A 13-year-old female athlete presented to the office with left foot pain of 2 weeks duration. The pain had started gradually as she transitioned directly into basketball following her soccer season, moving from soccer cleats to basketball shoes. She participated at a high level for both sports for her age. She had no history of similar pain, but had sprained her ankle 1 month ago. She had no recent dietary changes, and there were not any concerns about her diet from her parents. The pain was located in the arch and described as tingling, worse at night, and after practice, but improved in the morning. She tried putting inserts in her shoes without relief. On exam, she was well nourished and in no acute distress. She had no visible swelling, and the alignment of her ankle, knees, and hips appeared normal. She had good arches of her feet that were symmetric bilaterally, and her gait revealed no abnormalities. Range of motion of the foot and ankle were normal. She had tenderness over the proximal second and third metatarsals on both the dorsal and plantar surfaces. She also had tenderness over the dorsal and plantar surfaces of the cuneiforms, including the arch of the foot. X-rays were obtained in the office and were negative. Due to concern for a stress injury, a magnetic resonance imaging (MRI) was obtained. The MRI showed a stress fracture involving the distal and plantar aspect of the middle cuneiform, with a stress phenomenon noted at the base of the second and third metatarsals. Figures 1 and 2 show this finding.
She was placed in a boot for all weight-bearing activities. At 4 weeks, she was only having occasional pain. The decision was made to continue the boot for 2 more weeks. At follow-up, 2 weeks later (6 weeks total), the patient was still having pain. She admitted to participating in impact activity outside the boot at the gym since her last appointment. After discussion with the patient and her father, she was made partial weight-bearing in the boot with crutches with instructions to wean off the crutches once pain free. At a recheck 2 weeks later (8 weeks total), she was pain free walking in the boot without the crutches. She was weaned out of the boot over the next 2 weeks (10 weeks total) and then began a gradual return to impact activity without set back.