Bilateral Foot Pain-Middle Distance Runner

Abstract

HISTORY: A 14-year-old female middle-distance athlete presented with a history of unilateral (right) foot pain, diagnosed as a navicular stress fracture which was managed non-surgically and made a full clinical recovery. Nine months later she sustained a suspected traumatic spring ligament injury on the opposite side, with subsequent recurrence of pain in the right foot due to overload from the non-weight bearing management of the left foot injury. She therefore presented with bilateral athletics-related foot pain, one-sided apparently traumatic in nature and the other an overload injury. PHYSICAL EXAMINATION: On clinical examination she was noted to have bilateral mild cavus feet with an antalgic gait pattern. Right foot: Calf and Achilles tendon did not reveal any abnormalities (Silfverskiold negative). Ankle was asymptomatic. The hindfoot joints were mobile and non-tender. There was significant tenderness over the talar navicular bone (”N” spot). The mid and forefoot examination did not reveal any abnormalities. The foot was neurovascularly intact. Left foot: Calf and Achilles tendon did not reveal any abnormalities (Silfverskiold negative). The ankle was asymptomatic. The hindfoot joints were mobile and non-tender. There was once again significant tenderness over the talar navicular bone with mild swelling. The spring ligament was not tender. The mid and forefoot examination did not reveal any abnormalities. The foot was neurovascularly intact. DIFFERENTIAL DIAGNOSIS: Navicular stress fractures, tendinopathy of the posterior tibialis tendons, tear of the spring ligament, separation of an accessory navicular TEST AND RESULTS: Imaging with MRI revealed bilateral navicular stress fractures (figure 1), as indicated by bony edema and a fracture line. On close inspection, the navicular fracture lines were visible on x-ray (Figure 2). Further imaging with CT scans confirmed the navicular fractures and demonstrated sclerosis along the fracture borders with no cross trabeculation, suggestive of a non-union (figure 3). FINAL WORKING DIAGNOSIS: Bilateral navicular stress fractures TREATMENT AND OUTCOMES: Open reduction and internal fixation (ORIF) and bone grafting. Postop rehabilitation and graded return to activity. Back to sports with no pain or swelling in her feet 1 year post surgery.