Foot Pain in aCross Country Runner

Nicole Huntress M.D.Primary Care Sports Medicine FellowSteadman Hawkins Clinic of the CarolinasSEACSM ConferenceFebruary 10, 2012

HPI 13yo female c bilateral foot pain >1 year Worst on inside of L foot Activity related No systemic symptoms

PE Inspection: nl arches, prominent L navicular,

no swelling/ecchymosis/erythema TTP L posterior tibialis tendon and navicular FROM, ankle stable Strength: resisted inversion painful on L, weak core c single

leg stance, squat, hip adduction Flexibility: bilateral tight heel cords and hamstrings, R hip

flexors and quadriceps Negative tinels

X-RAYS

Weight bearing bilateral AP, lateral, oblique views Accessory navicular on L, open physes, no fracture or other bony

abnormality

Differential Diagnosis Symptomatic accessory navicular Stress fracture/reaction Tendinopathy Other neurologic etiology

Initial Treatment Orthotic shoe insert Physical Therapy Activity as tolerated, ice afterward

Follow-up Initial improvement Worsened with cross country onset MRI of L foot

extensive patchy marrow edema of tarsal bones, accessory navicular

Follow-up No interval change Short walking boot L Labs

Normal: CBC, CMP, Mg, Phos, ESR, CRP, Ferritin, Iron, TIBC, Reticulocyte, TSH

Vitamin D low at 29.8 Dexa Scan

lower limits of normal, 0.841 to 0.957gm/cm3, z-score -0.6 to -0.9 Nutritionist referral MRI R foot

Numerous foci of increased marrow signal of hindfoot and midfoot, no accessory navicular

Conclusions 13yo female cross country runner with painful Bone Marrow

Edema Syndrome short L cast and R boot Now wearing custom orthotics Ongoing bilateral mid-foot pain Endocrine consult pending

Thank youQUESTIONS?

A ‘normal’ finding?Shabshin, Schweitzer, Morrison, Carrino, Keller, Grissom. High Signal T2 changes of bone marrow of the foot and ankle in children: red marrow or traumatic changes? Pediatric Radiology 2006.

402 bones in 41 pediatric (1-18yo) patients BM changes on T2 MRI in 11% overall, 59% <16yo Calcaneous 54%, talus 35%, navicular 35% Most bilateral and most resolve by 15yo Hematopoietic red marrow, physiologic stress, biomechanics?