Ryan Fitzgerald, DPM PRESENT RI Associate Editor Hess Orthopedics & Sports Medicine, Harrisonburg, Virginia

HPI: The patient is a 57-y/o who presents with persistent pain in right midfoot following a fall approximately seven months ago. The patient was evaluated by a local orthopedist, who diagnosed a 2nd metatarsal fracture and elected to treat the patient conservatively with cast immobilization for a period of six weeks. The patient states that she has had persistent and increasing pain in her right midfoot following removal of the cast approximately five months ago. The patient states that her pain is worse with long periods of weight bearing, and resolves somewhat with non-weight bearing. The patient states that her most recent blood sugar was 150 mg/dl, but states that she doesn’t check her sugars regularly and does not remember having a recent HgBA1C level drawn. The patient denies any recent history of nausea, vomiting, fevers, chills, chest pain, shortness of breath, or calf pain.

PMH: Diabetes mellitus, HTN      PSH: Hysterectomy ’99, right wrist ORIF ‘02
Meds: Ibuprofen for pain, HCTZ, Glipizide     ALL: NKDA
Social: The patient relates to social consumption of alcohol, denies tobacco or drug usage.

Physical Exam: Upon physical exam, the patient demonstrates Pedal pulses are palpable and graded +2/4 bilaterally with CFT <3 seconds, with no varicosities noted. There is hair growth noted on the leg to the distal 1/3 of the tibia bilaterally. Upon palpation, the patient demonstrates significant tenderness along the midfoot region, with the point of maximum tenderness noted at the 1st tarsometatarsal articulation. Muscle strength is noted to be +5/5 in all muscle groups tested, and DTR’s are graded +2/4 at both the Achilles and patella tendons. ROM is noted to be within normal limits in both dorsiflexion, plantarflexion, inversion and eversion, although the patient does have pain across her right midfoot with motion of her foot, predominantly with pronation and supination. The patient demonstrates intact protective sensation to her feet, bilaterally, via 5.07 SWMF test, and demonstrates appropriate vibratory and proprioceptive sensation.

Radiographs: Click on the images below for a larger view.
Figure 1:  This image is the original radiograph obtained by the patient upon her initial presentation to her orthopedist following a fall.		Figure 2:  This radiograph was obtained upon her presentation to our foot and ankle clinic, approximately seven months following her initial injury.

Figure 3:  A lateral view of the right foot on the day of presentation to the foot and ankle clinic.

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