March fracture is a pathological change in the structure of the metatarsal bones that occurs due to excessive loads. It develops in soldiers, especially at the beginning of service, as well as after intensive drill, marches and crosses. It may occur in people whose profession requires constant standing on their feet, carrying heavy loads or long walking. Predisposing factors are flat feet and wearing uncomfortable tight shoes. It is manifested by pain in the foot area, sometimes – sharp, unbearable. The pain increases with exertion and is accompanied by local swelling of the foot. The diagnosis is confirmed radiographically. The treatment is conservative, the prognosis is favorable.
ICD 10
M84.4 Pathological fractures not classified elsewhere
Meaning
March fracture (recruits’ disease, march foot, Deutschlander’s disease) is a disease caused by a pathological restructuring of the metatarsal bones due to excessive load. It can occur acutely or chronically, but more often has a primary chronic course. It is treated conservatively, carried out by specialists in the field of traumatology and orthopedics, ends with a full recovery.
Causes
March fracture is observed in soldiers, athletes and people whose profession is associated with prolonged walking, standing or carrying heavy loads. The probability of development increases with the use of uncomfortable shoes and flat feet. According to studies conducted in different countries, people with a low level of habitual physical activity are more likely to develop a march fracture after intense exercise. It is believed that this is due to the lower strength of the bones. It is no coincidence that another category of such patients today is increasingly becoming tourists – office workers who actively “run” around tourist attractions in uncomfortable shoes during the vacation period.
Pathogenesis
In Deutschlander’s disease, changes occur in the middle (diaphyseal) part of the metatarsal bones. The pathological restructuring of the bone tissue in this case is due to the changed mechanical and static-dynamic factors. The second metatarsal bone is most often involved in the process, less often – III, even less often – IV and V. This distribution is due to the peculiarities of the load on the foot when standing and walking, since in such cases the inner and middle parts of the foot are more “loaded”. I the metatarsal is never affected. This is probably due to its higher density and strength.
Usually one bone suffers, although it is possible both simultaneous and consecutive damage to several bones on one or both feet. It has been established that a march fracture is a special type of transformation of bone tissue that is not associated with a tumor or inflammation.
At the same time, the views of experts on the nature of the damage are still divided. Some believe that bone restructuring is accompanied by an incomplete fracture or a so-called “micro-fracture”. Others believe that the term “march fracture” should be considered outdated and untrue, since there is only local resorption of bone tissue, which is subsequently replaced by normal bone without the formation of a callus.
Symptoms
There are two clinical forms of the disease: acute and primary chronic. The first is observed less frequently, develops 2-4 days after a significant overstrain (for example, a long march). The second arises gradually, gradually. Her symptoms are less pronounced. There is no acute trauma in the marching foot in the anamnesis. Patients with this diagnosis complain of intense, sometimes unbearable pain in the middle part of the foot.
Lameness appears, gait becomes uncertain, patients try to spare the damaged limb. On examination, local edema is determined above the middle part of the metatarsal bone and a denser swelling in the lesion area. Skin sensitivity in this area increases. Hyperemia (redness of the skin) is noted quite rarely and is never pronounced. Patients also never have common symptoms: there is no increase in body temperature, no change in the biochemical or morphological picture of the blood. The pain may persist for several weeks or even months. The average duration of the disease is 3-4 months. The disease ends with a full recovery.
Diagnostics
The diagnosis is made on the basis of a survey, examination and radiography data. The picture obtained during the X-ray examination is crucial in this case. In Deutschlander’s disease, a change in the structural pattern is detected in the diaphysis of the affected metatarsal bone (sometimes closer to the head, sometimes to the base, depending on the localization of the most functionally overloaded area). The oblique or transverse band of enlightenment (the zone of enlightenment of the Loozer) is determined – the area of bone restructuring. It looks as if the metatarsal bone is divided into two fragments. However, unlike the X-ray picture of a fracture, there is no displacement in this case.
Subsequently, periosteal growths occur around the affected part of the bone. At first they are thin and tender, then they are dense, similar to a fusiform callus. Later, the zone of enlightenment disappears, sclerosis occurs. Over time, the periosteal layers dissolve. At the same time, the bone remains thickened and compacted forever. The defining signs are the absence of acute trauma, the typical localization of damage, as well as the presence of a zone of restructuring in the absence of displacement of fragments and maintaining the correct shape of the bone. It should be borne in mind that during the first few days or weeks, radiological signs of the disease may be absent. Therefore, with characteristic symptoms, it is sometimes necessary to perform several radiographs with a certain time interval.
Treatment
Traumatologists are engaged in therapy. Treatment is strictly conservative, surgical interventions are contraindicated. In acute form, a plaster splint is applied to the patient and bed rest is prescribed for a period of 7-10 days. After the acute manifestations of the disease subside, as well as with the primary chronic form of the disease, massage and thermal (paraffin applications, baths) and other physiotherapy procedures are prescribed. Subsequently, patients are recommended to use insole inserts and avoid long walks.
Prognosis and prevention
The prognosis is favorable, with the elimination of stress and adequate conservative therapy, all symptoms disappear within 3-4 months. Prevention consists in the selection of comfortable shoes, the choice of reasonable physical activity and careful medical supervision of soldiers-recruits.
Literature
- Jacobs JM, Cameron KL, Bojescul JA. Lower extremity stress fractures in the military. Clin Sports Med. 2014 Oct;33(4):591-613. – link
- Sanderlin BW, Raspa RF. Common stress fractures. Am Fam Physician. 2003 Oct 15;68(8):1527-32. – link
- Pegrum J, Dixit V, Padhiar N, Nugent I. The pathophysiology, diagnosis, and management of foot stress fractures. Phys Sportsmed. 2014 Nov;42(4):87-99. – link