Author: Eugene Palatulan, MD
Co Author #1: Dr. Kristina Quirolgico, MD Hospital for Special Surgery
Senior Editor: Mandeep Ghuman, MD, FAMSSM
Editor: Bernadette Pendergraph, MD

Patient Presentation:
49-year-old healthy female runner with prior history of right foot bunionectomy presented with chronic right foot pain, which developed one year after bunionectomy.

History:
She described the pain as waxing and waning in both plantar and dorsal aspects, localizing to the second metatarsal and metatarsophalangeal joints. She had two corticosteroid injections from a podiatrist separated by a few months, which did not alleviate her pain or improve function. An x-ray of her right foot in 2011 showed an osteochondral abnormality in the second metatarsal head with mild flattening. She saw a sports medicine physician in 2018 and was advised six to eight weeks of no physical activity. She went against the advice and tried stiff soled shoes and continued to run, which exacerbated her pain to the point that it occured at rest and at night. At baseline, she was active and had done heavy training for 4 half marathons in the past 8 years. She had no known significant past medical history except for the right foot bunionectomy.

Physical Exam:
Observation: She had normal arches without the presence of bunions or hammertoes.

Range of motion: Her right 1st metatarsophalangeal joint dorsiflexion was 45 degrees while the left 1st metatarsophalangeal joint dorsiflexion was 90 degrees. Right ankle passive dorsiflexion with knee extended 0 degrees is 0 degrees while passive dorsiflexion on the left ankle is 10 degrees.

Palpation: She had tenderness of the right 2nd metatarsophalangeal joint, metatarsal head, and metatarsal shaft. She had no tenderness in the right 1st metatarsophalangeal joint, 1st metatarsal, medial or lateral malleoli, navicular, cuboid, 3rd through 5th metatarsals, webspaces, and sesamoids.

Strength and sensation were intact.

Special tests: She had pain with metatarsal squeeze. She had a negative talar tilt, anterior drawer, and Mulder's click. She was unable to do a single or double leg hop due to pain in the plantar aspect of her right foot.

Gait: She had a non-antalgic gait with appropriate base of support, normal cadence and step length.

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