What is the appropriate management for a patient with anterior foot pain, no deformity, and no signs of infection, who was given Toradol (ketorolac) in the office?

Management of Anterior Foot Pain After In-Office Ketorolac Administration

For a patient with anterior foot pain without deformity or infection who received Toradol in the office, continue NSAIDs at home for up to 5 days maximum, provide strict offloading instructions with appropriate footwear or walking boot, and schedule follow-up within 1-2 weeks if symptoms persist.

Immediate Patient Education on Ketorolac Use

• Ketorolac (Toradol) is FDA-approved for short-term use only—maximum 5 days total including the office dose, as longer duration significantly increases risk of gastrointestinal bleeding, renal complications, and cardiovascular events 1
• If oral ketorolac is prescribed for home use, the combined duration of IM and oral formulations must not exceed 5 days 1
• Patients must avoid all other NSAIDs (ibuprofen, naproxen, aspirin) while taking ketorolac due to cumulative risk of serious adverse effects 1
• Transition to alternative analgesics (acetaminophen or standard-dose ibuprofen 400-800mg) as soon as tolerable, typically within 1-3 days 1

Home Management Instructions

Offloading and Activity Modification

• Strict offloading is the cornerstone of treatment for anterior foot pain—patients must avoid walking barefoot and minimize weight-bearing activities 2
• Prescribe or recommend a removable offloading walker boot (such as CAM walker) for moderate pain, or at minimum well-cushioned athletic shoes with rigid soles to reduce forefoot pressure 2
• Ill-fitting shoes are the most frequent cause of foot ulceration and pain progression even in non-diabetic patients, so examine current footwear and provide specific guidance 2

Adjunctive Measures

• Ice application for 15-20 minutes every 2-3 hours during the first 48-72 hours to reduce inflammation 3
• Elevate the foot above heart level when resting to minimize swelling 2
• Relative rest does not mean complete immobilization—gentle range of motion exercises should begin after acute pain subsides 3

Pain Management Transition

• After ketorolac course ends (maximum 5 days), transition to:
  • First-line: Ibuprofen 400-800mg every 6 hours as needed (maximum 2.4g/day) 2
  • Alternative: Naproxen sodium 275-550mg every 6-12 hours (maximum 1.5g/day) 2
  • For patients with NSAID contraindications: Acetaminophen 650-1000mg every 4-6 hours (maximum 4g/day) 2

Follow-Up Criteria

Schedule Follow-Up Within 1-2 Weeks If:

• Pain persists despite 5-7 days of conservative management 2
• Any new symptoms develop (numbness, tingling, color changes, temperature differences between feet) 2
• Patient cannot bear weight or pain worsens despite treatment 2

Urgent Re-Evaluation Required If:

• Signs of infection develop (increased warmth, redness, purulent drainage, fever) 2
• Severe pain out of proportion to examination findings 2
• Development of skin breakdown or ulceration 2
• Inability to palpate pedal pulses or signs of vascular compromise 2

Diagnostic Workup at Follow-Up

• Weight-bearing plain radiographs of the foot are first-line imaging if not already obtained, to evaluate for stress fractures, arthritis, or bony abnormalities 2
• Radiographs have 12-56% sensitivity for stress fractures initially but are appropriate screening given low cost and availability 2
• Advanced imaging (MRI or bone scan) should be reserved for cases where diagnosis remains unclear after clinical evaluation and radiographs, or if symptoms persist beyond 6 weeks 2

Red Flags Requiring Immediate Referral

• Refer to podiatric foot and ankle surgeon if no improvement after 6 weeks of conservative treatment 2
• Consider vascular surgery consultation if pedal pulses are diminished or absent, especially with non-healing wounds 2
• Neurologic consultation if symptoms suggest nerve entrapment (burning pain, numbness in specific distributions, positive Tinel's sign) 2

Common Pitfalls to Avoid

• Do not prescribe ketorolac beyond 5 days—this is the most common error and significantly increases adverse event risk without additional analgesic benefit 1
• Do not allow patients to continue walking barefoot or in inadequate footwear, as this is the primary cause of treatment failure 2
• Do not delay imaging if pain persists beyond 2 weeks, as early stress fractures may not appear on initial radiographs 2
• Avoid local corticosteroid injections in the acute setting without clear diagnosis, particularly near tendons where rupture risk is significant 4