1. Foot Pain in a Cross Country Runner Nicole Huntress M.D. Primary Care Sports Medicine Fellow Steadman Hawkins Clinic of the Carolinas SEACSM Conference February 10, 2012

2. HPI  13yo female c bilateral foot pain >1 year  Worst on inside of L foot  Activity related  No systemic symptoms

3. PE  Inspection: nl arches, prominent L navicular, no swelling/ecchymosis/erythema  TTP L posterior tibialis tendon and navicular  FROM, ankle stable  Strength: resisted inversion painful on L, weak core c single leg stance, squat, hip adduction  Flexibility: bilateral tight heel cords and hamstrings, R hip flexors and quadriceps  Negative tinels

4. X-RAYS  Weight bearing bilateral AP, lateral, oblique views  Accessory navicular on L, open physes, no fracture or other bony abnormality

6. Differential Diagnosis  Symptomatic accessory navicular  Stress fracture/reaction  Tendinopathy  Other neurologic etiology

7. Initial Treatment  Orthotic shoe insert  Physical Therapy  Activity as tolerated, ice afterward

8. Follow-up  Initial improvement  Worsened with cross country onset  MRI of L foot  extensive patchy marrow edema of tarsal bones, accessory navicular

10. Follow-up  No interval change  Short walking boot L  Labs  Normal: CBC, CMP, Mg, Phos, ESR, CRP, Ferritin, Iron, TIBC, Reticulocyte, TSH  Vitamin D low at 29.8  Dexa Scan  lower limits of normal, 0.841 to 0.957gm/cm3, z-score -0.6 to -0.9  Nutritionist referral  MRI R foot  Numerous foci of increased marrow signal of hindfoot and midfoot, no accessory navicular

12. Conclusions  13yo female cross country runner with painful Bone Marrow Edema Syndrome  short L cast and R boot  Now wearing custom orthotics  Ongoing bilateral mid-foot pain  Endocrine consult pending

13. Thank you QUESTIONS?

14. A ‘normal’ finding? Shabshin, Schweitzer, Morrison, Carrino, Keller, Grissom. High Signal T2 changes of bone marrow of the foot and ankle in children: red marrow or traumatic changes? Pediatric Radiology 2006.  402 bones in 41 pediatric (1-18yo) patients  BM changes on T2 MRI in 11% overall, 59% <16yo  Calcaneous 54%, talus 35%, navicular 35%  Most bilateral and most resolve by 15yo  Hematopoietic red marrow, physiologic stress, biomechanics?