A 16-year-old female age-group international player presents with an insidious onset of activity-related right foot pain. She was unable to hop without pain and had localised tenderness over her proximal second metatarsal. A provisional diagnosis of a stress response was made and she was referred for an x-ray and MRI of her midfoot.
An AP x-ray shows a small articulation between the bases of the right first and second metatarsals (which represents an anatomical variation). An MRI showed focal bone oedema around the articulation, consistent with impingement change or a stress response. There also some associated soft tissue oedema/bursitis. A subsequent CT scan further defines the large variant articulations but does not show any cortical irregularity, sclerosis or cystic change.
This player was managed with a period of partial weight bearing rest. She wore a supportive sports shoe and had a temporary orthotic created by a podiatrist. She was able to continue non- and partial weight-bearing activities. She remained quite symptomatic after eight weeks of treatment. As the pain was slow to settle she had a CT scan to ensure that there was no obvious fracture to explain the prolonged pain. The player’s pain eventually improved and she was able to return to football three months after her initial presentation.
There are a range of normal anatomical variants around the foot and ankle. This particular type of articulation can be seen in up to 25% of the population. In this patient they are prominent, large and associated with pronounced indentation and concavity of the medial second metatarsal base. Other ‘normal’ anatomical findings that can cause pain in the feet of a football player include an os naviculare, an os trigonum and an os peroneum. An acute ankle injury can disrupt the synchondrosis separating an os navicular from the body of the navicular (resulting in localised medial midfoot pain). An os trigonum can contribute to posterior impingement while an os peroneum can be a cause of lateral foot pain.
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