Forefoot Pain in a 14 y/o

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Hi All, I have just seen a 14 year old active male who c/o pain in the Left 4th MPJ. O/e he has pain on palpation of the metatarsal head, especially on to the distal end of the 4th met if I dorsiflex the toe and palpate in a proximal direction onto the met head. No pain on the shaft proximal to the metatarsal and dorsal aspect of the met shaft or head,

6 month pain Hx. Doesn't remember a traumatic event. No pain at rest, evening or morning. Only really gets pain when walking barefoot. Plays plenty of basket ball in bball shoes and sometimes other casual and slightly crappy tennis/school trainers (my words, not his). Slightly exacerbated by exercise but not immensely so. Pt also reports "it feels like there is blood rushing to the area".

My question is that what are the chances this could be something more sinister (like an avascular necrosis or stress #) rather than a regular capsulitis/synovitis, which, I am led to believe, is uncommon in someone this young.

There were no remarkable development abnormalities. Pt has grown about 4cm in last 6 months.

Pt was referred by ortho who want "insoles" for "flat feet" :bash:

I have found nothing particularly remarkable from my examination of him other than he has a flexible but mild pes planus. Slightly everted heel during RSCP. In gait pt appears to toe off over the lesser metatarsals although jacks test was fine.

I'm treating at the moment with some OTC orthoses which have a poron extension across the forefoot and will RV in 4/52. I've advised him to steer clear of running around barefoot and not to wear flip flops. I've also asked him to bring bball shoes next time and to change the insoles into whatever footwear he is wearing.

Any thoughts would be very gladly received!

Kind regards,

Sam

 

Has there been any images done of the feet ?

Would be my 1st port of call if your unsure, Did you also suggest the patient ice the foot 1-2 twice a day if it is inflammation type problem it may help and give you some answers.

Michael Weber

 

No images done yet..

 

Hi Sam,

I would definately want to rule out an osteochdroses, so x-rays would probably be a good starting point.

Regards,

Dan

 

Hi

I think that it could be a deutshlander fracture! is very frequent at that age, and it usually occurs ate the 3,4rd mtt head! but you can only be sure if you ask for a x-ray!

What do you think about my idea?

Have you already solve de case?

when you know somethink please tell me!

jscgodinho@msn.com

Joaquim Godinho

 

I will feed back when I have more information.. Although many of the Dr's here are very nice and open to polite suggestions.. That particular ortho, while generally pleasant, tends to smile politely and then ignore any suggestions that I give him.. it is frustrating. I will persevere though.