Chuck North: A 32-Year-Old Veteran With Pain in the Ball of His Foot

Learning Objectives

•

Learn the common causes of foot pain.
•

Develop an understanding of the anatomy of the metatarsals.
•

Develop an understanding of the causes of metatarsalgia.
•

Develop an understanding of the differential diagnosis of foot pain.
•

Learn the clinical presentation of metatarsalgia.
•

Learn how to use physical examination to identify metatarsalgia.
•

Develop an understanding of the treatment options for metatarsalgia.

Chuck North

Chuck North is a 32-year-old veteran with the chief complaint of, “The bottom of my foot hurts.” Chuck stated that over the last couple of months, he has been experiencing increasing pain on the ball of his right foot. He went on to say that it came on gradually since he began his cross-country trek that he started on Veterans Day last year. “Doc, I know I look like 10 miles of bad road, but the Army taught me how to take care of my feet, and I have been very careful about that. But I am barely making it 20 miles a day with this foot pain. A veterans group in Kansas City gave me some new shoes, and I thought that would help, but it really didn’t.”

Chuck noted that the pain got a little better when he got off his feet, but walking was making the pain much worse. He figured that if he took it a little easier that he would get better over time, but it just didn’t happen. Walking became a real problem, as did any weight bearing. He tried to elevate his feet at night, which provided only minimal relief. He used Extra-Strength Tylenol when he could get it, which he felt took the edge off. “Doctor, please help me. I need to complete this walk to honor my buddies who didn’t make it back.”

I asked Chuck if he had experienced any foot pain in the past, and he replied, “Never. Doc, like I said, even if I am between places to stay, I take good care of my feet. You know it’s not true that an army moves on its stomach. An army moves on its feet. You can do okay if you miss a few meals, but let me tell you, you are in trouble if your feet hurt! Ask any GI and they will tell you the same thing: Take care of your feet.”

I asked Chuck how he was sleeping, and he said, “Not worth a crap, Doc. I haven’t slept that well since I rotated out, but this foot hurts 24/7. Every time I roll over, the pain wakes me up. The biggest problem is that I can’t walk for more than a few minutes without the pain playing up. It really slows me down. Walking has become a real problem. I try to hitchhike, but that kind of defeats the purpose.”

I asked Chuck to show me where the pain was, and he pointed to the area over his right metatarsal heads. “Doc, this is right where the pain is. Most of the time I feel like I have something in my shoe, like a rock or something. I bet I empty my shoes 100 times a day. There is rarely anything to dump out.” I asked, “Does the pain radiate anywhere?” Chuck shook his head and said, “It’s just the ball of my right foot. It is sore all of the time. I must have broken it or something. In the Army, there was a thing called a march fracture, although it’s been a while since I marched. Does walking across country count?” I asked Chuck about any fever, chills, or other constitutional symptoms such as weight loss or night sweats, and he shook his head no. He denied any musculoskeletal, systemic symptoms, or bowel or bladder symptoms.

On physical examination, Chuck was afebrile. His respirations were 18, his pulse was 72 and regular, and his blood pressure was 124/76. Chuck’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was his thyroid exam. Auscultation of his carotids revealed no bruits, and the pulses in all four extremities were normal. He had a regular rhythm without ectopy. His cardiac exam was otherwise unremarkable. His abdominal examination revealed no abnormal mass or organomegaly. There was no peripheral edema. His low back examination was unremarkable. There was no costovertebral angle (CVA) tenderness. Visual inspection of his right foot revealed a callus over the metatarsal heads ( Fig. 15.1 ). Otherwise, the skin over his metatarsal heads was unremarkable. Specifically, there was no rubor or calor, and there was no evidence of ecchymosis or anything suggestive of plantar warts. Palpation of the metatarsal heads caused Chuck to cry out in pain. “Doc, you’re right on it! Please don’t push that hard! I have had about all the fun I want to with that, enough already!” A careful neurologic examination of both lower extremities was within normal limits, specifically there was no evidence of tarsal tunnel syndrome. I had Chuck wiggle his big toe on the right and the pain stayed localized, making the diagnosis of sesamoiditis less likely. Mulder sign was negative. Deep tendon reflexes were physiologic throughout.

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

The History

■

History of onset of severe pain in the ball of the foot after prolonged walking
■

Pain is localized to the metatarsal heads
■

Any activities that cause pressure of the metatarsal heads cause pain
■

Significant sleep disturbance
■

No fever or chills

The Physical Examination

■

Patient is afebrile
■

Marked tenderness to palpation of the metatarsal heads
■

Callus formation over the metatarsal heads on the right (see Fig. 15.1 )
■

Pain remains localized over the metatarsal heads when the patient flexes and extends toes
■

Palpation of the metatarsal heads did not reveal any obvious bony deformity or abnormal mass
■

No evidence of plantar warts ( Fig. 15.2 )

Fig. 15.2

Myrmecia (plantar) warts appear as rough, horny elevations on the plantar surface. They are caused by human papillomavirus type I.
■

Normal neurologic examination