What is the appropriate evaluation and management for a teenager with persistent toe pain and swelling for a month?

Evaluation and Management of Persistent Toe Pain and Swelling in a Teenager

The most likely diagnosis is Sever's disease (calcaneal apophysitis), which is the most common cause of heel pain in adolescents and children, though the specific location of "toe" pain requires careful differentiation from other conditions including stress fracture, osteomyelitis, enchondroma, or inflammatory arthritis. 1, 2

Initial Clinical Assessment

Key History Elements to Obtain

• Activity level and sports participation: Sever's disease typically occurs in adolescent athletes involved in running or jumping activities during the pubertal growth spurt (mean age 10, range 7-15) 2
• Pain characteristics: Posterior heel/toe pain worse with activity and relieved by rest suggests Sever's disease, while night pain or pain at rest raises concern for infection or tumor 2, 3
• Trauma history: Absence of precipitating trauma with unilateral presentation should raise suspicion for atypical pathology 2
• Systemic symptoms: Fever, weight loss, or involvement of other joints suggests inflammatory arthritis or infection 4
• Response to NSAIDs: Lack of response warrants further investigation 4

Critical Physical Examination Findings

• Point tenderness location: Palpate the Achilles insertion, lateral calcaneal wall, metatarsal shafts, and individual toe joints to localize pathology 1, 5
• Calcaneal compression test: Squeeze the calcaneus medially to laterally—pain suggests stress fracture 1, 5
• Swelling characteristics: Non-pitting edema with thickened skinfold suggests lymphatic issues, while localized bony swelling raises concern for tumor 4, 6
• Neurologic assessment: Check for burning, tingling, or numbness that would indicate nerve involvement 1, 5

Diagnostic Algorithm

Initial Imaging

Obtain weight-bearing radiographs of the foot and ankle as the first-line imaging study 1, 5, 7

• However, initial radiographs have poor sensitivity (12-56%) for stress fractures, so negative X-rays do not exclude the diagnosis 7
• Look for lytic lesions, cortical scalloping, or whorl of calcification that suggest enchondroma 6

Advanced Imaging When Indicated

If radiographs are negative but pain persists >1 week, obtain MRI without contrast or CT without contrast 1, 7

• MRI should be performed in all atypical cases of Sever's disease to rule out osteomyelitis or other disorders 3
• Technetium bone scanning is an alternative for suspected stress fracture with negative initial radiographs 1, 5

Laboratory Testing

Obtain inflammatory markers (WBC, CRP, ESR) if infection or inflammatory arthritis is suspected 8

• Consider comprehensive metabolic panel, ANA, and other rheumatologic workup if bilateral symptoms or other joint involvement 4

Management Based on Diagnosis

For Sever's Disease (Most Common)

• Activity modification and rest 2
• NSAIDs for pain control 2
• Heel lifts or orthoses 1
• Stretching exercises for gastrosoleus complex 1
• This is entirely self-limiting and resolves at skeletal maturity or earlier 2

For Stress Fracture

• Protect and immobilize the foot 1
• Non-weight bearing or protected weight bearing 1
• Symptoms often precede radiographic findings, requiring advanced imaging for early diagnosis 1, 5

For Suspected Osteomyelitis

Immediate hospital admission with intravenous antibiotics after obtaining blood cultures and wound cultures 8

• A 9-year-old with Sever's disease complicated by calcaneal osteomyelitis required six weeks of parenteral antibiotic treatment 3
• MRI findings showing osteolytic zone with peripheral enhancement and surrounding edema confirm the diagnosis 3

For Suspected Tumor

Urgent referral to orthopedic oncology 1

• Enchondromas presenting with progressive swelling may require surgical excision with bone grafting 6
• Atypical features such as night pain, absence of precipitating activity, or localized bony expansion warrant immediate investigation 2

Critical Pitfalls to Avoid

Do not assume benign Sever's disease without considering red flags 2, 3:

• Unilateral presentation with atypical features
• Night pain or pain at rest
• Lack of response to conservative treatment
• Absence of sports/activity history
• Systemic symptoms

Reexamine the patient 3-5 days post-initial evaluation if excessive swelling limited the initial examination 1

Never rely solely on initial radiographs to exclude stress fractures or early osteomyelitis 7, 3

Referral Indications

Refer to subspecialist if 1:

• No improvement after 6-8 weeks of appropriate conservative treatment
• Need for advanced imaging or diagnostic testing beyond plain radiographs
• Any suspicion of infection, tumor, or inflammatory arthritis
• Consideration of surgical intervention