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A friend who lives 300 miles from me phoned today to ask advise on her daughter.

She is an 11year old girl, not particularly sporty, started complaining of pain in the ball of her foot (vaguely 2-4 M. P. J. area) about 3 weeks ago. She does not remember hurting herself, just gradually got worse. Her mum took her to hospital and they x-rayed it but said there was nothing abnormal found and told her to rest it. She got crutches but when the pain had not eased 1 week later her mother took her to another hospital and it was x-rayed again but they too found nothing abnormal. Her mother said she thinks it was abit swollen over the 'ball of the foot' at the beginning but not now. No pins and needles or burning. Rest does ease it.

I told her not to rule out fracture/freigberg's etc yet and said that if it doesn't settle she should have it x-rayed again. Also advised her to ice 20mins, 3 times daily and tried to explain how to strap 2nd and 3rd toes into plantarflexed position.

Her GP has referred her to Podiatrist but she isn't sure when appt will be.

Sorry, I can't comment on her biomechanics and imformation is abit vague but would appreciate any thoughts or similar cases.

Could this be plantar tear plate/capsulitus etc at this age?

If symtoms don't ease soon when would be best time to re x-ray?

What else could this be at this age?

 

Freibergs ?

 

Additional diagnostic imaging may help ( MRI/CT/bone scan)?

 

Im not sure when the plantar plate is completly formed but. About this age I would guess, but an MRI or diagnostic ultra sound would be the next step rather than another set of x-rays.

 

your friend anywhere near the north-east?

 

How long would it take for Freigberg's to show up and what would the first changes on x-ray/ultrasound be?

 

In an 11yo girl this is Frieberg's until proven otherwise.

X-ray changes early are non-descript at this point, and limited to increased joint space, and some periarticular swelling. If you are particularly fortunate, you might observe a small osteochondral defect precipitating the whole cascade of events towards this self limiting avascular necrosis. Often it is centrally positioned, and can be observed on an AP or MO view with magnification.

You will no observe the classic radiographic findings for up to a year or two, by then bony remodelling will have occured leaving just about the only situation that mimicks degenerative joint disease in a lesser MTP joint.

Immobilise in a CAM walker or similar for 6-8 weeks then move to any type of footwear that can limit MTP joint extension +/- orthosis if indicated. Get an MRI if you really need to confirm this, but I would be satisfied with a clinical diagnosis based on history and examination findings alone.

LL

 

Ultrasound is quick, relatively cheap and dynamic. Bone is a barrier, bit it could show flexor plate disruption, effusion (dorsally), and FHL pathology. I was amazed the other week when I traced a FHL tendon right to its insertion on the distal phalanx. I have seen MTJ/Lisfrancs joint line changes/osteophytosis when a normal X-ray has been reported, so it can add value, but yes it wouldn't change your Rx plan

 

My 7 year old daughter had similar pain for 3 weeks and several journeys to A and E. The X Ray showed no abnormalities and the radiographer said no fractures visible. However when on one of our outings to A and E the doctor re examined the X Ray and examined my daughter he found a slight SHADOW along the area of pain. He said could be a fracture as he had the extra bonus of examining my daughter not just looking at an X Ray. Good News is that after total non weight bearing with crutches for 3 weeks pain now resolved and swelling gone down. Not the first time A and E have missed fractures in my kids as my 14 year old broke his 2nd met head a few years ago, clearly palpable swelling and excruciating pain on palpation, but was only my insistance that he had a fracture that got consultant paediatrician to re examine his xrays and get him in a cast. Good Luck

 

Just to update. My friend took her daughter to A&E again with my diagnosis of Freigberg's Infraction and they X-rayed again and this time picked up on changes around 2nd met. head. They weren't going to do anything but with her mothers insistance they put her in plaster cast (weren't willing to prescribe Aircast walker). Hopefullly this will allow area to rest. Have advised mother to keep her appt. with Podiatrist as orthotics may still be needed when cast comes off.

 

an appropriately placed met dome or U'd PMA pad works a treat and more often than not eliminates ALL pain. You can just do one in felt on 1st apt while waiting to have it made more permanent. Only ever had one that needed a cast, and I've had some weeks where I've seen a few in the same week.

I agree with earlier posts, Freiburgs is your first choice and assume it's that until otherwise demonstrated. Consider yourself lucky if you see a patient before any changes on XR. Just to help the radiologist along a but it's worth writing on you are wishing to exclude Freiburgs, so they pay a bit more attention to any early signs. off the top of my head it takes a month or two to show on XR.

 

In this instance I believe cast/ walker boot was nessesary as child could not bear to even put foot to ground it was so painful so insole would have been of little use. In less painful case padding to relieve stresses to 2nd met. may have been sufficient I agree.

 

Quite right if they couldn't weight bear. My comments were based on my own experience. I WISH I had these children referred that early on, they usually don't make it to my (NHS) clinic until months and months down the track. All depends on your area and your referrers.

I have a nice series of XR done over few months of a girl, much like the one described above, that show the progression. GP ordered the originals, reported no bony abnormality (although if you know what you are looking for you can see some early subchondral sclerosis and every so slight flattening of the met head). So the GP told her nothing to worry about. Still in pain and presents to my clinic and voila! the 2nd XR shows much more significant flattening. I think it was only 4 months between them.

 

If you could post these up it would be a valuable resource...

 

I'll see if I can find them, I am on maternity leave since October and not sure if I have them here at home