Hi there,
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I would love some input from the arena brains trust on a case of mine.
Pt:
38 year old female in good general health. Relatively sedentary - works an office job sitting most of the day, 4days a week and works retail standing up in flat, hard ballet flat style shoes 2days per week. This has been the work situation for over a year. No previous foot pain or trauma is reported.
Presenting complaint:
Sudden and severe onset of sub right 1st MPJ pain 10 days ago - Woke up in the evening with pain and swelling. 3 days prior to seeing me her General Practitioner sent for x-rays and ultrasound (no diagnosis was made as yet). Pt cannot recall any incident of trauma or unaccustomed activity that would cause such pain. Pt asked to point to most focal point of pain - corresponds to lateral sesamoid region.
Antalgic gait - Pt chooses low gear propulsion to avoid pain.
Pt has not been taking any pain meds consistently since it happened. No treatment thus far.
On assessment:
Pain to palpate anywhere sub Right 1st MPJ -especially lateral sesamoid.
Pain sub 1st mpj and associated shooting nerve pain into MLA when dorsiflexing hallux. Mild swelling still present. No abnormal plantar HK patterns seen (no HK at all really). Mild forefoot valgus with 1st MPJ in line weth lesser MPJs. Without seeing normal weight baring (WB) foot posture due to pain cannot tell the functional foot posture. However, non-WB pedal joint ROM all seem WNL. Very weak eversion strength and mild weakness of inversion strength on Right vs Left.
X-ray: I have attached an AP view. No sesamoid axial was taken unfortunately.
Ultrasound showed irregularity of lateral sesamoid, soft tissue thickening and increased vascularity around the sesamoid indicating a current inflammatory process.
There is clearly fragmentation of both sesamoids on x-ray with the lateral also very opaque indicating poor bone health/density. I also query the eroded appearance of the lateral aspect of the distal metatarsal head which looks eroded and sclerotic.
Current diagnosis: Lateral sesamoid stress fracture with possible AVN. I think the medial sesamoid may have a fracture at proximal medial aspect also.
Anyone see anything tell tail in this image to aid in diagnosis or prognosis? This amount of damage seen on x-ray obviously didn't happen 'overnight'.
Currently I have her in a rocker sole CAM boot with felt deflective padding to reduce plantar pressure sub 1st MPJ. She has been advised on a course of oral anti-inflammatories, iceing 2x15min daily and a compression sleeve to help settle the acute pain and inflammation also.
In others experience is this just an atypical presentation of a sesamoid stress fracture or am I missing something? If there is avascular necrosis will this generally change the management plan. I'm considering sending for MRI.
Any input greatly appreciated.
Cheers,
Tom do Canto
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Painful TNA site 14 weeks post procedure
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A Biopsychosocial Model of Ultrasonography Assessment of Ankle/Foot Pain
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Painful TNA site 14 weeks post procedure
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A Biopsychosocial Model of Ultrasonography Assessment of Ankle/Foot Pain
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