Learning Objectives
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Learn the common causes of foot pain.
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Develop an understanding of the unique anatomy of the midtarsal joint.
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Develop an understanding of the causes of midtarsal joint arthritis.
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Learn the clinical presentation of osteoarthritis of the midtarsal joint.
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Learn how to use physical examination to identify pathology of the midtarsal joint.
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Develop an understanding of the treatment options for osteoarthritis of the midtarsal joint.
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Learn the appropriate testing options to help diagnose osteoarthritis of the midtarsal joint.
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Learn to identify red flags in patients who present with foot pain.
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Develop an understanding of the role in interventional pain management in the treatment of foot pain.
Shirley McCain
Shirley McCain is a 62-year-old dance instructor with the chief complaint of, “My right foot is killing me.” Shirley went on to say that she wouldn’t have bothered coming in, but, “It’s getting harder and harder for me to teach my students. By the end of a class, I can barely stand up, let alone demonstrate a dance step.” I asked Shirley if anything like this has happened before. She shook her head no, and said that she had been a dancer all her life and that she had always taken great care of her feet. “Doctor, I started out as a ballet dancer, which is really hard on the feet. I was a good dancer—but not good enough. Fortunately, very early on, I learned that I really enjoyed teaching. Unlike professional dance, your successes as a dance instructor are up close and personal. But I apologize, Doctor, I am rambling. What do you want to know? Oh, and one of my students said you could give me a cortisone shot to get my foot better. I really hope you can. I’m sorry, I guess coming to the doctor makes me nervous, and when I’m nervous I tend to chatter.”
I asked Shirley about any antecedent trauma to the right foot. She thought about it for a minute, then said that she did sprain her foot many years ago when she was still an understudy with the ballet company. She went on to say that it was, in fact, that sprain that got her thinking about what she could do if she couldn’t continue with ballet. “Doctor, I was young and thought it would last forever. It never entered my mind I would do anything other than be in the ballet. It took longer for my ankle to heal than I thought it would, so I picked up some part-time work teaching ballet to grade-school children. Who would have thought? I loved it, and I guess the rest is history. But there I go again. I’m so sorry, Doctor.” I smiled and told Shirley that I was enjoying her story.
I then asked Shirley to point with one finger to show me where it hurt the most. She pointed to the top of her right foot and said, “Doc, it hurts right here, especially when I push off. Like when I do the cha-cha. You know, right, left, cha-cha-cha? When that right foot goes back, it really hurts.” I asked if she had any fever or chills, and she shook her head no. I continued, “What about steroids? Did you ever take any cortisone or drugs like that?” Shirley again shook her head no. “Doctor, I am not one to take pills, but I need to do something because my foot soaks are not doing the trick.”
On physical examination, Shirley was afebrile. Her respirations were 18, and her pulse was 74 and regular. Her blood pressure was normal at 122/74. Her head, eyes, ears, nose, throat (HEENT) exam was normal, as was her cardiopulmonary examination. Her thyroid was normal. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. Visual inspection of the right ankle and foot revealed no cutaneous lesions or abnormal mass. The area overlying the dorsum of the right ankle and foot was cool to touch, with no evidence of infection. Her dorsalis pedis pulse was 1+. Palpation of the right foot revealed mild diffuse tenderness, with no obvious effusion or point tenderness. I did not appreciate any popping or crepitus with movement of the foot and ankle. Dorsiflexion and plantar flexion of the right foot and ankle reproduced Shirley’s pain. The left foot and ankle examination was normal, as was examination of her other major joints. A careful neurologic examination of the upper and lower extremities revealed no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.
Key Clinical Points—What’s Important and What’s Not
The History
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A distant history of acute trauma to the right ankle
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No fever or chills
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Gradual onset of right anterior foot pain over the last several weeks with exacerbation of pain with foot use
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Difficulty working as dance instructor due to increased foot pain
The Physical Examination
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Patient is afebrile
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Normal visual inspection of ankle and foot
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Palpation of dorsum of the right ankle and foot reveals diffuse tenderness
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No evidence of infection
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Pain reproduced with dorsiflexion and plantar flexion of the right ankle and foot
Other Findings of Note
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Normal blood pressure
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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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Normal upper extremity neurologic examination, motor and sensory examination
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Examinations of joints other than the right ankle were normal
What Tests Would You Like to Order?
The following tests were ordered:
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Plain radiographs of the right ankle and foot
Test Results
The plain radiographs of the right foot revealed significant joint space narrowing and cartilage loss of the tarsal joints consistent with severe osteoarthritis ( Fig. 2.1 ).
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