What is the appropriate workup for a 13-year-old with a sore foot pad after a stomping injury, given that the x‑ray shows no bony lucency, cortical buckling, or dislocation?

Workup for 13-Year-Old with Sore Foot Pad After Stomping Injury

Given the negative initial radiographs, the next step is to obtain an MRI of the foot without IV contrast to evaluate for occult fracture, bone marrow edema, or soft tissue injury such as plantar plate tear. 1

Rationale for Advanced Imaging

The ACR Appropriateness Criteria (2020) explicitly states that CT or MRI of the foot without IV contrast is usually appropriate for the next imaging study when radiographs are normal or equivocal in a child older than 5 years with acute trauma and suspected occult fracture, tendon injury, or Lisfranc injury 1. In your case, the mechanism (stomping injury) and persistent pain despite negative radiographs warrant further investigation.

Why MRI Over Other Modalities

• MRI is superior for detecting bone marrow edema, which is a common finding in pediatric foot trauma with persistent pain despite normal radiographs. A recent case report (2026) demonstrated an 11-year-old with persistent foot pain after trauma where plain radiographs were normal, but MRI revealed bone marrow edema 2

• Ultrasound has limitations in the foot: While ultrasound can detect occult fractures in children with 92.9% sensitivity 3, studies show it is inferior to X-ray in the lower limb 3. However, ultrasound excels at evaluating plantar plate injuries (96% sensitivity) 1 and can be considered if soft tissue injury is the primary concern

• CT is less useful here: CT is reserved for high-energy polytrauma or when evaluating complex fractures like Lisfranc injuries where bony architecture needs detailed assessment 1

Clinical Considerations

Specific Pathologies to Consider in This Age Group

Given the "foot pad" location and stomping mechanism, consider:

• Plantar plate injury: The forefoot pad area suggests possible lesser toe plantar plate tear, which MRI or ultrasound can detect 1
• Bone marrow edema/contusion: Common in pediatric trauma with persistent pain beyond 1-2 weeks 2
• Occult metatarsal or sesamoid fracture: Not visible on initial radiographs but detectable on MRI 4
• Sesamoiditis or other overuse injuries: Relevant in this age group 5

Timing Considerations

If pain persists beyond 2 weeks despite conservative management, proceed with MRI 2. The case report showed that persistent pain and gait impairment after trauma warrants high clinical suspicion, with MRI being the preferred confirmatory modality 2.

Common Pitfalls to Avoid

• Don't dismiss normal radiographs: Up to 52% of occult fractures in children show no bone abnormalities on initial radiographs (13 of 25 cases in one series) 4
• Don't delay imaging if symptoms persist: Bone marrow edema and occult fractures require early diagnosis to guide appropriate non-weight-bearing protocols 2
• Consider ultrasound as adjunct, not replacement: While ultrasound can identify cortical discontinuity in 92% of occult fractures 4, it should complement rather than replace MRI in the foot when radiographs are negative

Management Algorithm

1. Initial management: Conservative care with rest, ice, elevation, and protected weight-bearing
2. If pain persists >1-2 weeks: Order MRI foot without IV contrast 1
3. If MRI shows bone marrow edema: Non-weight-bearing for 4-6 months with physical therapy 2
4. If MRI shows occult fracture: Immobilization and orthopedic follow-up
5. If MRI shows plantar plate tear: Consider ultrasound for dynamic assessment and guided treatment 1