Avulsion fractures of the peroneus longus tendon are seldom seen and potentially can go undiagnosed during an emergency visit. If not managed appropriately, it can lead to chronic pain and suffering. This case report presents a 55-year-old postman who was seen in the clinic complaining of persistent pain over the instep of his right foot with no history of trauma. His pain was localized to the first metatarsophalangeal joint with some radiation to the heel. Magnetic resonance imaging revealed an isolated avulsion fracture of the first metatarsal, which was initially missed on X-ray. In this case, the patient was successfully treated with a mixture of steroid and local anesthetic injections. Following our intervention, the Manchester Oxford Foot Questionnaire was reduced from 33 to 0. The goal of this article is to raise awareness of this rare finding for doctors who may face this in accident and emergency (A&E), Orthopedic clinics or at a general practice (GP) practice.
An isolated avulsion fracture of the peroneus longus tendon is seldom seen and potentially can go undiagnosed using basic imaging methods during an initial emergency visit. If not managed appropriately it can lead to chronic pain, a reduced range of motions and eventually affect mobility. This article brings to light the effectiveness of managing such injuries conservatively.A 55 year old postman presented to clinic with pain over the instep of his right foot for 2 months with no history of trauma. Clinically the pain was confined to the right first metatarsophalangeal joint with occasional radiation to the calf. X-ray films did not detect any obvious bony injury. MR imaging revealed an ununited avulsion fracture of the base of the 1st metatarsal. The patient was subsequently injected with a mix of steroid and local anesthetic injections at the painful nonunion site under fluoroscopic guidance.Post procedure there was no neurovascular deficit. The patient was reviewed at three months and his pain score and functional outcome improved significantly. Moreover following our intervention, the Manchester Oxford Foot Questionnaire reduced from 33 to 0. At the one year follow up he remained asymptomatic and was discharged.The peroneus longus tendon plays a role in eversion and planter flexion of foot along with providing stabilization to arches of foot. The pattern of injury to this tendon is based on two factors one is the mechanism of insult, if injured, and second is the variation in the insertion pattern of peroneus longus tendon itself.There is no gold standard treatments by which these injuries can be managed. If conservative management fails we must also consider surgery which involves percutaneous fixation, or excision of the non-healed fracture fragment and arthrodesisTo conclude isolated avulsion fractures of peroneus longus tendon are rare injuries and it is important to raise awareness of this injury and the diagnostic and management challenges faced. In this case conservative management was a success in treating this injury however it is important to take factors such as patient selection, patient autonomy and clinical judgement into account before making the final decision.
Every year, as many as 2 million patients worldwide present with plantar heel pain, with men and women being affected equally. This case reports reflects upon a healthy 46-year-old female who presented with a subtype of true neoplasm called as neural fibrolipoma arising from the plantar nerve. This 17 × 7 × 11-mm painful soft tissue mass was firstly detected by USS, which showed this mass extended deep to the plantar fascia and not arising from it, hence ruling out the common misconception of plantar fibromatosis. Later, as discussed in the Yorkshire Sarcoma MDT with magnetic resonance imaging images, a malignancy was ruled out. The patient eventually opted for an excision biopsy which confirmed the neural fibrolipoma followed by an excellent outcome at a 2-year review. This case report highlights the need to consider the neural fibroplipoma as a rare case of plantar/heel pain, and excision of the lesion would provide an excellent outcome.
A 64-year-old lady with a background of rheumatoid arthritis presented to the foot and ankle clinic with lump underneath the sole of her foot causing significant discomfort. Examination revealed she had a swelling of the first and the second metatarsophalangeal joints. Magnetic resonance imaging revealed abnormal soft tissue thickening between the second and the third metatarsal and a single large encapsulating indeterminate soft tissue mass with a peripheral inflammatory rim. The appearance was suggestive of a malignant sarcoma rather than a rheumatoid nodule or rheumatoid tenosynovitis. The patient was referred to the regional sarcoma unit where the scans were reviewed, and a sarcoma was ruled out. The patient then underwent excision of the indeterminate soft tissue mass. Histology revealed granulomatous infiltration suggestive of a rheumatoid nodule. This has not been described previously in the literature.
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