An Uphill Battle

HISTORY: 59 year old female hobbyist hiker presenting for chronic left foot/ankle pain that has been on and off for several years. She is able to walk without gait changes but certain positions aggravate pain, and it hiders her ability to hike as she typically does. No numbness or tingling is associated with this pain. She does wear an orthotic on her right side for a leg length discrepancy. Previous treatments trialed have included steroid injection without relief and lidocaine patches which does alleviate pain, she has not had prior imparting nor done physical therapy. She does not have any other joint pain. She does note that she exclusively hikes in tennis shoes.PHYSICAL EXAMINATION:Vital signs within normal limits. Afebrile.Constitutional: Appearance: Normal appearance.Pulmonary: Effort: Pulmonary effort is normal.Musculoskeletal:Left foot: No deformity, bunion, Charcot foot, foot drop, or prominent metatarsal heads. Tenderness over middle cuneiform/navicular. Additionally tender to palpation over peroneal tendon near insertion onto base of the fifth metatarsal with decreased strength.Comment: Dorsal pedis pulse is 2+, posterior tibial pulse is 2 + Mental Status: She is alert and oriented to person, place, and time. DIFFERENTIAL DIAGNOSIS: Navicular stress fracture/stress reactionPeroneal tendinitisLisfranc injuryMidfoot arthritisOveruse injury TEST AND RESULTS: XR of left foot without acute abnormality but with moderate osteoarthrosis of talonavicular joint and small calcaneal enthesophytes. MRI of left foot with findings of osteophyte formation, joint space narrowing, subchondral cystic change, and remodeling of talonavicular joint. Type II os naviculare with subtle increased signal at the synchondrosis. Peroneal tendons were not well imaged on this imaging, but otherwise no focal tendon signal abnormality or evidence for tenosynovitis. FINAL WORKING DIAGNOSIS: Talonavicular osteoarthritis TREATMENT AND OUTCOMES: Marginal improvement of pain with usage of NSAIDs and ice as well as continued usage of topical patchesShe changed her hiking shoes to provide further support and continues to hike at this point in timeBegan physical therapy for additional likely peroneal tendinitisAt this time, will proceed with ultrasound guided injection