Hi everyone! This is my first thread so be gentle. I should also point out that this patient is my housemate, and I've been copping grief about being unable to diagnose or manage her sore foot. I also have a great support base of more experienced podiatrists here where I work, I'd just like to cast a wide net!
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Here we go, case presentation...
21 year old female, moderate activity levels. Pain instigated from stopping suddenly and foot sliding forward playing netball around 2 weeks, same level of discomfort now.
Chief Complaint (CC) - Pain localised to the dorsal aspect of the 1st metatarsocuneiform joint left foot. Radiates through the other metatarsocunieform joints. Worse with cold and prolonged activity, slightly relieved by heat and rest. Post-static dyskinesic pain also. Better in more supportive footwear, but only a little better. Best in high heeled shoes. Described as a deep ache. Nil associated redness, heat, swelling etc.
History of Present Illness (HPI) - no current other medical problems. Slightly overweight.
Past Medical History (PMH) - Has orthotics (blake, 6 degrees) for management of occasional plantar fasciitis, along the medial band, not the insertion point. Really only wears them playing netball, was wearing them when injured foot. No complaints with orthotics or plantar fascia at the moment. Orthotics have no effect (negative or positive) on the current complaint.
Physical Exam (PE) - See above. Biomechanically, moderately pronated through the rearfoot, moderately pronated through midfoot both feet. If I had to put a figure on it I'd say 6 degrees everted rearfoot in resting calcaneal stance position, compared to rectus "neutral". Slight, occasional in-toeing at gait. Normal muscle strength, tone, slight bilateral muscular equinus. Sharp pain elicited with passive inversion.
Diagnostic Tests - Haven't done any yet. The initial management of RICE doesn't seem to be helping much, probably doesn't help she detests sensible supportive footwear. Thinking x-ray to identify any stress fracture but should wait weeks for that right? Can't really afford to dish out for anything better than an ultrasound i.e. bone scan.
Differential Diagnosis - Initially thought a tendon sprain as it's not exactly at the point of joint margin. Now thinking "bone jarring, bruising", synovitis, capsulitis and other vague ideas.
Treatment Plan - sticking with RICE at the moment, heat instead of ice. Also thinking heel lifts, to take off some of the dorsal impingement that might be going on. I should also add that I've just read the other threads on dorsdal midfoot pain and will go home now and try out the different diagnostic tests - in particular the superficial peroneal nerve percussion for nerve entrapment and the plantarflexing forefoot to rearfoot. I'll also try those heel lifts and see if strapping helps, although hopefully the orthotics are already helping with some of that.
Any other ideas, my fellow wise podiatrists? Would be greatly appreciated, thank you. I'll be back to let you know how it works! Would also like to know what length of time we'd expect for improvement to allow her back to her exercise activities?
Matt.
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