Treatment to fifth metatarsal fracture in football

TREATMENT TO FIFTH METATARSAL

FRACTURE IN FOOTBALL: CASE REPORT

FEATURE / GOMEZ-BERNAL, ET AL

Fracture of the fifth metatarsal bone is a common injury in professional soccer players. An 18-year-old player suffered a fracture of the fifth metatarsal bone of the left foot during a match. A biomechanical study was performed and three plantar orthoses with different prescriptions for everyday shoes, running shoes, and football boots were designed and fabricated by subjecting the virtual 3D profile of the orthoses to the baropodometric loads of the patient using the Finite Element Method (FEM) calculation. FEM is a mathematical model is the use of calculations, models and simulations to predict and understand how an object might behave under various physical conditions. Engineers use FEM to find characteristic and vulnerabilities in their design prototypes. The use of plantar orthoses showed positive results that reduced the perception of VAS pain from 9/10 to 1/10. At the same time, a reduction of plantar pressure at the location of the lesion was observed with the use of the orthosis, allowing a rapid return to play thanks to this novel treatment.

The return to sport after suffering a stress injury to the fifth metatarsal can be difficult and time-consuming for a football player. Bone healing problems or fractures are some of the problems that can jeopardize a player’s career. The time of absence and the prognosis of the injury will be marked mainly by the location of the fracture and the treatment applied (1-4).

Different classifications describe proximal fractures in the fifth metatarsal, according to the location. The classification proposed by Dameron is the most widely used (Figure 1) (5).

Zone 1 includes fractures generated at the base by avulsion. The mechanism of injury is usually a forced inversion of the foot, which generates excess traction of the short lateral strut and plantar fascia. Zone 2 corresponds to fractures generated in the area immediately adjacent to the base, up to approximately one-third of the total length of the fifth metatarsal. Fractures in this area are known as jones. Zone 3 comprises the area immediately adjacent to the jones fracture distally. It is in this area that stress fractures are generated, coinciding with the least irritated metatarsal area. The vascularisation of the fifth metatarsal plays a fundamental role in the localization of fractures and their consolation. The proximal third is nourished at the blood level thanks to the styloid process and its base which provides a great contribution due to the different insertions of the tendon and ligamentous structures that cover the area. However, the diaphysis is characterised by the absence of this type of insertion, so there is less blood supply. In particular, the diaphysis is irrigated by a nutrient artery, which provides blood supply to the area, along with a slight contribution from the periosteal blood vessels. There is no continuity with the anastomosis of the base irrigation and dialysis, generating an avascular zone responsible for the consolidation problems (6,7) (Figure 2).

To understand the relevance of this type of fracture and the characteristics of the fifth metatarsal bone, Low et al (8) studied fractures of this bone in soccer and pointed out that consolidation problems occur in 1% after surgical treatment and 20% after conservative treatment. Cuboid

4th metatarsal

93% 4% 3%

5th metatarsal

Zone I Zone II Zone III

Figure 1. Fracture classification by location according to Dameron.

In our clinical case, we present an 18-yearold professional soccer player, with a weight of 72 kg and a height of 173 cm. He had never been treated with a plantar orthosis as prevention in his biomechanics of the footprint by his own choice. The patient suffered an injury to the lateral area of his left foot during a soccer game as a result of a foot strike during a play. Immediately after the incident, the patient left the field with the help of medical assistance. He was advised not to put any weight on that foot at any time. At the end of the game, the patient was taken directly to the hospital for a CT scan and a diagnosis of the injury. After the first physical examination, the player presented a visual analog pain scale (VAS) score of 9. Upon examining the etiology and area of pain, a bony injury to the fifth metatarsal bone was suspected. The hospital radiologist and the club’s chief of medical services issued a diagnosis of a crack of the fifth metatarsal in the proximal third, corresponding to the area where Jones fractures occur (Figure 3).

