Transcript Great Toe Pain

Great Toe Pain:
An Unexpected Finding
Kennieth McCollough, MD
American Sports Medicine Institute
SEACSM
February 10, 2012
History
 17 year old female cross country runner
 Swelling of medial aspect of right great toe for two
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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 running
Activity modification has not helped
History
 No medications or allergies
 No past medical history
 No past surgical history
 Lives with family, NS/ND
 Family history unremarkable
 ROS otherwise negative
Physical Exam
 Swelling 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 Diagnosis
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First MTP sprain
Stress Reaction/Fracture
Arthritis(OA, Septic, Gouty)
Sesamoiditis
Tendinitis(Flexor, Extensor tendons of great toe)
Bursitis
Neoplasm
Imaging
 Initial Radiographs
 Working Diganosis: Calicific Peri-arthritis
Initial Treatment
 Placed 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
Treatment
 Surgical resection of soft tissue mass on medical
aspect of right first metatarsal joint secondary to
worsening clinical picture and poor response to
conservative management
Pathology
 Described 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