When a runner has a Jones fracture, is it better to have surgery to fix the broken bone? Well, that is a great question and that is what we’re talking about today on the Doc On The Run Podcast.
Now, one of the worst types of fractures in your foot is a thing called a Jones fracture and it is a fracture in a very specific place in a very specific bone, specifically the fifth metatarsal bone. The Jones fracture happens right at this junction where you have the skinny cortical part of the bone turning into this flared out part that we call the metaphyseal section of the bone. Well, the diaphysis is the cortical skinny part, and the metaphysis is the thick flared out part and it is what we call the metaphyseal-diaphyseal junction is what the medical term is, but the reason for that and it is such a problem there is that there is a very poor blood supply in that specific area.
You have some blood supply coming up from the base of the bone here and from the shaft of the bone there, but it kind of stops in this one spot where you can get a Jones fracture. That is why it is bad. Now, if you get one of these Jones fractures and you’re a runner, depending upon the circumstances, the doctor might recommend surgery.
I had a Jones stress fracture myself when I was in medical school and so I know this firsthand, and I know how frustrating it is when you’re told to use a fracture walking boot for a long period of time because that is exactly what I did. That is part of why I do it differently now.
This episode though is a really good example of the confusion that comes from Jones fractures, and this was hosted as a comment on the Doc On The Run YouTube channel on a video that was entitled, “What is a displaced versus a non-displaced fracture?” The viewer who posted the comment said, “My daughter’s a D1 athlete in soccer. She fractured her foot on September 1st, so that would have been just over a couple of weeks ago. It was a non-displaced Jones fracture. What does that mean?“
Well, displaced is where it is cracked, and it is moved out of position. When it is displaced, that is different. Displaced means it is out of position. Non-displaced means it is in the right position. She said that she’s gotten three opinions so far. The first one was surgery that was advised by the school surgeon. The second was conservative therapy, meaning non-surgical treatment by an external surgeon and they also saw a foot doctor.
She’s not taking any medications. She has little to no pain, which is a good sign. She’s been told that healing would save some time if she had surgery versus conservative and that surgery could also come with some complications, which is true. She’s in an air cast and uses crutches more often than not. She has never been so confused over selecting a direction to go in.
I understand why this is so confusing. There are a lot of things about this example that confuse me. Number one, says that she’s using crutches more often than not. If you want to delay healing, all you have to do is apply stress to the bone that moves that fracture while it is trying to heal. I think fracture walking boots are the most over-prescribed thing for runners with fractures. I also think crutches are the most under-prescribed thing. They’re also the most underutilized thing by runners as a treatment that doesn’t cost anything and doesn’t have any risk.
The complications that she mentions here in this comment are things like infection, nerve damage, those kinds of things that put you at risk for healing. If surgery always made you better, we would always do it. There are really only two reasons to have surgery.
The first reason is that there is zero chance the fracture is going to heal in the right position predictably if you don’t have surgery. For example, if you break the bone and it is sticking out 45 degrees to the side, well, it is never going to be normal if it heals in that position. In that case, if we can’t just push it back under x-ray, we need to make an incision, go down, reposition the bone, do something to stabilize it like put a plate and screws on it so that it will be in the right position and have some hope of healing correctly.
The second reason to consider surgery for a Jones fracture is that the doctor will convince you, and this is not wrong, but the doctor convinces you, successfully convinces you that you will heal faster, and you will return to running earlier and hence be able to get back to running faster and sooner if you actually do repair the bone.
How does that happen? Simple. Let’s say you have a non-displaced Jones fracture. First of all, if we put a plate and screws or something like that on it, if it is going to keep it more stable, in theory, it should heal faster. The downside of that is that if we put a big plate and stuff on the bone, it can compress the periosteum or the covering of the bone that has some of the blood supply that can actually slow some of the healing. That is why this gets so confusing.
We also know that about half the time people have Jones fractures, they don’t heal and then you have to go do surgery later. So, if you use a splint or a boot or a cast and crutches off and on for a couple of months and it doesn’t heal, then the doctor will often say we got to go in, put a plate, put some screws, put a pin, something in there to hold the bone still so it’ll start healing. That obviously is going to make it take much longer for you to get back to running.
So, it gets very confusing very easily. But the one thing that I heard in this is that she’s confused. She’s gotten several different opinions. Somebody said surgery. A couple of people say no surgery. She’s using a boot. She’s kind of using crutches, but not really using crutches all the time. And all of those things affect the rate of healing.
The main reason that you want to avoid the surgery is that the risk of surgery really doesn’t outweigh the potential benefit. Let’s say the bone has a crack, but it is not even broken all the way across. Well, it seems a little crazy to go in there and do surgery to put a plate on it because if it is not broken all the way across and it is stable, it is not going to move that much anyway. And then there is obviously additional healing that has to happen if you do the surgery itself.
Now, any time a doctor’s talking about performing surgery on a metatarsal fracture, we’re basically saying that we want to put it back together so it is going to prove the alignment, make it more stable or something so that it will heal faster. Generally speaking, this is not for everybody, but if we do that, if we put it back in a better position, what that means is that, number one, as a runner, since it can’t move as much because we’ve secured it with plates and screws or something else, that means that you should start moving your foot sooner. You can loosen up your ankle sooner.
You can start doing some exercises sooner. Maybe not running, but you can do things that will help maintain your running fitness sooner. And that, of course, stands to reason that if you do things that maintain your running fitness like flexibility and strength while the bone’s healing, you’re going to get back to running sooner.
Now, if you don’t have any hardware, plates, screws, pins, whatever, holding all this together, holding the bone in place, then you have to wait for the physiologic process to happen that makes the bone stable so it can withstand you doing some things like range of motion, like sitting on a sled, pushing your foot on a plate, doing leg presses, doing anything else that is going to rebuild your running fitness, and so it may take you longer to get some of that flexibility and strength back before you start running.
So, the million-dollar question to ask your doctor when you have a fracture and they’re recommending surgery or trying to get you warmed up to the idea of surgery, this is how I would put it. I would say, “Okay, can you guarantee that if I have surgery, I will start running sooner than if I do not have surgery?”
You’re not trying to get a guarantee on the outcome of the surgery. You just want to know really and truly, if you do the surgery, does that mean I’ll get back to running sooner? And if they say, “Yeah, definitely.” Say, “Okay, what do you think the timeline is on me starting to run if I have surgery versus if I don’t have surgery?” And if the foot surgeon kind of like recoils and gets a little freaked out that you put them on the spot like that, well, then you want to ask her a different question, a little different ways if she’s sidestepping. You say, “Can you guarantee that if I do not have surgery, you’re telling me for sure, if I don’t have surgery, that I won’t get back to running in the same amount of timeframe as I do have surgery?” So, you can kind of flip it around and ask it the other way.
But anytime a runner has a fracture, the goal should always be to reframe the conversation with the doctor so that you can get the doctor to focus on your timeline for return to running. Rather than the injury itself, rather than what it looks like on the x-ray or even the treatment, the boot or crutches or surgery or whatever, you want everything defined as how long is it going to take me to get back to running? Will this help or not? If you reframe your questions to focus on running and returning to running, it will remove a whole lot of the confusion for you and the doctor too.
If you want to learn more about the strategies I use with runners that have metatarsal fractures, the same strategies I teach to physicians at medical conferences, you can get it for free. It is in the Stress Fracture Masterclass. Just go to www.docontherun.com/stressfracturemasterclass, sign up, and I’ll see you in the training.
