Forefoot Pain - Recreational Walker

Title: Forefoot Pain - Recreational Walker HISTORY: A 48-year-old female with a history of multiple sclerosis and gastric bypass surgery presented to the sports medicine clinic with right forefoot pain. The patient walks recreationally and complained of pain in her right foot. She reported a fall approximately 3-4 weeks prior, landing on her left side. Although she did not experience pain initially, several days later she noticed pain on the plantar aspect of the first metatarsal head and was unable to fully bear weight on this area. PHYSICAL EXAMINATION: She presented with a limp favoring the right side. There was no effusion or ecchymosis over her right foot or ankle. Pain was noted over the plantar aspect of the right first metatarsophalangeal (MTP) joint during both active and passive maximal dorsiflexion of the right ankle and MTP joints, as well as with active plantar flexion of the right first metatarsophalangeal joint.Resisted plantar flexion of her right first MTP joint also elicited pain in the area. She had point tenderness upon palpation lateral to the first metatarsal bone, between the first and second metatarsals. DIFFERENTIAL DIAGNOSIS: ● Sesamoiditis ● Traumatic or stress fracture of sesamoid or adjacent bone● Bursitis● Osteochondritis● Flexor hallucis brevis tendinopathy● Medial plantar digital nerve entrapment● Chondromalacia● Sesamoid-MTP arthritis● Sesamoid osteonecrosis TEST AND RESULTS: - Foot Xray:No acute fracture or dislocation. Bipartite lateral hallux sesamoid bone-Foot MRI:sesamoiditis with fragmented fibular sesamoid as well as 1st 2nd and 3rd intermetatarsal bursitis. FINAL/WORKING DIAGNOSIS:-Right lateral sesamoiditis-Right forefoot fracture with delayed healing due to a pathologic condition-Right hallux digital nerve neuritis TREATMENT AND OUTCOMES:- Limited weight bearing and activity modification- Voltaren gel and Tylenol - Walking boot (worn during the daytime for two months)- Physical therapy for two months- Lateral sesamoidectomy with right hallux digital nerve neurolysis- Post-operative cast and non-weight bearing for six weeks- After six weeks, she returned to work half-days for two weeks before resuming her normal schedule.