Ortho Dx: Foot pain that is worse in the morning - Clinical Advisor

Ortho Dx: Foot pain that is worse in the morning

Slideshow

  • Anteroposterior X-ray.

    110817_OrthoDx_Figure1_ap.foot

    Anteroposterior X-ray.

  • Axial MRI.

    110817_OrthoDx_Figure2_axial.MRI

    Axial MRI.

A 64-year-old man presents with right foot pain that he has had for several months. He denies having a prior injury or known precipitating event. The pain is worse in the morning and when going downstairs. On examination, he has pain to palpation over the distal 2nd metatarsal. Anteroposterior X-ray of the foot shows mild flattening of the 2nd metatarsal head. MRI shows collapse of the 2nd metatarsal head with subarticular sclerosis and edema.

This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.

 

Freiberg disease is a poorly understood condition in which the articular surface of the second metatarsal head begins to collapse, causing pain at the second metatarsophalangeal (MTP) joint. Although less common, the condition can occur in the 3rd and 4th...

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Freiberg disease is a poorly understood condition in which the articular surface of the second metatarsal head begins to collapse, causing pain at the second metatarsophalangeal (MTP) joint. Although less common, the condition can occur in the 3rd and 4th metatarsal heads as well. The cause is thought to be from a disruption in the blood supply of the metatarsal head. This is why the condition is also referred to as a Freiberg infarction. On X-ray, Freiberg starts with a subchondral fracture and collapse (which may only be seen on MRI) and later may progress to further collapse, joint space narrowing, and arthritis. Patients may present initially with little to no changes on X-ray, and an MRI is often necessary to establish the diagnosis. Symptoms include forefoot pain that is made worse with activities and localized pain to the second metatarsal head.

Initial treatment aims at taking pressure off the effected metatarsal head. Patients can be placed in a walking boot or use a stiff shoe insert with a metatarsal pad. Activity modification and NSAIDs can help manage symptoms. A metatarsophalangeal (MTP) joint steroid injection may provide temporary relief and is particularly useful with advanced arthritic changes. If conservative treatments fail, the most common operative treatment is an MTP joint arthrotomy with removal of loose bodies and osteophytes. The metatarsal head can be drilled or bone grafted to treat the collapsed metatarsal head. Metatarsal head resection is usually avoided as it increases the weight-bearing load on the adjacent metatarsal heads.

Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).

References

  1. Sheth U. Freiberg’s disease. https://www.orthobullets.com/foot-and-ankle/7018/freibergs-disease. Accessed on 11/7/2017.
  2. Vosseler J. Freiberg’s disease. http://www.aofas.org/PRC/conditions/Pages/Conditions/Freibergs-Disease.aspx. Accessed on 11/7/2017. 
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