Facilitating A Return To Running After Metatarsal Stress Fractures

I tend to see a high percentage of runners despite having a surgical practice. The community of runners in Akron, Ohio stick together as most runners do and they tend to trust the advice of a physician who is also a runner. I am not saying I offer any different or better advice than my colleagues. I just think that it is the common love we share of running that creates the chemistry between the runners and I.

Of the runners who come in, many present with a predetermined diagnosis of a stress fracture. I am not sure why they so often think they have a stress fracture but some runners view stress fractures as a badge of honor as a result of the constant “pounding” and overuse.

When I suspect a metatarsal stress fracture, I follow a very strict protocol that tends to work really well for me. My number one goal with these runners is to get them back to running as soon as possible. Obviously, each presentation will be different so this will be a bit of a generalization. I start with an X-ray. If runners have had the pain for longer than two or three weeks, I tend to rely more on symptoms at this point and explain to them that they most likely have an overuse condition and progress them back to running if they can walk without a limp and run without a limp. I forbid patients speed work such as interval training or tempo runs.

If the pain persists, I have patients return immediately and we will take serial radiographs pending the timeframe. Then we will discuss immobilizing the foot or moving straight to magnetic resonance imaging (MRI). In a perfect world, I order the MRI and within 24 to 48 hours, we have an answer as to why patients have pain. Many times, I will get runners in for an open MRI within 24 hours.

The only problem that moving toward an MRI presents is the insurance company barrier. Many of the private carriers are now recommending that you treat the pain for three weeks in a controlled ankle motion (CAM) walker before they will approve the MRI. I had this happen recently for a patient who was a very competitive high school cross-country runner who was unable to run because of a forefoot pain that began after a meet. Her father believed she was very nervous about the pain and was afraid to run through it. We took radiographs of her foot and found no signs of a stress fracture, but I was hesitant to send her back to running as her symptoms had only been present for one week. After discussing all possibilities with her father, we agreed to move forward with the MRI.

The runner’s insurance company subsequently denied this because we had not attempted therapy for three weeks with an immobilization device such as a CAM walker. I explained to an insurance peer reviewer that the patient needed to be back to running as soon as possible to be able to compete for a chance to make the state championships. This peer reviewer asked me why I would allow her to run with pain even if the MRI was normal. I explained that soft tissue injuries can sometimes take many weeks to resolve but are not detrimental to running. Many times, we will treat runners with tendonitis without having them halt their running. He did not agree with me and would not approve the MRI without three weeks of guarded weightbearing with a CAM walker. She went on to run and compete without the MRI at the discretion of her parents, who understood all possible consequences. 

Treating runners, especially competitive runners, requires the physician to look at the patient in an entirely different manner. You may not be able to alleviate the pain completely before getting patients back to running. In the aforementioned situation, the patient was able to run and the pain eventually resolved after several weeks. If you can rule out any bony pathology or stress fracture with the gold standard MRI, then allowing patients to run can be fine as long as they can do so with no alteration of their gait. Running with any change in gait can lead to other injuries as well as preventing healing from the primary injury.

There was another patient who turned out to have a stress fracture. The patient was a 17-year-old cross country runner who presented with a sudden onset of pain to her right foot in the region of the second metatarsal. She had made no changes to her running other than increasing speed by pushing her pace in practice and competing in a meet. She had been running in the Nike Free for more than six months and had transitioned to the shoe uneventfully.

The initial X-rays were negative before she presented to me. By the time I saw her, she had pain for two weeks so I decided to repeat the radiographs, presuming that if there was a stress fracture, it would have shown up by now. The radiographs were negative. She felt the pain was too severe to run so we placed her in a walking boot, advised applying ice and started a non-steroidal anti-inflammatory drug (NSAID). She was still in pain when she returned one week later so we proceeded with a MRI. We got insurance approval without the need for a peer-to-peer discussion and the MRI was positive for a stress fracture of the second metatarsal. She again wore the CAM walker and I advised her to follow up in three weeks for clinical evaluation and serial radiographs.  

After diagnosing a metatarsal stress fracture in runners, I have them use a walking boot, re-evaluate them every two to three weeks with serial radiographs and use clinical findings as a guide for a return to running. When patients can walk with pain and radiographs demonstrate callus formation, they progress to running, presuming there is no pain. If there is pain, they again wear the boot for one week at a time and the process continues until running can resume. When running resumes, I allow patients no speed workouts such as interval running or tempo workouts until they can run pain-free for two to four weeks. Therapy for each case varies and depends on the goal in mind, and the level of fitness patients have achieved prior to the injury. Running at an aerobic pace as determined by heart rate occurs during this phase of getting back into running. It is very crucial not to push the pace or distance during this period. 

The MRI is a very valuable tool for runners and it can safely and quickly be the determining factor in deciding whether there is a bone or soft tissue injury. Knowing this can help direct your plan for how soon you can get the patient back to running.