What is the best course of treatment for a patient with acute right foot pain, localized to the top of the foot, worsened by weight-bearing and movement, with no history of trauma, diabetes, or gout?

Management of Acute Dorsal Foot Pain Without Trauma

For this patient with acute, localized dorsal foot pain worsened by weight-bearing, normal X-rays, and no signs of infection or gout, the best treatment is NSAIDs combined with rest, ice, elevation, and activity modification for 2 weeks, followed by reassessment if symptoms persist. 1, 2

Immediate Management

Pain Control

• Ketorolac (Toradol) injection provides effective analgesia for acute musculoskeletal pain, with onset within 30-60 minutes and efficacy comparable to morphine for moderate-to-severe pain 3, 4
• Continue oral NSAIDs (ibuprofen or ketorolac) for 5-7 days to reduce inflammation and pain 1, 2
• Avoid muscle relaxants - they provide no benefit for musculoskeletal foot pain and cause significant drowsiness and dizziness (NNTH 3) 5

Activity Modification

• Strict rest and avoidance of weight-bearing activities for at least 2 days, with gradual return to activity based on pain response 2
• Ice application through a wet towel for 10-minute periods to reduce pain and inflammation 2
• Elevation when possible to minimize swelling 2

Differential Diagnosis Considerations

Given the presentation, the most likely diagnoses are:

Stress Fracture (Most Concerning)

• Pain on dorsum of foot with weight-bearing is classic for metatarsal stress fracture, even with negative initial X-rays 6
• Symptoms often precede radiographic findings by 2-4 weeks 1, 6
• If pain persists beyond 1 week despite conservative treatment, obtain repeat X-rays at 2-4 weeks or consider MRI/bone scan 1, 6
• Calcaneal compression test (squeezing heel medially-laterally) can suggest stress fracture if positive 6, 7

Soft Tissue Injury

• Extensor tendonitis or dorsal ligamentous strain from repetitive stress
• The patient's physically demanding job with walking and climbing provides mechanism for overuse injury 2

Plantar Spur Contribution (Less Likely for Dorsal Pain)

• The calcaneal plantar spur identified on X-ray typically causes plantar heel pain, not dorsal midfoot pain 2
• This finding is likely incidental to the current presentation 2

Treatment Algorithm

Weeks 0-2: Initial Conservative Management

• NSAIDs (ibuprofen 400-600mg TID or ketorolac per protocol) 1, 2
• Rest, ice, elevation 2
• Avoid strenuous activity and prolonged weight-bearing 2
• Consider heel cushions or arch supports if plantar symptoms develop 2

Week 2-6: If No Improvement

• Reexamine at 3-5 days post-injury when swelling subsides to better assess injury severity 1, 7
• Repeat X-rays at 2-4 weeks if stress fracture suspected 1, 6
• Continue activity modification and NSAIDs 2
• Consider immobilization with walking boot if stress fracture confirmed 2

Week 6-8: Persistent Symptoms

• Refer to podiatric foot and ankle surgeon if no improvement after 6-8 weeks of appropriate conservative treatment 2, 6, 7
• Advanced imaging (MRI or technetium bone scan) to evaluate for occult stress fracture 1, 6
• Consider custom orthotics if biomechanical issues identified 2

Critical Pitfalls to Avoid

Medication Errors

• Never inject corticosteroids near tendons - this dramatically increases tendon rupture risk, particularly around the Achilles tendon 2, 6, 7
• Muscle relaxants provide no benefit for foot pain and cause significant sedation 5

Diagnostic Delays

• Do not assume negative initial X-rays rule out stress fracture - radiographic changes lag behind symptoms by weeks 1, 6
• Reexamine within 3-5 days when initial swelling obscures findings 1, 7

Activity Management

• Avoid complete immobilization unless fracture confirmed - this causes muscle atrophy and deconditioning 2
• However, continued weight-bearing on undiagnosed stress fracture risks progression to complete fracture 6

Red Flags Requiring Immediate Referral

• Constant pain at rest (suggests infection, tumor, or vascular compromise) 2, 7
• Numbness, tingling, or neurologic symptoms 7
• Signs of infection (fever, erythema, warmth) - though absent in this case 1
• Inability to bear weight after 1 week of conservative treatment 6

Expected Outcomes

• Most patients with soft tissue injuries respond to conservative treatment within 6-8 weeks 2
• Stress fractures typically require 6-12 weeks for healing with appropriate activity modification 6
• The patient's pain reduction from 6/10 to 4/10 after Toradol injection suggests good initial response to anti-inflammatory treatment 3, 4