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M3) Foot pain in a military recruit
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with foot pain.
- Review the DDx considerations in a patient with foot pain.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with foot pain.
History
A 24 year-old male returning from basic training camp presents with 6 weeks of increasing left lateral mid-foot pain. The pain started after wearing new combat boots, and significantly increased ambulation with increased weight bearing. The pain improves but does not completely resolve with rest. He reports no specific trauma to his foot prior to pain onset. The patient previously had an internal fixation of their 5th metatarsal after sustaining a Jones fracture on the jobsite.
Physical Exam
BP: 135/88, HR 67, RR 16, Temp 37C, O2 saturation 99%. MSK: Point tenderness 4th metatarsal.
Labs
None
Provisional Diagnosis
Select the Dx you believe is most appropriate
This patient is most likely suffering from a metatarsal stress fracture considering the foot pain with new footwear, increase in physical activity, and point tenderness without traumatic injury.
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Potential Acuity
What is your assessment of the likely acuity for this patient?
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While the patient’s condition is not immediately life or limb threatening, they require further workup.
First Imaging Study
What is the first imaging study you will order?
A plain radiograph is the first study of choice. Although it has low sensitivity for early stress fractures, it is inexpensive with a low radiation burden. Further imaging like CT or MRI may be ordered if the X-ray is negative and clinical suspicion for a stress fracture remains.
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Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
Plain radiograph of left foot
The 5th metatarsal screw is displaced.
The 5th metatarsal cannulated screw is in proper positioning and the 5th metatarsal has grossly anatomic alignment. There are no cortical irregularities or signs of bone remodeling.
There is a sign of fracture on another metatarsal bone.
Radiographs show a transverse fracture with associated callus formation at the mid-diaphysis of the 4th metatarsal.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
No further imaging is needed. Combined with the clinical history, the imaging findings are strongly suggestive of a metatarsal stress fracture.
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What is your Diagnosis now that you have seen the imaging results?
The patient’s clinical presentation and imaging findings of a fracture line with periosteal reaction are consistent with a subacute stress fracture of the 4th metatarsal.
Assessment and Plan
Please provide your assessment and plan for this patient
This patient is a 27-year-old military recruit suffering from a metatarsal stress fracture due to overuse and poor fitting new shoes. The patient should be counseled to partially weight bear on the right foot for the next two weeks and reduce strenuous activities for 4-8 weeks. They should be prescribed non-narcotic analgesics as needed for pain. A walking boot may be indicated after 4 weeks. The patient should also be provided with resources for orthotic footwear.
Lessons Learned: Metatarsal stress fractures often occur secondary to abrupt increases in physical activity and change in footwear. Jumping, dancing, and running are common causes. The most common location for a metatarsal stress fracture is the 2nd metatarsal, though it is also often seen in the 4th and 5th metatarsals. The common patient demographics are military recruits, runners, ballet dancers, gymnasts.
Socioeconomic Factors:
- Though CT and MRI are more sensitive, plain radiographs should be used first as they are more cost effective.
- Military recruits are commonly affected due to overuse and abrupt onset of activity in basic training.
That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.
Contributors:
John Cerillo, MS2 - Content Contributor
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator
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