How to manage a patient with an accessory bone near the cuboid bone, presenting with a hard, solid red lump that has decreased in size and redness after antibiotic treatment, but still experiences ongoing pain?

From the Guidelines

For a patient with a painful accessory bone at the lateral border of the foot near the cuboid, I recommend a conservative management approach initially. This approach is based on the most recent evidence from the IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections 1. The patient's symptoms of a solid red lump that feels hard and was larger and redder until treated with antibiotics, suggest that the pain is likely due to inflammation of surrounding tissues rather than infection. The x-ray showing the protuberance to be an accessory bone with ossification further supports this diagnosis. The following steps should be taken:

• Start with rest, ice application for 15-20 minutes several times daily, and elevation of the foot when possible.
• Prescribe an NSAID such as naproxen 500mg twice daily or ibuprofen 600mg three times daily with food for 7-10 days to reduce inflammation and pain.
• Custom orthotic inserts or padding to offload pressure on the accessory bone can provide significant relief.
• A short period of immobilization with a walking boot for 2-3 weeks may be beneficial if pain is severe.
• Physical therapy focusing on foot and ankle strengthening exercises should be initiated once acute pain subsides.
• If conservative measures fail after 4-6 weeks, consider a corticosteroid injection (such as methylprednisolone 40mg with 1-2ml of 1% lidocaine) around but not into the accessory bone.
• Surgical excision of the accessory bone should only be considered if all conservative measures fail after 3-6 months of consistent treatment, as suggested by the IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes 1. It is essential to prioritize a conservative approach to manage the patient's pain and inflammation, given the potential risks and complications associated with surgical interventions, as highlighted in the 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections 1. Additionally, the assessment and management of diabetes-related foot infection according to the new international working group on the diabetic foot guidelines 2023-multidisciplinary grand rounds 1 support the use of a conservative approach in the initial management of accessory bone-related pain.

From the Research

Management of Ongoing Pain

Given the patient's ongoing pain, the following management options can be considered:

• The use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) can be effective in managing pain and inflammation, as they inhibit the cyclooxygenase enzymes and induce no change in mood and dependency 2.
• A guide to pain assessment and management in adults suggests that pain is universally experienced and extremely complex, involving the mind as well as the body, and that nurses require skills to assess and manage an individual patient's pain 3.
• NSAID injections may be safe and effective alternatives to steroid injections, especially in shoulder impingement syndrome and knee osteoarthritis, with no significant difference in pain visual analogue scale (VAS) between subacromial NSAID injections and corticosteroid injections at 1 month 4.

Considerations for NSAID Use

When considering the use of NSAIDs, the following should be taken into account:

• NSAIDs are a valuable class of medications for orthopedic surgeons and often play a pivotal role in pain control, but there are many common stipulations resulting in avoidance of its use in the treatment of musculoskeletal disease 5.
• Reflective practice is a mindful approach to practice that grounds clinicians in the moment with the individual patient to ask questions and then to listen to the patient's message about their pain experience, and can help provide patient-centered pain management 6.
• The osseous effects of NSAIDs with regard to bone healing and heterotopic ossification should be considered, as well as the differences between commonly used NSAIDs 5.

Next Steps

Based on the patient's presentation and the evidence available, the next steps in management could include:

• Further assessment of the patient's pain and inflammation to determine the best course of treatment.
• Consideration of NSAID use, either orally or via injection, to manage pain and inflammation.
• Monitoring of the patient's response to treatment and adjustment of the management plan as needed.