Including:
– How to identify Freiburg’s vs Metatarsal Stress Fracture;
– Sesamoiditis vs sesamoid fracture.
Video Notes:
Freiburg’s (Avascular necrosis of the metatarsal head):
– Excruciatingly painful. Pain is disproportional to the stimulus, e.g. very light touch.
– 10/10 pain every time – unlike a soft tissue injury that generally fluctuates more on the pain scale depending on load or standing after rest.
– Will be painful on palpation of the bone rather than the metatarsal area.
– Swelling present
– Often hot
– Doesn’t respond to anti-inflammatory medication.
DDX: stress fracture, plantar plate, capsulitis.
X-ray presentation: flattening/squaring off of the head of the metatarsal.
Rx: Moonboot, keep them in this based on symptoms -> when pain levels come down, start to transition them out.
8:40 Stress Fracture:
– Painful, but not as painful as Freiburg’s
– Focally sore in that specific spot
– Won’t get as much swelling
– No heat
– Doesn’t respond to anti-inflammatory medication.
– Pain stops as soon as they stop weightbearing, unlike Frieburg’s.
Subjective History often involves a period of no exercise or little exercise and then suddenly going back to what they were doing before, particularly with running.
Stress Fracture can lead to avascular necrosis if it’s left ongoing.
11:55 Sesamoid Conditions:
Important to recognise sesamoids have no vascular status and not good at healing themselves, therefore need to completely offload quickly (moonboot).
If someone has had a fracture to a sesamoid for a few months, it is unlikely to heal, especially if 6+ months, because vascular status is not good enough.
However, if a fractured sesamoid doesn’t heal, it doesn’t mean it’s going to be painful forever.
Educate the client that it is a 6-12month pathology, especially if they want to get back to wearing high heals, due to the process of offloading and then rehabbing and re-loading.
X-ray referral: NEEDS TO INCLUDE AXIAL/SKYLINE VIEW OR IT WON’T GET RECOGNISED.
MRI referral: Need to make sure you request small 0.01mm slices otherwise it may get missed as the sesamoids are so small.
An osseous problem, in this case with sesamoid, it will be the same level of pain on the pain scale every time the client goes up on tip toes and aggravates it. Unlike a soft tissue issue, which will vary from a 10/10, to a 4/10, 6/10 depending on different factors to do with load.
A fracture to the sesamoid or any osseous problem, will not respond to anti-inflammatory medication.
Rehabbing and healing an osseous problem:
– pick a load, keep them at that load till the pain resolves or gets to a 1-3/10, then step up the load, and maintain that load until the pain comes down etc.
vs. Soft tissue:
– constantly increasing load, decrease only if pain increases the next day.