With the diagnosis established and due to the technical team’s need to have the player integrated into the team for the competition, the decision was made to treat

Figure 2. Diagram of vascularisation of the fifth metatarsal. Figure 3. CT in plantar view of the initial fissure (A) and after 4 weeks of evolution (B).

the injury conservatively. The conservative option allows for a quicker return to the training routine. During the first two weeks, the foot was completely unloaded thanks to ambulation with crutches and was also completely immobilized with the application of short, fixed Walker (OrIimanO’). From the tenth day of the injury, the player was allowed progressive support with fixed walker (Figure 4).

From the second to the fourth week, the transition was made from the fixed walker to sports shoes for walking without crutches. At this time, after a biomechanical gait study was completed, conservative treatment was integrated consisting of an insole designed to offload the fifth metatarsal in running shoes, with insole graduation consisting of a 5° / 8 mm lateral heel elevation. This treatment technique was described by podiatrist Kevin Kirby to prevent heel inversion and thus reduce loads in the lateral compartment of the foot (9). At this time, the player has a score of 4 on the VAS scale.

From the fourth week to the sixth week, specific readaptation was performed on the playing field with dynamic exercises aimed

Figure 5. Hindfoot kinematic analysis. Comparison of left and right foot at sporting movements specific soccer skills. Two more biomechanical studies were carried out at this time. One of them consisted of a study with “Gebiomized” instrumented insoles to analyse plantar pressures on the playing field. On the other hand, a study without joint kinematics with the “Younext 4D motion Capture 6” motion analysis system, quantifies the degrees of calcaneus varus and hindfoot varus that the patient is generating (Figure 5). Dynamic baropodometry with running shoes and dynamic baropodometry with Firm Grass (FG) soccer boots were analysed separately. Different corrections were established, which consisted of an orthopedic correction in the player’s insole with a rearfoot grading consisting of a lateral heel elevation of 10° / 3 mm for running shoes, while the grade for soccer cleats consisted of a lateral heel elevation of 10° / 8 mm (9).

Molding of the feet was performed with a 3D scanner. The three manufactured insoles were digitally designed through specific computer software. The patient’s weight was digitally applied axially to the plantar support structure and the load distribution zones on the plantar support were observed using a colorimetric scale. It is verified that the treatment objective is met in terms of axial load reduction in the area corresponding to the fifth metatarsal (Figure 6). All the orthopedic insoles were produced by milling machine-assisted fabrication numerical control, with double-sided milling of carbon polypropylene material (Dynamic Podoactiva@).

An on-field control test was performed for all plantar supports that modify the biomechanics of the player’s foot. The improvement of the load in terms of plantar pressure in the injured area after the application of the plantar supports was quantified. It was observed that thanks to the effect of the correction applied with the lateral inclination of the heel of the insole, the desired effect is obtained (Figure 7). After two weeks of

Figure 6. Digital design of the different hindfoot corrections of the custom-made insoles and colorimetry of loads simulated with finite element calculations. Figure 7. Baropodometric analysis in the shoe before and after applying the plantar support.

PRE POST

use of the orthotic treatment by the player, the last evaluation was performed with the VAS scale and the player reported a score of 1 out of 10.

This clinical case describes the treatment after a fracture of the fifth metatarsal in a professional soccer player. This type of fracture represents a serious problem in the career of a professional soccer player, and can even lead to the end of his career (1).

The sporting movements of soccer are characterised by acceleration and braking movements, movements of the fifth metatarsal and the fifth metatarsal of the fifth metatarsal (2). Lateral and cross movements; and single limb support gestures (jumping, striking); as those that lead to the patient’s injury. The pressures received in the fifth metatarsal during these sports gestures have been previously studied, concluding that in most of these situations, an increase in the contact area and an increase in the time of integral pressure are generated (10,11).

In this case, conservative treatment is chosen, due to the time of the season, to shorten the recovery period. In addition, the injury was a partial fracture and the patient had not suffered any fracture before (10). According to I. Úbeda-Pérez de Heredia (11), functional treatment of fractures of the fifth metatarsal provides a shorter duration of temporary disability of the injured, as well as fewer complications and less severity than conventional treatments; even evaluating the function of these treatments using the AOFAS scale (12).

