One foot forward, two steps back [Meeting Abstract]
Learning Objectives: Radiologist interpretations contribute to anchoring bias. Differentiating problems with similar presentations requires thorough exams and detailed patient histories. Correct management often requires a patient-centered approach. Case Information: A 48 year old woman developed a limp from pain in the ball of the right foot while training for her fifth half marathon. A radiologist diagnosed Freiberg's Disease Stage 2, a rare avascular necrosis of the metatarsal head, based on an x-ray ordered by her podiatrist. X-ray findings include flattening of the metatarsal head, which is a normal variant in 10% of people. The podiatrist prescribed a fracture boot. The patient consulted an orthopedist who changed management to a metatarsal pad for her insole after reviewing the x-ray without an alternative diagnosis. Doubting her diagnosis, the patient consulted a physiatrist who confirmed Freiberg's Disease. After 6 weeks of pain, her orthopedist ordered an MRI that ruled out Freiberg's and showed a partial plantar plate tear with significant localized bursitis. She was taught to tape her toe, but pain persisted with the metatarsal pad. A new podiatrist noticed that the metatarsal pad was creating gait problems and he altered her running shoe insole instead. After two weeks, she was running again.
Discussion(s): Metatarsalgia has many causes, yet three doctors anchored their diagnosis on an incorrect radiology report. Listening to the nuances of the patient's story and performing an extensive exam may have expedited the correct diagnosis. Many doctors use metatarsal pads, but this management may cause harm in some patients. (Figure Presented)