Dr. Runco recently helped two patients that had each been experiencing foot pain for two years. Read on for his personal account of helping these patients get the proper diagnosis (differentiating between stress fractures and bone marrow edema) and treatment for their conditions.
I had the opportunity to examine a young 14 year old cross-country runner yesterday. She has suffered from 2 years of foot pain. Unfortunately she has been the victim of mis-diagnosis.
She explained that the pain stays fairly constant (a 5 on a 1-10 scale) and gets progressively worse when she runs. Her mother told me that she had X-rays and MRI’s a year ago that were “negative”. They did not bring the images to their appointment but I was highly suspicious of the result. In the world of diagnosis there is always a logical reason for a runner’s pain. If the attending physician is not used to seeing running injuries than that logical reason may not be so obvious. In my world, where 80% of my patients are runners it is very obvious. She explained that the pain is near her 3-4th metatarsal on the top of her foot and that on occasion her foot will swell and “turn colors”.
I began the exam the way I begin all exams of this nature. I asked her to stand up and hop up and down on the painful foot. This is called the “jump test”. When she hopped the pain worsened significantly, suggesting stress fracture. There is another, less known condition called Bone Marrow Edema which can also hurt during the single leg jump test so I continued with my exam. I next used a pulsed ultrasonic wave over the involved area. Normally the runner will feel nothing. If there is a fracture they will feel pain…and she did. I wanted to confirm the diagnosis so I used a tuning fork to create vibration over the injured area. This too caused significant pain.
At this point my exam was over with a working diagnosis of Bone Marrow Edema. Why Bone Marrow Edema versus Stress Fracture you may want to know? Because she had previous x-rays and an MRI which supposedly did not show a fracture. I have to assume they were accurate, at least until I can personally view them. Since Bone Marrow Edema presents in much the same way and will react to the same set of testing but not show on X-ray that became the working diagnosis.
The patient was instructed to get another X-ray and retrieve all of the old tests so that I could review them. I explained to her mother that “I treat patients not their MRI”. It is common for X-rays and MRI’s to be inaccurate. X-rays often do not show stress fractures and can not show Bone Marrow Edema. MRI’s are often mis-read or not interpreted accurately. It is common for me, after receiving the Radiologist report to call the Radiologist and ask them to look at the MRI again. This second time they have me literally in their ear going over all of the patients complaints. It is not unusual at this time for the Radiologist to say “well, maybe I do see this or that in that area. How about if I send you over an addendum to my report”? What I have come to realize is that MRI’s are not as specific as you are led to believe!
Let’s look at another example that occurred in my office the exact same day.
A young man presented with a 2 year history of pain on the top of his foot that would get progressively worse as he ran. He was seeking a second opinion as he had already seen a podiatrist who had ordered an MRI. The podiatrist told him the MRI was “negative”.
I went through the same 4 exams as I had with the cross country runner earlier in the day. This time there was a negative jump test, negative ultrasound, negative tuning fork and no pain with deep pressure anywhere on the muscle, tendon, joints or bone. I said “Well nothing is testing positive so without seeing the MRI I have to speculate that whatever was wrong finally healed”. At this point he said “Oh, I have the MRI report right here”.
He handed it over and I immediately went to the report conclusion, “There is acute marrow edema along the plantar aspect of the first metatarsal head with sub adjacent marrow edema in the first tibial sesamoid”. I turned to the patient and read it aloud while wondering why on earth the podiatrist would have told him his MRI was “negative”. In this case the MRI was right on…..the doctor was “negative”!
I explained to the patient that since he had been resting for so long that his injury was mostly healed. We had a conversation about how stress fractures and bone marrow edema occur and I asked him to resume running and send me a follow-up email in 2 weeks so that I knew his injury was continuing to repair and heal.
Common areas for stress fractures to occur in runners are in the sesamoid bones, 1-3rd metatarsals, 5th metatarsal, the tibia near the ankle and the tibia near the knee. Sometimes a runner can develop bone marrow edema. In this situation the bone swells inside and results in similar pain that stress fractures produce. Both injuries are commonly mis-diagnosed as shin splints and other sprain/strain injuries.
Bone pain typically gets progressively worse during a run while muscle pain will often “warm up”. Of course there are always exceptions to this rule. Limping after running is a common sign of marrow edema or stress fracture. If hopping up and down on one leg reproduces pain stress fracture is likely and continuing to run will only worsen the situation.
When accurately diagnosed early, stress fractures and bone marrow edema can heal quickly. Measures then need to be taken to prevent future occurrences. At SDRI we evaluate lower body strength, running biomechanics and nutritional status. Any of these variables can result in a runners bones not being strong enough to withstand the repetitive nature of long distance running.
Both of these conditions are treated in similar ways, with rest being the number one prescription. SDRI also offers the Anti-Gravity Treadmill. This lets patients actually run, even when injured, because the Alter-G negates their body weight.