Severe Bilateral Foot Pain In A High School Football Player

Abstract

HISTORY We present a high school football player with bilateral forefoot pain. During the first week of the season, he trained once a day without pain. There was no acute injury. He then began practicing three times a day and developed gradually worsening bilateral foot pain. The pain was initially present only with activity. However, after one week of the intense training schedule, it became constant. PHYSICAL EXAMINATION The patient was a well-built football player (200 lbs. 6 ft. 3 in.) with bilateral limping. He had normal hip and leg strength and range of motion. The arches were also normal. His feet had no swelling, edema, ecchymosis, or deformities. His right forefoot was diffusely tender to palpation and the pain was greatest along the first and third metatarsals. His left forefoot was also diffusely tender to palpation, with the greatest pain along the second metatarsal shaft. DIFFERENTIAL DIAGNOSIS Metatarsal fractures, metatarsalgia, Freiberg's infraction, myofascial strain of the interossei, sprain of the transverse ligament, extensor digitorum tendonitis, Lis Franc Ligament sprain, Morton's neuromas, or metatarsal stress fractures. TEST AND RESULTS To distinguish between the above etiologies of foot pain, MRI of the feet was performed. T2 weighted images demonstrated significantly increased signal within the shafts of the right first and third metatarsals, as well as the left second metatarsal. The remainder of the metatarsals also showed mild T2 signal abnormality. There were no fracture lines seen on either T1 or T2 images. FINAL WORKING DIAGNOSIS Grade II stress fractures of the right first and third metatarsals and left second metatarsal with diffuse stress reaction throughout both feet. TREATMENT AND OUTCOMES The patient was held from athletic participation and was weight bearing as tolerated for 3 weeks, but had little improvement. He was then given crutches for 2 weeks and his symptoms improved significantly. Dietary counseling was provided and he was educated on proper footwear and training regimens. Gait analysis is planned after the symptoms are fully resolved.