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You are seeing a 15-year old girl with pain in her right foot. She is moderately overweight, and joined a running club 1 month ago to improve her fitness and lose weight. Over the past 1 ½ weeks she has slowly developed pain in the area of her 3rd metatarsal shaft. At first she only had it after running, but now she has it more often. Ibuprofen does reduce the pain, but it returns. She has had no fever, fatigue, or other symptoms, and has lost 5 pounds. (She is also modifying her diet.) She has been having normal menses and did not have any specific traumatic injury. On exam, she is tender over the area of pain but there is no swelling. Radiographs of the foot are read as normal.
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July 9, 2024 at 11:47 am
E) Discharge her in a hard sole orthopedic boot, with crutches, instructions to rest (no running), to take ibuprofen as needed for pain, and to follow up within 1-2 weeks
The patient is presenting with symptoms typical of a low-risk stress fracture. Stress fractures are overuse injuries, and commonly occur with an acute step-up in activity, particularly in someone with decreased fitness at the beginning. Other risk factors include: worn footwear, disordered eating, and female sex. Radiographic changes often lag by several weeks. MRI is the best imaging technique for definitive diagnosis. Common and low-risk for complications sites are: 2nd and 3rd metatarsal shafts, posteriomedial mid-tibia, fibula, femur, inferior and superior pubic rami. These can be managed conservatively (rest, NSAIDs, protection) with follow-up in 1-2 weeks. Other areas may be at high risk for non-union, and an orthopedic surgeon should be consulted.