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Severe Foot Pain in a Runner

Severe Foot Pain in a Runner

Patient Profile:
A 36-year-old man complains of right foot pain of several months' duration that limits his ability
to run. He has been able to keep running by icing the foot and by stopping his running program
for a few days when the pain increases.

The pain is worst when he arises in the morning—especially when he first puts his foot on
the floor. The pain diminishes with continued ambulation and recurs with exercise. When he
runs, pain occurs when the heel strikes the ground and increases when he pushes off. He experiences no numbness or tingling.

This morning he had severe foot pain 4 miles into his usual 7-mile run, in the middle of a
significant hill climb. He was unable to complete the run and walked home with a limp.

The patient is in good health and has been running for about 10 years. He had a stress fracture in the calcaneus of the same foot 8 years earlier. Examination reveals tenderness on the plantar surface of the heel over the medial tubercle of the calcaneus (Figure 1). The pain is aggravated by dorsiflexion of the great toe and standing on the tips of the toes. The left foot is normal. The feet are
not pronated; in fact, the arches are high (pes cavus) (Figure 2). Tightness and weakness are noted in the gastrocnemius and soleus muscles. Neurologic examination reveals no sensory or motor deficit.

WHAT WOULD YOU DO NOW?A. Obtain a radiograph of the foot.
B. Order a complete blood cell (CBC) count and
uric acid level.
C. Order nerve conduction studies.
D. Start treatment; the diagnosis is evident.

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