Sarah Davidow: A 64-Year-Old Homemaker With Foot Pain

Learning Objectives

  • Learn the common causes of foot pain.

  • Develop an understanding of the unique anatomy of the digital nerves.

  • Develop an understanding of the causes of Morton neuroma.

  • Develop an understanding of the differential diagnosis of Morton neuroma.

  • Learn the clinical presentation of Morton neuroma.

  • Learn how to examine the foot.

  • Learn how to use physical examination to identify Morton neuroma.

  • Develop an understanding of the treatment options for Morton neuroma.

Sarah Davidow

Sarah Davidow is a 64-year-old homemaker with the chief complaint of, “I feel like I’m walking on a stone.” Sarah stated that over the past several months, her right foot started “hurting when I walked. I kept taking my shoe off and dumping it out because I thought something was in it, but nothing was there.” She went on to say, “This is so embarrassing. My husband, Artie, says it’s all in my head.” I asked Sarah if she had ever had anything like this before, and she said, “Absolutely not. I have beautiful feet, and they have never bothered me. I get a pedicure every couple of weeks, and lately it hurts when the gal pushes the pressure points on the bottom of my feet.”

I asked Sarah what made her foot pain worse, and she said that whenever she put any weight on her right foot, she felt the stone. It was really bad when she stood on the tile floor of her kitchen for any length of time. “Doctor, I used to take Lucky, that’s my Yorkie, on long walks, but I just can’t do it anymore. Lucky and I are both putting on weight! Doctor, you don’t think this is cancer or something bad, do you? It just won’t get better!”

I asked her what made the pain better, and she said Advil seemed to help a little but not with the “stone in the shoe” sensation. Advil, however, upset her stomach. She noted that the heating pad felt good, but she thought it made her foot swell. “I also tried using an Ace wrap, but I felt like it was cutting off my circulation.” I asked Sarah about any antecedent foot trauma, and she could not recall anything.

I asked Sarah to point with one finger to show me where it hurt the most. She pointed to the ball of her foot and said, “Right here.” I told her that I had a pretty good idea what was going on, and we would do all we could to get it fixed.

On physical examination, Sarah was afebrile. Her respirations were 16, and her pulse was 74 and regular. Her blood pressure was 126/76. Sarah’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was her cardiopulmonary examination. Her thyroid was normal. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination revealed some tenderness to deep palpation of the paraspinous musculature. Visual inspection of the right foot revealed no bony abnormality or evidence of a plantar wart. The Tinel sign over the deep peroneal nerve was negative bilaterally, and Sarah had no numbness between the web of her great and second toes, decreasing the probability of anterior tarsal tunnel syndrome. The Mulder sign was positive on the right, as was the digital nerve stretch test. Both were negative on the left ( Figs. 11.1 and 11.2 ). Range of motion of the foot joint, especially resisted extension and passive flexion of the foot joint, caused Sarah to cry out in pain. The left foot examination was normal, as was examination of her 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.

Fig. 11.1

Eliciting Mulder sign for Morton neuroma. Mulder sign is elicited by firmly squeezing the metatarsal heads together with one hand while placing firm pressure on the interdigital space with the other.

From Waldman SD. Physical Diagnosis of Pain: An Atlas of Signs and Symptoms . Philadelphia: Saunders; 2006:381.

Fig. 11.2

To perform the digital nerve stretch test for Morton neuroma, the patient is placed in the supine position. The patient is then asked to bring both ankles into full dorsiflexion. The examiner then fully extends the toes on each side of the webspace suspected of harboring the Morton neuroma. The test is positive if this maneuver reproduces the patient’s symptoms.

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

The History

  • Gradual onset of pain in the ball of the patient’s foot

  • Patient complaint that it felt like walking on a stone

  • Pain made worse with weight bearing and walking

  • No other specific traumatic event to the area identified

  • No fever or chills

The Physical Examination

  • Patient is afebrile

  • Pain with palpation of the plantar interdigital space

  • Positive Mulder sign

  • Positive digital nerve stretch test

  • No evidence of infection

Oher Findings of Note

  • Normal HEENT examination

  • Normal cardiovascular examination

  • Normal pulmonary examination

  • Normal abdominal examination

  • No tenderness to deep palpation of the lumbar paraspinous muscles

  • No peripheral edema

  • Normal upper and lower extremity neurologic examination, motor and sensory examination

  • Examination of joints other than the right foot was normal

What Tests Would You Like to Order?

The following tests were ordered:

  • Ultrasound of the left foot

Test Results

Ultrasound examination of the left foot revealed a large Morton neuroma between the second and third metatarsals ( Fig. 11.3 ).

Nov 19, 2022 | Posted by in PAIN MEDICINE | Comments Off on Sarah Davidow: A 64-Year-Old Homemaker With Foot Pain

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