Download diagnosis of medial foot pain in a 20

DIAGNOSIS OF MEDIAL FOOT PAIN IN A 20-YEAR OLD FEMALE COLLEGE
BASKETBALL PLAYER: A CASE STUDY
Guyer, MS, Rochbert, O,: Springfield College, Springfield, Massachusetts
A 20-year old female basketball player came into the athletic training room complaining
of point tenderness over the medial aspect of her right foot. The athlete denied any acute
mechanism of injury. Inspection revealed mild swelling and erythema over the navicular.
Palpation revealed point tenderness over the posterior tibial tendon from point of
insertion to four centimeters proximal. Further investigation of the athletes’ foot reveled
excessive pronation and pes planus. Passive, active and resistive ankle ranges of motion
were full, strong and painless. The resulting clinical impressions were; posterior tibial
tendonitis, flexor hallucis longus tendonitis or a navicular stress fracture. The athlete was
referred to an orthopedic specialist for further evaluation and diagnostic testing.
Radiographs were negative and the patient was diagnosed with posterior tibialis
tendonitis. The patient was prescribed, rehabilitation and non-steroidal anti-inflammatory
medications and was told to participate as tolerable. The athletes’ pain increased and she
returned to the specialist who reevaluated and diagnosed flexor hallucis longus tendonitis
and placed her into a fracture boot for a period of four weeks. With the pain not
resolving, an MRI was ordered and fluid was evident over the posterior tibialis tendon.
The athlete continued wearing the fracture boot for two more weeks. The athlete
attempted to return to a slow progression of activity to which she did not respond well
and the pain immediately intensified. She was referred to a foot and ankle specialist for
further evaluation. Orthotics were prescribed with an additional midtarsal control to shift
the tarsus laterally and rehabilitation was continued. After two months of rest and
rehabilitation the treating physician released the athlete to return to light activity. Within
two days of attempting to start a run/walk program the athlete complained of increasing
pain. The physician ordered a CT scan, which reveled an accessory navicular bone.
Surgery was scheduled immediately and the accessory navicular bone was successfully
removed and the fibers of the posterior tibialis tendon, which were attached to the
accessory navicular, were surgically reattached to the remaining normal navicular. The
athlete is currently performing rehabilitation, which consists of passive range of motion,
non-weight bearing plantar and dorsiflexion, toe flexion exercises and pool walking. The
athlete will continue rehabilitation and hopes to return to basketball asymptomatically
three months post-operative. Final diagnosis and surgical intervention took place
approximately one year after the initial evaluation. Radiographs and MRIs did not
provide adequate results to assist with the diagnosis of this injury. Accessory navicular
bones are fairly uncommon and are present in approximately 2-12% of the population. A
CT scan should be the diagnostic test of choice when assessing for a possible accessory
navicular. Posterior tibial tendonitis is uncommon in a young healthy athlete and further
investigation regarding other possible causes of the chronic pain over the navicular bone
should have been considered in a timelier manner.