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 allergiesNo past medical historyNo past surgical historyLives with family, NS/NDFamily history unremarkableROS otherwise negative

Physical ExamSwelling noted over medial aspect of right first MTPSwelling and tenderness on palpationActive 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 ankleCalcaneal valgus and pronation of bilateral feet on

standing, but lateralizes on right to avoid toe-offNormal 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 RadiographsWorking Diganosis: Calicific Peri-arthritis

Initial TreatmentPlaced in Cam Boot,started NSAIDS and

restricted from runningBecame acutely more inflamed and swollen over

the next five daysConsult was made to Foot and Ankle specialistMRI 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-arthritisUn-remarkable post operative course Resumed running in six weeks

Questions?

Thank You