I'm pretty good at guessing ages, having looked at 30,000 patients and the forms they fill out for my office. So when I first saw this patient, I figured she was an incredibly fit 44-year-old. Wrong. She was an incredibly fit 64-year-old. She'd been a high level cyclist since she was in her early 20's. Her super-exercise kept her looking and feeling young. But she was certain that her life was about to change because of her foot.
For two years, she'd had worsening pain at the ball of her foot. For six months, worsening pain at her heel. She'd seen podiatrists and two orthopedic surgeons. She'd had thirteen cortisone shots, physical therapy, orthotics for her street shoes and cycling shoes, taken anti-inflammatory medications, and currently was seeing an athletic trainer who was vigorously massaging her foot. Nothing was helping, she was only getting worse. It took me less than a minute to realize that her blasé attitude about our visit was a product of the frustration to which her distress had succumbed.
After I examined her heel, I decided, based on the feel of the tissue and the sites and degree of pain, that it was at worst a mild plantar fasciitis/heel bruise. But when I examined the originator at the ball of her foot, the results were at first strange. For all this disability, it took quite a bit of meticulous examining before I could elicit the typical pain. Further, the pain was located across three bones at the ball of her foot, in a straight line. At each of these sites, there was a tiny, exquisitely-tender little mass of soft tissue. It felt like she had three little scars within her foot, distributed in a straight line but at different structures (a bone and two joints). Barring a macro-trauma, like a fall or a big enough accident to remember (neither occurred in her case), humans just don't get things like this. Except due to one thing: footgear.
Out of curiosity, I took a look at her MRI, which she said had been read as negative. Benefiting from the exam I just did, I looked and lo, there were three dots of inflammation beneath the ball of her foot, distributed at arbitrary sites on the joints and one bone, but arranged in a straight line. I asked her how long she'd had her present cycling shoes. She got them two months before the pain started. I asked her to bring the shoes on her next visit. When I checked inside, under the liner was a plastic plate with an edge which, when I used my purple skin marking pen on her pain places and asked her to put the shoe on, wound up having three little purple dots on it.
I told her to stop the massage, ice her heel and ball, change cycling shoes, put adhesive foam callus pads on her foot around the pain spots, go out cycling that weekend, and call me on Monday. Pain gone.