A 34-year-old man comes to the office with 2 weeks of left forefoot pain. He is a runner and has participated in many marathons without any problem. For the past 2 months, he has been training for a cross-country race with hill runs. His pain has worsened to the point that he has had to stop in the middle of many training sessions. The pain improves with rest. Holding the left second toe and pushing it in toward the foot produces pain. X-rays of the left foot are normal.
Which of the following is the most likely diagnosis?

Question

A 34-year-old man comes to the office with 2 weeks of left forefoot pain.  He is a runner and has participated in many marathons without any problem.  For the past 2 months, he has been training for a cross-country race with hill runs.  His pain has worsened to the point that he has had to stop in the middle of many training sessions.  The pain improves with rest.  Holding the left second toe and pushing it in toward the foot produces pain.  X-rays of the left foot are normal.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_993e_a605_853d_3d74b4b7b0c8_MD0002_00 This patient's presentation suggests a metatarsal shaft stress fracture, which is usually due to repetitive weight-bearing activities (eg, running, dancing, jumping) injuring the forefoot. Risk factors include anatomic defects (eg, pes planus), obesity, female athlete triad (oligo-/amenorrhea, decreased caloric intake, and osteopenia/porosis), and poorly fitting shoes. Bone can remodel in response to mechanical stress, but abruptly increasing physical activity (intensity, duration, or frequency) without adequate rest causes repeated tension or compressive stress, leading to microfractures and eventually to a discontinuity of the cortical bone. Metatarsal stress fractures occur most commonly in the 2nd, 3rd, and 4th metatarsal shafts. Patients usually develop gradually worsening forefoot pain and with continued activity can progress to swelling or frank fracture. Examination may show focal tenderness, or holding the corresponding toe at the same level as the metatarsal and pushing it in along the long axis of the metatarsal (axial loading) may elicit the pain. The diagnosis is made clinically but may require imaging in uncertain cases. Plain x-rays can be normal up to 6 weeks after symptom onset, and more sensitive modalities (eg, MRI, bone scan) may be required for definitive diagnosis. (Choice A) Morton neuroma is associated with numbness or pain between the third and fourth toes and with a clicking sensation (Mulder sign) that occurs when this space is palpated and the metatarsal joints are squeezed simultaneously. (Choice B) Plantar fasciitis causes burning pain in the plantar (not dorsal) area of the rearfoot that worsens with the first steps in the morning. The pain decreases as activity increases during the day but can worsen at the end of the day with prolonged weight bearing. Point tenderness is the hallmark. (Choice C) Sesamoiditis usually presents with focal pain of the sesamoid bones on the plantar surface of the first metatarsophalangeal joint. The pain typically increases with walking, running, and dorsiflexion of the great toe. (Choice E) Tarsal tunnel syndrome is due to compression of the tibial nerve as it passes through the ankle. It usually develops after acute bony injuries. Patients develop burning, numbness, and aching of the distal plantar (not dorsal) surface of the foot/toes that may radiate up to the heel and calf. Educational objective: Metatarsal shaft stress fracture is usually due to repetitive weight-bearing activities (eg, running, dancing, jumping) and causes gradually worsening pain. Examination usually shows focal metatarsal tenderness or pain with axial loading of the metatarsal. __________ References: Stress fractures about the tibia, foot, and ankle. (http://www.ncbi.nlm.nih.gov/pubmed/22382289) Foot injuries in runners. (http://www.ncbi.nlm.nih.gov/pubmed/23531971)

A 34-Year-Old Man Comes to the Office with 2 Weeks