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
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