Left Forefoot Pain And Discoloration- Runner

Abstract

HISTORY: A 24-year-old female recreational runner with a past medical history of ADHD on Vyvanse presented to clinic for worsening left forefoot pain and great-toe numbness without antecedent trauma. She also noted blue color changes to the great toe. She presented on crutches due to an inability to bear weight on the forefoot. PHYSICAL EXAMINATION: On inspection of the ankle and foot, there was a bluish-hue to the great toe; no swelling was evident in the foot. She was most tender over the plantar second and third metatarsal heads. Range of motion and strength were preserved. PT pulses were symmetric bilaterally, DP pulses were difficult to appreciate. The foot was cool to the touch with hyperalgesia. DIFFERENTIAL DIAGNOSIS: 1. Vasospastic disease2. Arterial embolization 3. Chronic regional pain syndrome TEST AND RESULTS: Left foot AP, lateral, and oblique radiographs: --Normal. Vascular physiological ABI with maneuvers, arterial ultrasound of the bilateral legs:--No arterial disease noted except for flat toe waveforms in toes of BOTH feet. Left great toe is worse. However, pulsality returns with toe warming implying vasospastic component. Plantar flexion and dorsiflexion did not change popliteal flow velocity. Normal ABIs. No evidence of popliteal artery disease. Left foot MRI without contrast:--Inflammatory changes in the soft tissue deep to the second MTP joint. There is an associated ganglion of the plantar plate measuring 4x2mm- although no discrete plantar plate injury is identified, ganglia can be associated with a small tear.ESR: 5. ANA: neg. RF: <15. Centromere B Ab: neg. FINAL WORKING DIAGNOSIS: Digital vasospasm and possible second metatarsal plantar plate injury TREATMENT AND OUTCOMES: From clinic she was immediately referred to vascular surgery, who noted that although the patient’s toe waveforms were dampened in multiple digits she did show improvement with warming. This suggested vasospastic disease, and given Vyvanse’s association with the same, it was discontinued. Her vasculopathic symptoms improved. Due to ongoing metatarsal head discomfort with ambulation, an MRI was obtained to for further evaluation. Results suggested a plantar plate injury, and taping was used to offload the plate. She was eventually transitioned out of the boot and into a carbon plate insole with eventual return to running.