Blog

Addressing Recurrence Of A Fifth Metatarsal Fracture With Orthotic Modifications

Bruce Williams DPM

12/19/2018

Two or three years ago, I worked with an NBA player who had a history of a fifth metatarsal fracture in his left foot. He had surgery to fix this issue but the foot never seemed to get better. He eventually had to have another surgery with a bone graft to repair that fracture site, which never fully healed. His team was concerned that he could continue to have issues again when he started having some soreness in that foot with his orthotics and several different pair of shoes.

When the athlete came to the office, I did a very thorough segmental exam specifically to grade his ankle joint dorsiflexion range of motion, both off-weightbearing and with the ankle joint lunge test, as we have discussed previously.¹ I also graded the stiffness of his fifth ray, which was still moderately high, even after two surgeries. These two metrics are the most important, in my opinion, when deciding if an athlete is at risk for fifth metatarsal injuries. The more compliant the structures, the less likely an injury will occur in that area. Increased stiffness can cause a risk of injury.

These pressure mapping images represent the athlete’s current orthotics. Note the higher green pressures under the lateral column bilaterally greater in the left than right. The left side was the injured side.

After the physical exam of the athlete, we also did in-shoe pressure analysis to see how he functioned with and without his current orthotic devices. Unfortunately, his current devices were not properly offloading his fifth ray bilaterally (see photo 1). I modified the orthotics and then retested the devices and his pressures decreased significantly (see photo 2). In the images, you can see the differences in the pressures pre- and post-modification at the lateral column. All I did was add bilateral heel lifts and thin the material under the fifth ray bilaterally to decrease the lateral column pressures.² I also added digital wedging under the hallux to encourage the windlass mechanism to engage and to increase the pressures under the first metatarsophalangeal joint (MPJ), which will also tend to equalize the pressures under MPJs one through five.

These pressure mapping images show modified orthotics. Note the decreased pressures under the lateral column in the left fifth ray.

This did the trick for this athlete and he’s had no reinjury at this previous surgery sites or to his opposite foot since.

Next month, we will discuss the player’s shoes. I will show you pressure mapping images that will demonstrate how different basketball shoes also put him at a potential increase in risk for reinjury despite my improving his orthotic function.

Happy holidays to you all!

References