motion exercises, for now, and concentrate on various modalities that help reduce inflammation. This at the very least, should make the foot less painful.

Marc Mitnick DPM
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