Foot Pain In A Competitive Surfer

HISTORY: A 49-year-old male, short board goofy stance, competitive surfer presented with bilateral foot pain, worse on the left. He first noticed soft tissue nodules on the plantar aspect of his left 1st and 5th metatarsophalangeal joints (MTPJs) 3 years ago, with a similar smaller nodule in the medial plantar arch appearing over the past 3 months. These caused a 3/10, dull, non-radiating pain when surfing. He had modified his surfboard by putting a double thick pad for support and took ibuprofen prior to competition to help with symptoms. PHYSICAL EXAMINATION: There were soft tissue nodules 2-3 cm in size on the medial plantar aspect of his 1st and 5th MTPJs, with a smaller 1-2 cm soft tissue nodule along the medial plantar arch on the left. All nodules were soft, mildly tender to palpation, without overlying skin changes. There was full range of motion of his ankle and toes with full strength including extension and flexion of great toe. Sensation was grossly intact. DIFFERENTIAL DIAGNOSIS: 1. Plantar fibromatosis 2. Ganglion cysts 3. Surfer's knots 4. Gouty tophi 5. Rheumatoid nodules TEST AND RESULTS: Left foot radiographs: - Mild hallux valgus with prominent bunion. No soft tissue calcification. Left foot MRI: - Foci of fibrotic tissue within the subcutaneous tissues beneath the first and fifth MTPJs - Nodular foci associated with plantar aponeurosis in midfoot at level of the tarsometatarsal articulations FINAL WORKING DIAGNOSIS: Plantar fibromatoses and surfer's knots TREATMENT AND OUTCOMES: 1. Reassurance was provided. 2. Continued conservative management including supportive wide to box shoes, padding on his surfboard, and topical diclofenac gel as needed for pain. 3. Discussed use of topical verapamil or localized corticosteroid injection for plantar fibroma should symptoms worsen. 4. He returned to full surfing participation.