1055 - A Teacher’s Forefoot Pain

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

NG

Nadejda Godoroja, BS

Medical Student
California Northstate University College of Medicine
Sacramento, California, United States

Co-Author(s)

CN

Camille Ng, BS

Medical Student
California Northstate College of Medicine
Elk Grove, California, United States
RR

Raenier Reyes, BS

Assistant Specialist
University of California, Davis
Sacramento, California, United States

Co-Author(s)

AM

Anton Matveev, MD, MBS, RMSK

attending physician
Center for Sports and Regenerative Orthopedics
Alexandria, Virginia, United States

Case Diagnosis: Tarsal Tunnel Syndrome

Case Description: A 46-year-old woman presented with right plantar forefoot pain for 6 months. The pain was burning, achy, and rated 8/10. There were associated paresthesias in the plantar forefoot, and intermittent radiation to the medial calf and knee. Examination revealed mild pes planus with normal range of motion of the ankle, forefoot and toes. There was poorly-localized forefoot tenderness in the region of the plantar 2nd-3rd distal metatarsals and metatarsophalangeal (MTP) joints. There was 4/5 weakness with resisted ankle inversion and a positive Tinel sign at the tarsal tunnel. Gait was mildly antalgic. Diagnostic ultrasound of the 2nd-3rd metatarsals, phalanges, MTP joints, intermetatarsal region was unremarkable. Medial ankle ultrasound revealed a 1.5 x 0.75 cm ganglion cyst, arising from the flexor hallucis tendon (FHL) sheath, with compression of the tibial nerve at the tarsal tunnel. Ganglion cyst aspiration with prolotherapy targeting the FHL tendon sheath was performed.

Discussions: Tarsal tunnel syndrome (TTS) presentation is varied and should be considered in a patient with poorly localized plantar forefoot pain. Thus, ultrasound examination for forefoot pain should include the medial ankle neurovascular bundle. We propose the underlying etiology for our patient presentation was likely tibialis posterior (TP) weakness which led to overuse tendinosis of the flexor hallucis as a compensation, leading to ganglion cyst formation and subsequent compressive neuropathy. Therefore, focused strengthening exercises targeting the tibialis posterior and foot intrinsic musculature were prescribed for this patient for long-term management.

Conclusions: Plantar forefoot pain has a broad differential diagnosis, one of which is tarsal tunnel syndrome. Extension of ultrasound examination of the medial ankle was key in confirming the diagnosis and providing an appropriate treatment plan in this patient.