Residency Insight -- A PRESENT Podiatry eZine

Ryan Fitzgerald, DPM
PRESENT RI Associate Editor
Hess Orthopedics & Sports Medicine
Harrisonburg, Virginia

Case Presentation:
21 Year old female with right foot pain

HPI: The patient is a pleasant 21-year-old female who presents with Right foot pain. The patient describes her pain as diffuse and states that it began one year ago at which time it was mild and intermittent. She says now her pain has progressively become more intense and more frequent. Presently, she rates her pain a 6 out of 10 and says that it occurs mostly when or after she exercises. She states that she is very athletic, plays intra-mural lacrosse and is a member of a swim club. She denies any history of trauma.

	Click on the image below for a larger view

	The clinical exam demonstrates pain with palpation along the length of her right 4th metatarsal dorsally.

PMH: hay fever

PSH: lasix, previous ORIF right wrist, appendectomy

MEDS: Singulair, Alesse

ALL: NKDA

SOCIAL: The patient is a full-time college student who smokes less than one pack of cigarettes per week. She drinks alcohol socially and drinks caffeine daily.

VS: BP: 132/84, HR: 82, RR: 18, Temp: 98.1

PE: The patient exhibits an athletic body habitus, weighs approximately 130 lbs, and stands 5’6’’ tall. Upon focused exam of her lower extremities, her pedal pulses are palpable and graded +2/4 bilaterally, CFT is < 3 seconds, with no evidence of edema, erythema or ecchymosis. Manual muscle testing is graded +5/5 upon dorsiflexion, plantarflexion, inversion, and eversion bilaterally. The patient demonstrates pain with palpation along the length of her right 4th metatarsal, with less pain elicited on palpation of the adjacent intermetatarsal space (Fig. 1). There is no pain on range of motion of the right 4th metatarsal phalangeal joint. There are no masses palpable and no open lesions. Weight bearing exam demonstrates a slightly valgus heel in resting calcaneal stance position. There is pain in her right foot during ambulation at this time.

Imaging Studies: Plain film radiographs of the patient's right foot

Considering the clinical exam presented, and the physical and radiographic findings, how would you proceed in the management of this patient? Follow this link, or click on the image below, to participate in the on going eTalk thread on this topic. The Conclusion of this case will be posted in an upcoming Residency Insight.

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