Case report
Walking Gait Before and After Chiropractic Care Following Fifth Metatarsal Fractures: A Single Case Kinetic and Kinematic Study

https://doi.org/10.1016/j.jcm.2018.02.002Get rights and content

Abstract

Objectives

The purpose of this report is to describe the kinetic and kinematic analysis of walking gait following healed left proximal fifth metatarsal fractures.

Clinical Features

A 62-year-old female presented at a chiropractic clinic with concerns that recent metatarsal fractures had not fully resolved and reported abnormal gait due to pain and several weeks use of a “walking boot.” The patient’s walking gait was evaluated with a force-sensor treadmill and an inertial measurement unit motion capture system. Recordings were made before, at midpoint, and post-chiropractic care (11 visits total). Data were analyzed for spatio-temporal gait parameters, vertical ground reaction forces, and ranges of motion of the hip, knee, and ankle.

Intervention and Outcome

Pre-care, the patient’s self-rated disability in walking was 50 out of 80 on a Lower Extremity Functional Scale, which improved to 80 out of 80, post-care. Her self-selected preferred walking speed increased, as did step length, cadence, and single support time. Increased symmetry was seen in timing of peak ground reaction forces, stance phase percentages of loading and pre-swing, and ranges of motion for hip and knee flexion and extension.

Conclusions

The patient recovered completely, and the post-injury kinematic and kinetic data allowed for quantification of gait patterns and changes in the clinical environment.

Introduction

Foot injuries and alterations in walking gait are some of the concerns brought to chiropractors. The fifth metatarsal is among the more commonly fractured bones of the foot, often either as avulsion or Jones fractures.1, 2, 3 Jones fracture occurs at the metaphyseal–diaphyseal junction of the fifth metatarsal, an area with a low blood supply that is prone to prolonged healing or nonunion. Other types can occur in the head, neck, and mid-shaft. 1, 2, 3, 4, 5 Younger patients with metatarsal fractures are more often male, but older patients are more often female.6

Associated signs and symptoms include pain, swelling, tenderness, difficulty walking, and bruising. There is considerable variation in management, especially if a Jones fracture is suspected.1, 3, 4, 7, 8, 9, 10, 11, 12 Since 1984, Torg et al’s13 recommendation of conservative treatment for Jones fractures, with a non-weight bearing cast for a period of 3 to 12 weeks, has been frequently followed.5, 10, 12 In 2017, Brogan et al14 concluded that all fifth metatarsal fractures can be safely managed with immediate full weight-bearing in an orthotic boot without adverse effects and that often no long-term review is needed. Most experts agree, however, that if the injury involves a displaced bone, multiple breaks, or fails to adequately heal, then surgery may be needed.1, 2, 3, 5, 12, 15

Metatarsal fractures might result in alterations of walking. Bauer et al16 reported gait asymmetry in 11 out of 20 patients with fifth metatarsal fractures, most with no visible gait disorder. Kösters et al17 reported slower walking associated with multiple metatarsal shaft fractures. Queen et al18 found that women with a history of metatarsal stress fractures exhibit decreased forefoot forces.

Chiropractic literature describes management of foot and ankle conditions.19, 20, 21, 22, 23, 24, 25 However, only 1 chiropractic publication concerns fifth metatarsal fracture, which is only in terms of diagnostic imaging, not condition management.26 The purpose of this report is to describe the kinetic and kinematic investigation of post-injury walking gait of a patient, before and after receiving chiropractic care.

Section snippets

Patient Characteristics

A 62-year-old female presented to the research center with concerns that recent injuries of her left foot had not fully resolved and reported abnormal gait, due to pain and several weeks use of a “walking boot.” Acute inversion injury and Jones fractures of the proximal fifth metatarsal had occurred twice within 6 months. For both fractures, she received conservative treatment with non-weight-bearing casts for periods of several weeks. At 10 weeks from the onset of the second injury, she was

Discussion

Several findings document the participant’s improvements in walking, from pre-care to the post-1 and post-2 assessments. Considering that her main reason for seeking care was a distinctly asymmetrical problem, it’s important to note the greater symmetry seen in the post-1 and post-2 assessments for hip flexion and extension, loading and pre-swing periods during stance phase, and timing of the peak 1 and peak 2 force events.

The participant’s increased self-selected walking speed in itself

Conclusions

The patient in this case recovered completely, and the post-injury kinematic and kinetic data allowed for quantification of gait patterns and changes that, in many clinical environments, could only be judged more subjectively.

Acknowledgments

The authors thank Michael T. Weiner, DC, for data collection and review of this manuscript.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

  • Concept development (provided idea for the research): K.T.H.

  • Design (planned the methods to generate the results): B.S.R., K.T.H., R.S.H.

  • Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): B.S.R., K.T.H.

  • Data collection/processing (responsible for experiments, patient management, organization, or reporting data): B.S.R., R.S.H.

  • Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results):

References (57)

  • LH Wyatt

    Conservative chiropractic management of recalcitrant foot pain after fasciotomy: a retrospective case review

    J Manipulative Physiol Ther

    (2006)
  • PJ Battaglia et al.

    Diagnosis and serial sonography of a proximal fifth metatarsal stress fracture

    J Chiropr Med

    (2013)
  • F Verdini et al.

    Identification and characterisation of heel strike transient

    Gait Posture

    (2006)
  • HG Kang et al.

    Separating the effects of age and walking speed on gait variability

    Gait Posture

    (2008)
  • E Kodesh et al.

    Walking speed, unilateral leg loading, and step symmetry in young adults

    Gait Posture

    (2012)
  • H Sadeghi et al.

    Symmetry and limb dominance in able-bodied gait: a review

    Gait Posture

    (2000)
  • RL Lathrop-Lambach et al.

    Evidence for joint moment asymmetry in healthy populations during gait

    Gait Posture

    (2014)
  • CM Kim et al.

    Symmetry in vertical ground reaction force is accompanied by symmetry in temporal but not distance variables of gait in persons with stroke

    Gait Posture

    (2003)
  • S. Uthaikhup et al.

    The effects of head movement and walking speed on gait parameters in patients with chronic neck pain

    Man Ther

    (2014)
  • DP LaRoche et al.

    Low strength is related to diminished ground reaction forces and walking performance in older women

    Gait Posture

    (2011)
  • PE Martin et al.

    Step length and frequency effects on ground reaction forces during walking

    J Biomech

    (1992)
  • TS Keller et al.

    Relationship between vertical ground reaction force and speed during walking, slow jogging, and running

    Clin Biomech (Bristol Avon)

    (1996)
  • M Arvin et al.

    Effects of narrow base gait on mediolateral balance control in young and older adults

    J Biomech

    (2016)
  • PC Santos et al.

    Effects of leg muscle fatigue on gait in patients with Parkinson's disease and controls with high and low levels of daily physical activity

    Gait Posture

    (2016)
  • PO Riley et al.

    A kinematic and kinetic comparison of overground and treadmill walking in healthy subjects

    Gait Posture

    (2007)
  • JR Watt et al.

    A three-dimensional kinematic and kinetic comparison of overground and treadmill walking in healthy elderly subjects

    Clin Biomech (Bristol, Avon)

    (2010)
  • T Boutefnouchet et al.

    Metatarsal fractures: a review and current concepts

    Trauma

    (2014)
  • CN Cheung et al.

    Proximal fifth metatarsal fractures: anatomy, classification, treatment and complications

    Arch Trauma Res

    (2016)
  • Cited by (0)

    View full text