Within conservative treatment, improvement in pressure distribution and control of the biomechanical characteristics that can lead to mechanical stress of the fifth metatarsal (height of the internal arch of the foot), varus of the foot) are two elements that must be taken into account, according to different authors (13,14). To accomplish the above, the patient has customized plantar orthoses that generate adequate motion control in the different situations of the biomechanical demands of the athlete. However, Queen et al. (15) did not find an improvement in the loads on the fifth metatarsal using a rigid piece of carbon fiber. Probably, we can think that the difference is justified by the fact

that their treatment is a flat and rigid carbon fiber sheet, while the technology used in this case is a semi-flexible and customized treatment that applies finite element calculation for the correct distribution of loads. Our treatments are based on previous work in which a change in foot movement and weight bearing was achieved by employing plantar orthoses (16).

The boot of the player is an important element to study since several studies show that a poor choice of boot in relation to the playing surface can generate an increased risk of injury for the player (12,13).

Some authors have carried out studies on the relationship between the type of boot and the comfort of the player, concluding that the increase in pressure in certain areas of the foot during the sporting gesture, accompanied by poor sensation on the part of the player, especially in the fifth metatarsal, entails a greater risk of injury (14,16).

Among the actions we have carried out to treat the soccer player, one of them has been to change his soccer boots since they may have characteristics that affect the biomechanics.

On examination, the boot was not suitable, with high stiffness in the midfoot when talking about the risk of injury to the 5th metatarsal. The manoeuvre to detect this defect is performed with a uniform vertical pressure from the inside of the boot, to detect if the boot is deformed. It is important to note that poor mid-foot boot flexion is not attributable to all models of a particular brand, nor to all units of a particular model. In fact, insufficient mid-foot stiffness very rarely occurs due to the quality control and quality control processes of the manufacturers.

This defect is usually unique to a specific pair of boots that are likely to have an unusually undetected manufacturing defect (Figure 8). This defect is usually unique to a specific pair of boots that likely has an rare undetected manufacturing defect (Figure 8). It highlights the importance of checking the footwear being used.

In conclusion, the proposed conservative treatment has been effective, showing positive results that rule out the perception of pain utilising VAS. Concerning the data obtained by the instrumented insoles, the customized insoles for the player have improved the distribution of plantar pressure in the area corresponding to the fifth metatarsal, which allows for accelerating the return to play.

In fractures of the fifth metatarsal, as proposed in this clinical case, the effectiveness of custom insoles in reducing loads should be taken into account, after simulation with the finite element method. Orthotic treatment should be part of a multidisciplinary treatment with the rest of the medical team. The podiatrist of a professional soccer club has an important role in the study of the sporting gesture, relating it to the biomechanical characteristics of the foot, the study of the football boot, and the study of the foot.

Figure 8. Defective boot unit with mid-foot flexion and the preparation of customized insoles to control the above variables.

The patient’s footprint, thanks to the calculation of the finite elements applied to the fabrication of plantar supports. Further research is needed in this area to integrate this type of novel treatment into clinical practice on a regular basis.

The interesting and novel aspect of this clinical case is the verification of the forces that the plantar orthosis will support with the patient’s foot loading, thanks to the calculation of finite elements applied to the manufacture of plantar supports. Therefore, further research should be carried out in this area to integrate this type of novel treatment into clinical practice in a regular way.

