HISTORY: A 15 y/o female with no medical history, who participates in long jump, triple jump and 200-meter sprints arrived at our clinic (December 2019) with right foot pain partially treated with a pneumatic boot on October 2019. Patient states pain in her right foot, mainly in the first metatarsophalangeal (MTP) joint. Denies burning, irritation, acute trauma, past hospitalizations, surgery or toxic habit, but stated oligomenorrhea for months. Upon further questioning, patient reports having a previous sesamoid fracture of the left foot on May 2017.
PHYSICAL EXAMINATION:
Inspection: Mild edema in the first digit of the right foot
Palpation: Point tenderness in plantar aspect of the distal part of the first MTP joint bilateral
Range of Motion: Full passive and active in lower extremities
Strength: MMT 5/5 in lower extremities
Single leg hop test positive for pain
DIFFERENTIAL DIAGNOSIS: 1- First MTP joint sprain
2- Stress fracture of sesamoids
3- Sesamoiditis
4- Flexor hallucis brevis tendinopathy
5- Osteonecrosis of hallux sesamoids
TEST AND RESULTS: Lab results: CBC, CMP, uric acid level, U/A, TSH level, A1C, OGTT, RA factor; anti-CCP; C3 and C4 levels; IgA, IgG, and IgM levels; FT3 and FT4 levels; and Prolactin are all within normal reference ranges. Total testosterone: 119 ng/dL (normal= 5-75 ng/dL), T3 uptake: 35.77% (normal= 20.00%-34.00%), LDH level: 121U/L (normal= 125-243 U/L), and CRP: 1.6 mg/dL (normal= 0.0-1.2 mg/dL).
MRI: Fractured medial hallux sesamoid with bone marrow edema and a small first MTP joint effusion in the left foot, and a small, fragmented and sclerotic medial hallux sesamoid with lateral sesamoiditis (stress fracture) in the right foot.
Left Foot X-Ray anteroposterior, oblique, and lateral views: Left foot sesamoid fracture had healed.
Pelvic sonogram: Prominent right ovary (3.6x2.7x3.5cm), and normal left-sided ovary with an unilocular cyst measuring 2.2x1.5x2.3cm.
FINAL/WORKING DIAGNOSIS:
Right hallux sesamoid subacute stress fractures.
Left medial hallux sesamoid healed fracture
Suspected female athlete triad.
TREATMENT AND OUTCOMES
1. Physical therapy, home exercises and relative rest from running and jumping.
2. Calcium and Vitamin D supplementation
3. F/U DEXA scan to assess female athlete triad
4. Gradual return to Sports activity