Betty Bartholomew: A 32-Year-Old Pharmacist With Persistent Foot Pain

Learning Objectives

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Learn the common causes of foot pain.
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Develop an understanding of the unique vascular anatomy of the sesamoid.
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Develop an understanding of the causes of sesamoiditis.
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Learn the clinical presentation of sesamoiditis.
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Learn how to use physical examination to identify pathology of the sesamoid.
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Develop an understanding of the treatment options for sesamoiditis.
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Learn the appropriate testing options to help diagnose sesamoiditis.
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Learn to identify red flags in patients who present with foot pain.
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Develop an understanding of the role in interventional pain management in the treatment of sesamoiditis.

Betty Bartholomew

I entered the treatment room and sat down in front of my last patient and introduced myself. The young lady sitting in front of me looked familiar. As I was trying to remember where I had seen her, she must have noticed my perplexed look and stuck out her hand, saying, “My name is Betty Bartholomew. I work at the CVS Pharmacy on Main Street.” I asked her, “So what brings you here today, Ms. Bartholomew?” She reported, “There is something seriously wrong with my right foot. I feel like I am standing on a stone. I looked it up on the Internet and it says I have a Morton neuroma, but I thought I better come in and get it checked out. My foot has been getting more painful in spite of everything I have tried: new shoes, a gelfoam mat to stand on, a Medrol Dosepak, Epsom salt soaks. Nothing seems to work. My friend, Kathy Brown, one of the other pharmacists, recommended you. She said you fixed her knee up after she feel on the ice getting out of the car last winter.” I smiled and told her I was glad to hear that Kathy was doing well. Betty also noted that sometimes she used a heating pad, but she fell asleep with it on and accidently burned herself, so she was being really careful now to not use it as much.

I asked Betty if she had ever injured her foot before. She thought for a moment, then said, “No, I broke a finger when I slammed it in the car door about 10 years ago, but nothing with my feet. But, you know, foot pain is an occupational hazard for pharmacists. I stand all day long.” Betty then volunteered that the only medication she is on is birth control pills.

I asked Betty to point with one finger to show me where it hurt the most. She pointed to the area at the head of the first metatarsal. “It feels like I’m stepping on a rock or something, and it really gets my attention whenever I stand for too long.”

On physical examination, Betty was afebrile. Her respirations were 16. Her pulse was 68 and regular. Her blood pressure was normal at 112/76. Her head, eyes, ears, nose, throat (HEENT) exam was normal, as was her thyroid examination. Her cardiopulmonary examination was also normal, as was her abdominal examination, which revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. Visual inspection of the radial aspect of the right foot revealed no cutaneous lesions or evidence of infection. There was no obvious bony deformity that would suggest a previous fracture. Nor were there any fibromas or plantar warts, but there was callus formation over the head of the first metatarsal ( Fig. 14.1 ). The area overlying the head of the first metatarsal on the right was exquisitely tender to palpation. I had Betty flex and extend her big toe, and the tender area moved with the flexor tendon. Mulder sign was negative. The area was cool to touch. The left foot examination was normal, as was examination of her other major joints. A careful neurologic examination of the upper and lower extremities revealed no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not

The History

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History of increasing right foot pain with the sensation of standing on a stone
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An increase in pain with weight bearing
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An increase in pain with prolonged standing
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No history of previous trauma to the right foot
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No fever or chills

The Physical Examination

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Patient is afebrile
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Callus formation over the head of the first metatarsal on the right
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Palpation of area overlying the head of the first metatarsal on the right elicits sharp pain
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The painful area moves with the flexor tendon, which is highly suggestive of sesamoiditis
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Mulder sign is negative

Other Findings of Note

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Normal blood pressure
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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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No CVA tenderness
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Normal upper extremity neurologic examination, motor and sensory examination

What Tests Would You Like to Order?

The following tests were ordered:

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Plain radiograph of the right foot with special attention to the metatarsal heads
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Computed tomography (CT) scan of the right foot with special attention to the sesamoid bones