1. Ekstrand j, van Dijk CN. Fifth metatarsal fractures among male professional footballers: a potential careerending disease. Br j Sports Med [Internet]. 2013 Aug [cited 2018 May 11];47(12): Z54—8. Available from: http:// www.ncbi.mm.nih.gov/pubmed/23467966 2. Lareau CR, Hsu AR, Anderson RB. Return to Play in National Football League Players After Operative jones Fracture Treatment. Foot Ankle Int [Internet]. 2016 Jan 9 [cited 2018 May 11];37(1):8—16. Available from: http:// www.ncbi.mm.nih.gov/pubmed/26353796 3. Park j-Y, Kim H-N, Hyun Y-S, Park j-S, Kwon H-j, Kang S-H, et al. Effect of Weight-Bearing in Conservative and Operative Management of Fractures of the Base of the Fifth Metatarsal Bone. Biomed Res Int [Internet]. 2017 [cited 2018 May 11];2017:1—6. Available from: http://www.ncbi.mm.nih.gov/pubmed/29441351 4. Thomson A, Akenhead R, Whiteley R, D’Hooghe P, Van Alsenoy K, Bleakley C. Fifth metatarsal stress fracture in elite male football players: an on-field analysis of plantar loading. BMJ Open Sport Exerc Med [Internet]. 2018 jun 20 [cited 2018 Aug 21];4(1):e000377.Available from: http://bmjopensem.bmj.com/Iookup/doi/10.1136/b mjsem-2018-000377 5. Dameron TB. Fractures and anatomical variations of the proximal portion of the fifth metatarsal. j Bone Joint Surg Am [Internet]. 19Z5 Sep [cited 2018 May 12];57(6): 788—92. Available from: http://www.ncbi.mm.nih.gov/ pubmed/1099103 6. McKeon KE, Johnson JE, McCormick JJ, Klein SE. The Intraosseous and Extraosseous Vascular Supply of the Fifth Metatarsal. Foot Ankle Int [Internet]. 2013 Jan [cited 2018 May 12];34(1):117—23. Available from: http:// www.ncbi.mm.nih.gov/pubmed/23386771 7. Smith JW, Arnoczky SP, Hersh A. The intraosseous blood supply of the fifth metatarsal: implications for proximal fracture healing. Foot Ankle [Internet]. 1992 [cited 2018 May 12];13(3):143—52. Available from: http:// www.ncbi.mm.nih.gov/pubmed/1601342 8. Low K, Noblin JD, Browne JE, Barnthouse CD, Scott AR. jones fractures in the elite football player. j Surg Orthop Adv [Internet]. 2004 [cited 2018 May 12];13(3):156—60. Available from: http://www.ncbi.mm.nih.gov/pubmed/15559691 9. Kirby KA. The medial heel skive technique. Improving pronation control in foot orthoses. Artiej Am Podiatr Med Assoc [Internet]. 1992 [cited 2018 Aug 21 ]; Available from: https://www.researchgate.net/ publication/21557558 10. Baumbach SF, Prall WC, Kramer M, Braunstein M, Böcker W, Polzer H. Functional treatment for fractures to the base of the 3rd metatarsal - influence of fracture location and fracture characteristics. BMC Musculoskelet Disord [Internet]. 2017 Dec 16 [cited 2018 May 11 ];18(1):334. Available from: http://www.ncbi.mm.nih.gov/ pubmed/29246170 11. Úbeda-Pérez de Heredia I. El apoyo inicial sin inmovi- lización como terapia de elección en las fracturas del quinto metatarsiano. Rev Esp Cir Ortop Traumatol [Internet]. 2018;1—11. Available from: https://doi. org/10.1016/j.recot.2018.01.009 12. Bentley JA, Ramanathan AK, Arnold GP, Wang W, Abboud RJ. Harmful cleats of football boots: A biomechanical evaluation. Foot Ankle Surg. 2011;17 (3):140—4. 13. O’Connor AM, James IT. Association of Lower Limb Injury with Boot Cleat Design and Playing Surface in Elite Soccer. Foot Ankle Clin. 2013;18(2):369—80. 14. Nunns MPI, Dixon Sj, Clarke j, Carré M. Boot-insole effects on comfort and plantar loading at the heel and fifth metatarsal during running and turning in soccer. j Sports Sci. 2016;34(8): 730—7. 15. Queen RM, Abbey AN, Verma R, Butler RJ, Nunley JAJA. Plantar loading during cutting while wearing a rigid carbon fiber insert. j Athl Train. 2014;49(3):297—303. 16. Okholm Kryger K, Jarratt V, Mitchell S, Forrester S. Can subjective comfort be used as a measure of plantar pressure in football boots? j Sports Sci. 2017;35 (10):953—9.