Do I need surgery if my nonunion starts hurting? Well, that’s a great question, and that’s what we’re talking about Today On The Run Podcast.
Today we’re talking about metatarsal fracture, nonunion surgery versus no surgery.
I know some people will think that I probably should have gone straight from #665 to 667 because frankly, there are some negative connotations surrounding those three letters, 666…the number of the beast.
But I decided to do this episode anyway. And, I decided to dedicate this one to a buddy who is a beast.
He’s tough, he’s active, and he happens to have a metatarsal nonunion that hasn’t stopped him from doing a whole lot of fun, active things.
We were on a call and talking about what to do with his foot and the situation is this. He got a metatarsal fracture a long time ago. Basically, he broke his foot. It’s a pretty common injury, and it’s really common in runners, particularly those who get a metatarsal stress fracture and keep running on them until they actually get a full-on fracture. And then if you keep training, it can turn into what we call a nonunion. A nonunion is where two pieces of bones simply don’t heal together.
I’m hoping in this episode you can learn a little bit about the different options you have when you get a metatarsal fracture nonunion. The first thing is the way that we classify nonunions and believe it or not, the way that doctors classify nonunions in large part is painful nonunion or non-painful nonunion. So the question is, does it hurt or does it not hurt? Well, if it doesn’t hurt, what that means is that you’ve got, where these two ends of bone are connecting together, there’s enough scar tissue between there that they’re not rubbing against each other.
If you have raw bone grinding against one another end, it’s going to hurt a lot. But if you don’t have that, if you’ve got enough collagen in there in between, scar tissue that’s cushioning the bones, and they’re not moving enough to hurt, well then it’s not really that much of a problem, particularly if you can do that and still do okay.
I had a patient one time who had been playing tennis three to five times a week for about 50 years, and she had had a fracture in her foot that was never diagnosed, never treated, and turned into a non-painful nonunion. I saw her because she slipped and twisted on the court one day, she came in to see me, I did an X-ray, and saw that she had this huge, terrible looking nonunion on her X-ray. That’s not good, but I asked her, “Did you ever do anything to your foot that you remember hurting?” She said, “Yeah, actually.” She told me how she had this injury when she was in college, and that was her fracture. And so it had been there for 50 years, but it had become so stable with scar tissue around it that it didn’t bother her when she played tennis.
One option was to basically take her to surgery, in which case we would cut her foot open, cut out the dead pieces of bone at the ends of the fracture on either side, put a bone graft in there, which is a dead piece of bone from a cadaver. And then we hope that after we put a plate and screws and some hardware in there to hold it still, that eventually your body will fill all of that in with your bone that actually heals it and turns it into a solid bone.
At that time, she was in her 70s, so this was going to be a really long recovery for her, and it might not actually work. And in that case, what we had done if it didn’t work, was we actually took out the scar tissue that was cushioning and protecting that area and put in a dead piece of bone that might actually cause pain when it moved.
So back to my friend the beast, the guy who has this fracture who’s trying to figure out what to do, I just said, “You’ve got a couple of options. One of them is surgery. Surgery is reasonable. You could go in and do that to try to fix it now and hope that that works, but that might be a long recovery. Another option is to try to let it calm down.”
By calming down we mean that we assume that if you have a nonunion and you moved it, if the bone didn’t really break again, but you just tore the scar tissue that’s holding those two ends of the bone together, maybe you can get it to heal back to that point with more scar tissue repairing it and stabilizing it so that you could continue to do the things that you want to do without it becoming painful again. That’s really what we’re looking for.
So if you take a month off and you’re waiting to see if it will calm down and do that, if it will become a non-painful nonunion, again, what does it cost you? It costs you time. It doesn’t really cost you anything. It’s not really risky because if it doesn’t work, you could still do the surgery later, but it does cost you time. If you’re a runner and you have that issue, you’re going to be doing less activity, and you’re going to lose some running fitness, your form is going to suffer as a consequence of that, but you have to weigh all of that versus the risk of actually going back to surgery and potentially having it turn out worse later.
There’s no guarantee with surgery. No, that’s not true. There are two guarantees with surgery, actually. You’re going to get a bill and you’re going to get a scar, but that’s it. So if you’re going to wait to see if the nonunion is going to turn back into a non-painful one with some conservative non-surgical treatment, it’s reasonable, but you’ve got to figure out if it’s really probable that that could work or not. That’s the big thing here. So all nonunions do not need surgery necessarily, but you got to figure out what is the best for you given your particular circumstances.
If you like this episode, please like it, please share it, and I’ll see you in the next training.
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