Should I take NSAIDs when I have a fourth metatarsal stress reaction? Well, that is a great question and that is what we’re talking about today on the Doc On The Run Podcast.
If you get a metatarsal stress reaction, you might be confused for a number of reasons. Number one, you are probably trying to figure out is it really a subtle stress fracture or what is it? And two, you are probably trying to figure out how to make the pain go away as fast as possible so you can get back to running.
The reason for this episode is that last night I was talking to a physician who referred a runner to me who had a fourth metatarsal stress reaction. One of her questions was, would it really be a good idea or not a good idea for her to take something like ibuprofen or some other non-steroidal anti-inflammatory drug which we call NSAIDs for short. Well, the answer is simple. So, when you get a metatarsal stress reaction, in this case it was the fourth metatarsal bone, but you could get it in any of them theoretically. So most often we see it in the second or the fourth, but you can get it in the fifth, you can get it in the third, you could even get it in the first.
But what is it? Well, the reason that you are getting pain when you have a stress reaction is that you have swelling within the bone. For example, as a simple analogy, let’s say you go to the gym, and you start doing lots of bicep’s curls. You pick up heavy dumbbells, you do biceps curls, and what happens? Well, your biceps muscle gets sore. Why is it sore? Two reasons. Number one, tissue damage. You are tearing, micro tearing, some of the little fibers in the muscle. You understand that? That is easy.
But also, it will get swelling as a consequence of that tissue damage. The additional fluid in the muscle makes it hurt and so if it’s swollen and distended and stretching the nerves and you squeeze it, it hurts more because it’s stretching the nerves more. Just like when you squeeze a balloon, it pooches out somewhere. And the muscle when it’s swollen is doing the same thing.
If you squeeze the muscle and it distends the tissue and stretches the nerves even more, well it hurts, and a similar thing happens in the bone. What’s happening is that the covering of the bone where you have that stress reaction, the periosteum, it actually has fluid between the periosteum and the bone and when it lifts away, it stretches the nerve endings, and it hurts. And so, if you take non-steroidal anti-inflammatories, two things can happen.
Number one, it does act as a pain reliever. So, you may get a reduction in your pain without removing that inflammatory fluid. If you take non-steroidal anti-inflammatories long enough, it will usually reduce the inflammation, but it doesn’t happen immediately. Pain relief happens immediately. So why is that a problem? Well, this is really simple. When the covering of the bone, the periosteum is inflamed like that, we call it periostitis and itis means inflammation. That is the reason this doctor was asking me about whether or not a non-steroidal anti-inflammatory might be helpful.
This is the way I think about it. I was just lecturing last week at the International Foot and Ankle Foundation meeting in Las Vegas, and I gave a lecture called “Stress Response, Stress Reaction, and Stress Fractures in Athletes”. I was explaining these differences to all the physicians in the audience, and I told them, I said, “Pain is the most abundant and most underutilized diagnostic resource available to doctors and injured runners.” And I said, “I’ll bet that I could take any runner and if I could only listen to their story, only talk to them, only look at their foot and really track their pain very carefully, I’ll bet I could get them back to running faster than if you as a physician just use diagnostic imaging, testing, and all these other things to try to figure out when it’s better enough for them to start running on it.”
You can’t ignore the pain. You should use the pain. The pain is a tool for you to use. So, the way I think about it is that what you really want to do is track your pain very, very, very carefully. In these early stages, when you first get a fourth metatarsal stress reaction, what you are doing is you are trying to figure out how bad is it and there’s two things going on. You have pain from tissue distension or swelling from the inflammatory response. That is because there’s excess fluid in there. You also have pain because you have actual tissue damage.
If you have a crack in the bone and you remove the inflammation, it’s still going to hurt a lot when you touch it, move it, step on it, or anything else, because there’s a crack in the bone and the crack’s physically moving. But if the pain is only from the distension of the tissue and you get rid of the inflammatory response, but you are paying attention to the pain, it helps you figure out a lot faster how bad the problem really is.
I always tell runners, you should never use nonsteroidal anti-inflammatories when you are still in the figure it out stages. You are trying to determine how bad the injury is because the severity of the injury is more important than knowing what the injury is itself. And then later when you’ve returned to running, it’s really on its way to healing and you have some occasional aches and pains and you want to take nonsteroidal anti-inflammatories at that time, often I do recommend that, but I do not recommend it as a general rule in the figure it out stages unless there’s some very unique circumstances.
If you want to learn more about the strategies I use with injured runners who have metatarsal stress fractures and are trying to get back to running as quickly as possible, the exact same strategies I actually teach to physicians at medical conferences when I go lecture, you can get it for free. It’s the Stress Fracture Masterclass and you can sign up at www.docontherun.com/stressfracturemasterclass. So, go check it out and I’ll see you in the training.
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