Foot Pain In An Adolescent Baseball Athlete

CLINICAL CASE HISTORY: A 17-year-old senior high school baseball athlete (all positions including right-hand pitcher, except first base) presented with right foot pain without history of injuries or trauma. Pain was localized in the ball of his right lateral forefoot, and he feels like he has been pronating and placing more weight on his great toe to alleviate the pain. Pain is worse when weightbearing with barefoot, and there is no pain at rest. He has tried meloxicam and physical therapy without improvement. PHYSICAL EXAMINATION: Focused musculoskeletal examination of right foot revealed no effusion, bruising, atrophy, asymmetry, deformities on inspection. There was trace soft tissue swelling in the dorsum of the right foot most significant along the distal 3rd-5th metatarsals. There was a small palpable nodule deep to the FDL tendon of the 4th toe proximal to the 4th metatarsal head that was tender to palpation. There was decreased passive extension with pain of the 4th and 5th MTP joints and IP joints. There was normal 5/5 strength with resisted ankle dorsiflexion, plantarflexion, and EHL. Intact MTP / IP flexion in all toes. Sensory intact to light touch. Palpable DP and PT pulses 2 + . DIFFERENTIAL DIAGNOSIS: 1. Stress fracture of the 4th metatarsal. 2. Dupuytren’s contracture. 3. Tendon sheath neoplasm. TEST AND RESULTS: Right foot radiographs:- No fracture or dislocation is seen. - No periosteal reaction or sclerosis to indicate a healing injury seen. - No tarsal coalition. - Overlying soft tissues are normal. MRI right foot:- Small effusion of the fourth metatarsophalangeal joint. - The dorsal aspect of the head of the 4th metatarsal is flattened and irregular with mild edema in the head and neck. - Edema in the talar head, navicular, medial and intermedial cuneiforms and along the first and medial aspect of the 2nd rays and 4th phalanges.- There is marked fluid signal within the tendon sheath of the flexor hallucis longus tendon. FINAL/WORKING DIAGNOSIS: Early Freiberg’s Infarction of the head of the 4th metatarsal. TREATMENT AND OUTCOMES:- Continue with activities- Carbon fiber insoles to offload forefoot- Meloxicam 7.5 mg twice a day as needed-Intermittent boot use as needed for comfort-Return to clinic after baseball season for follow-up