A 15-year-old girl had a 4-year history of pain in the midarch region of both feet, which increased in severity during physical activity.
The pain improved when she wore a new pair of more rigid shoes, but once she wore the soles down to a comfortable position, the pain recurred, despite the orthoses.
On inspection, the girl was found to have good arches bilaterally, and the results of Jack’s test were normal: the arch increased and the hindfoot inverted on going on tiptoe.
The neutral calcaneal stance was normal and she had a subtle cavus foot, with progressive valgus tendencies of the hindfoot on Coleman block testing.
Her ankle had full range of movement, with tenderness along the medial aspect of her ankle joint.
There was clinical limitation in her midfoot, and midtarsal and subtalar motion seemed normal.
The movement of her first metatarsophalangeal joint was more than 60 degrees in dorsiflexion and 40 degrees in plantarflexion.
The plantar aponeurosis and Achilles tendon were found to be tight.
There was also, limited dorsiflexion of the first toe and ankle with the knee fully extended, compared with the knee flexed.
Initial plain radiographs identified a bar on the lateral film extending from the apex of the medial cuneiform to the navicular, without obvious altered navicular morphologic features.
MRIs were used to reveal bone marrow edema on the talus, evidence of abnormal loading and a severe stress reaction on the head and neck of the talus.
Conservative therapy was accordingly recommended, consisting of a combination of orthoses for the feet, changes in physical activities, analgesia and patient education; these treatment modalities enabled the girl to return to an active lifestyle.
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