Differential Diagnosis for Bilateral Foot Pain

The patient's presentation of bilateral foot pain, particularly in the metatarsal area, worsened by walking or bending the foot, and accompanied by a "ropy" or cord-like feeling, suggests several potential diagnoses. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Plantar Fasciitis: This condition is characterized by pain in the heel and bottom of the foot, often described as feeling like walking on pebbles. The "ropy" or cord-like sensation could be related to the inflamed plantar fascia. The patient's occupation as a dentist, which involves standing for long periods, and the absence of trauma, support this diagnosis. The fact that pain is aggravated by physical activity and weight-bearing also aligns with plantar fasciitis.

• Other Likely Diagnoses

  • Morton's Neuroma: This condition involves a thickening of the tissue around the nerves leading to the toes, causing pain, usually between the third and fourth toes, and can feel like standing on a pebble. The description of a "ropy" feeling could be interpreted as the sensation of the neuroma.
  • Metatarsalgia: General pain in the metatarsal area, which can be due to various factors including poor foot mechanics, overuse, or footwear issues. The patient's symptoms of pain in the metatarsal area when walking or bending the foot could fit this diagnosis.
  • Tendinitis or Ligament Sprain: Given the patient's frequent standing and potential for overuse, tendinitis or a ligament sprain in the foot could explain the pain, especially if it's worsened by activity.

• Do Not Miss Diagnoses

  • Peripheral Artery Disease (PAD): Although less likely given the patient's age and lack of other symptoms like claudication, PAD could cause foot pain that worsens with activity. Missing this diagnosis could lead to serious complications.
  • Diabetic Neuropathy: Even without a known history of diabetes, neuropathic pain could present similarly, and missing this could lead to delayed diagnosis of diabetes.
  • Bone Tumor or Cyst: A bone tumor or cyst, such as a plantar fibroma, could cause persistent pain and a sensation of a mass or "ropy" feeling on the bottom of the foot. Although rare, these conditions should not be missed due to their potential impact.

• Rare Diagnoses

  • Freiberg's Disease: A rare condition that affects the metatarsal bones, causing pain and tenderness, usually in adolescents but can persist into adulthood.
  • Kohler's Disease: A rare bone disorder causing pain and swelling in the foot, typically affecting children but could have a late presentation.
  • Plantar Fibromatosis: A rare condition where a benign growth forms on the bottom of the foot, leading to pain and discomfort, which could explain the "ropy" sensation described by the patient.