Great Toe Pain:An Unexpected Finding

Kennieth McCollough, MDAmerican Sports Medicine Institute

SEACSMFebruary 10, 2012

History17 year old female cross country runner

Swelling of medial aspect of right great toe for two months

Localizes pain to medial side of right first metatarsal phalangeal joint

Now having pain upon movement of the toe and with palpation

Interfering with runningActivity modification has not helped

HistoryNo medications or allergies

No past medical history

No past surgical history

Lives with family, NS/ND

Family history unremarkable

ROS otherwise negative

Physical ExamSwelling noted over medial aspect of right first MTP

Swelling and tenderness on palpation

Active and passive range of motion severely limited by pain.

Strength of right great toe was 4/5 secondary to pain. Normal strength in foot and ankle

Calcaneal valgus and pronation of bilateral feet on standing, but lateralizes on right to avoid toe-off

Normal alignment of 1st ray, MTP and proximal phalynx

Questions?

Differential DiagnosisFirst MTP sprainStress Reaction/FractureArthritis(OA, Septic, Gouty)SesamoiditisTendinitis(Flexor, Extensor tendons of great toe)BursitisNeoplasm

ImagingInitial Radiographs

Working Diganosis: Calicific Peri-arthritis

Initial TreatmentPlaced in Cam Boot,started NSAIDS and

restricted from running

Became acutely more inflamed and swollen over the next five days

Consult was made to Foot and Ankle specialist

MRI was performed

Magnetic Resonance Imaging

Radiology report read as focus of calcification medial to the first metatarsal with surrounding soft tissue edema

TreatmentSurgical resection of soft tissue mass on medical

aspect of right first metatarsal joint secondary to worsening clinical picture and poor response to conservative management

PathologyDescribed as fibrous tissue with dystrophic

calcification

Final Diagnosis and Outcome

Acute Calcific Peri-arthritis

Un-remarkable post operative course

Resumed running in six weeks

Questions?

Thank You