#747 How to rule out soft tissue vs. bone injury - DOC

#747 How to rule out soft tissue vs. bone injury

How do you rule out soft tissue versus a bone injury when you’re a runner and you’ve rolled your ankle? Well, that’s what we’re talking about today on the Doc On The Run Podcast.



If you have an injury like a sprained ankle, for example, or it could be a stress fracture or some other injury, but you have foot or ankle pain and you’re trying to figure out what’s really wrong, you’ve got to understand the first thing which is trying to figure out is it a bone injury or is it a soft tissue injury.

Let’s say you roll your ankle, the big concern is that you may have actually broken your ankle. A lot of times when you sprain an ankle, you have a lot of bruising, a lot of swelling, it looks really bad and so you think you may have broken it. And if you think you may have broken it, well, you’re going to want to get X-rays and that’s a big hassle.

So, when runners call me for a second opinion on ankle sprains, they’re usually trying to figure out number one, do I need to go get X-rays or not? And obviously, if you think you have an injury, and it’s definitely a soft tissue injury, there’s no value in X-ray anyways. So, I thought it might be useful to kind of talk about the thought process I use when I’m trying to figure out whether or not you have a bone versus soft tissue injury.

When you roll your ankle, there are a couple of big concerns. Number one, you could actually break a bone in your ankle, you could break the fibula, that’s the little lump on the outside of your ankle. And if you roll your ankle, and the tendon that attaches to the base of the fifth metatarsal bone on the outside of your foot, well, it’s pretty common that sometimes you actually pull so hard trying to get your foot back under, you actually rip off the end of the bone and get what we call an avulsion fracture of the fifth metatarsal bone. Those are obviously bone injuries.

Bone injuries typically hurt when you push on the bone. And so, if I’m looking at you in person, and I actually push on it, or if I have you push on it over webcam, I will show you exactly where those spots are. If it hurts when you push on it, you might have a bone injury and you might need X-rays.

You can also of course, you could tear a ligament or you can tear a tendon, for example, the tendon that attaches to that bone on the outside of your foot that pulls your foot back under you, you can actually strain the peroneus brevis tendon and an ankle sprain and it is just a tendon injury. Now that’s not going to show up on an X-ray. Well part of the really confusing piece in the very first step when you have one of these injuries, you’re trying to sort out which is which? Well, that’s to get rid of the swelling because some people when your ankle’s super swollen, it’s blown up like a pumpkin.

You have so much distension of the skin and the soft tissue that no matter where you push, it hurts. And if you push all over the place and it hurts, all of those things aren’t injured, it’s just that the nerves are stretched so much that they hurt when you push on it. So, step one is to get rid of all that swelling.

After you’ve gotten rid of the swelling, you start poking around and you’re probably only going to find one or two places that actually hurt. If it’s really on the bone, then you have to decide is it probably because it’s a fracture or is it because the tendon or ligament is strained? Well, simply put, if you push on the bone or you tweak the bone, you might have a fracture that’s going to hurt. If you do something to test the tendon or you stretch the ligament and that causes more pain than when you push on the bone, you’re more likely to have a soft tissue injury.

So, those are some of the general rules that I use to try to detail whether or not you’ve got a soft tissue injury or a bone injury. Truthfully, most of the time when people call me for a second opinion, and their foot’s really swollen, I tell them step one, get rid of all the swelling. As soon as you’ve gotten rid of the swelling, we can start testing these things individually and see does it hurt when you push on the bone? Does it hurt when you press the bone or bend the bone? Versus does it hurt when you stretch that tendon or ligament that could have been injured when you rolled your ankle?

That’s really the simplest way to think about this if you’re trying to figure out whether or not you have a soft tissue injury or a bone injury, like when you roll your ankle and you’re running and you’re trying to get back to running.

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