Review Question - QID 109541

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Lower Extremity Nerve Entrapments QID: 109541 (M2.OR.17.4867)

QID 109541 (Type "109541" in App Search)

A 27-year-old woman presents to her primary care physician for foot pain. The patient states that she has pain in her foot and toes whenever she exerts herself or is at work. The patient is an executive at a medical device company and works 60 hours/week. She is currently training for a marathon. She has a past medical history of anxiety, constipation, and irritable bowel syndrome. Her current medications include clonazepam, sodium docusate, and hyoscyamine. Her temperature is 99.5°F (37.5°C), blood pressure is 100/60 mmHg, pulse is 50/min, respirations are 10/min, and oxygen saturation is 99% on room air. Cardiac and pulmonary exams are within normal limits. Examination of the lower extremity reveals 5/5 strength with 2+ reflexes. Palpation of the interdigital space between the third and fourth toes elicits pain and a clicking sound. Which of the following is the most likely diagnosis?

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Inflammation and damage to the plantar fascia

3/55

Compression of the tibial nerve

1/55

Intermetatarsal plantar nerve neuroma

87%

48/55

Damage to the trabeculae of the calcaneus

2/55

Anterior talofibular ligament strain

1/55

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This patient is presenting with pain upon palpation of the space between her third and fourth toes with an audible click upon palpation suggesting a diagnosis of an intermetatarsal plantar nerve neuroma (Morton's neuroma).

Morton's neuroma presents with pain that typically occurs between the third and fourth digits of the foot. Pain and a clicking sensation/sound can be elicited with palpation of this area. Morton's neuroma classically occurs in individuals who wear improperly fitted footwear, in particular heels and cowboy boots. Treatment is rest, proper footwear, and surgical excision in severe/refractory cases.

Incorrect Answers:
Answer 1: Inflammation and damage to the plantar fascia describes plantar fasciitis which presents with pain along the plantar surface of the foot that is worsened with activity/exercise.

Answer 2: Compression of the tibial nerve describes tarsal tunnel syndrome which presents with numbness/tingling along the plantar surface of the foot that can be exacerbated with tapping of the tarsal tunnel.

Answer 4: Damage to the trabeculae of the calcaneus suggests a stress fracture of the calcaneus. This presents with pain over the heel that is associated with overuse.

Answer 5: Anterior talofibular ligament strain suggests a diagnosis of a twisted ankle and presents with erythema, edema, and pain with inversion of the foot.

Bullet Summary:
Morton's neuroma presents with numbness/pain between the third and fourth toes, and a clicking sensation/pain may be found on physical exam when palpating this area.

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