Foot Pain in a Cross Country Runner Nicole Huntress M.D. Primary Care Sports Medicine Fellow Steadman Hawkins Clinic of the Carolinas SEACSM Conference.

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?