Just after some advice here. I saw a 15 year old girl initially about 2 months ago. She presented with a 10 month history of left forefoot pain after kicking a soccer ball (she's a top soccer player). Her GP gave a intra-articular corticosteriod injection into the 2nd metatarsophlangeal joint (MPJ) about 3 weeks after the initial injury. She continued to have pain over the next 10 months. She saw a podiatrist who prescribed orthotics. She found these uncomfortable so she didn't wear them much. She continued to play soccer (she was limping by the end of games) though she required daily NSAIDs and analgesics (and her mum is a pharmacist!). She is amenorrheic and has a calcium deficiency.
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By the time she presented to me, it was 10 months down the track from the initial injury. I sent her for an MRI which confirmed Freiberg's infarction of the 2nd metatarsal head. On advice from the radiologist, we also got a plain x-ray done. I've attached a couple of the MRI image and the medial oblique x-ray.
I put her into a cam walker immediately and got her into custom orthotics to offload the 2nd metatarsal head. During this time, she consulted an orthopaedic surgeon. He told her that the cam walker wouldn't do any good and just to get out and play soccer because she can't make it any worse. I saw her a few days ago (when she told me about seeing the ortho). She'd been in the boot for 6 weeks. Clinically there was little, if any, improvement. She was still tender to palpate over the dorsal aspect of the metatarsal head and was quite painful to plantarflex the 2nd MPJ. She just wants to get back playing soccer and is happy to put up with the pain. I'm a little more concerned about doing more damage, requiring surgery etc.
I suppose my question is can she make it worse by playing soccer again now? Also, would a bone stimulater work for this as per fractures? I suspected with the amenorrhea that she may take longer than normal to heal. I would have liked to see her without any tenderness before going back to play soccer. Taping the toe in plantarflexion (as you would tape the toe for a plantar plate injury) reduces the pain so she just wants to play with the toe taped and the orthotics in her soccer boots.
Your opinions would be appreciated.:drinks
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