Toe Pain--- Cross-Country
HISTORY: A 12 year-old female cross country runner presented to the pediatric sports medicine clinic with 3 months of right second toe pain. Initially, the pain started after stubbing her toe. She developed a constant dull ache that was present at rest and worsened with prolonged walking and during cross country. She noted that her symptoms gradually worsened with time, and she was having no improvement with rest, icing and anti-inflammatories.
PHYSICAL EXAMINATION: Overlying skin with no rashes or lesions. Tenderness along the plantar surface of her right second metatarsophalangeal (MTP) joint. ROM was limited in both passive and active flexion and extension of the affected joint. Sensation was intact, and strength with flexion and extension of the toe was normal, however there was significant pain with testing. MT squeeze test was negative. Varus and valgus stress to MTP joint elicited no laxity, and “drawer test” of MTP joint showed mild instability.
DIFFERENTIAL DIAGNOSIS:
1. Sprain of plantar plate
2. Metatarsal fracture/stress fracture
3. Osteochondrosis of the metatarsal head
4. Metatarsalgia
5. Lisfranc injury
6. Intermetatarsal neuroma
TEST RESULTS:
X-ray R foot:
--- Flattening of the second metatarsal head.
MRI R foot without contrast:
--- Flattening/collapse of the 2nd metatarsal head/distal epiphysis with prominent marrow edema of the 2nd metatarsal head and neck. Mild MTP joint space narrowing.
FINAL/WORKING DIAGNOSIS:
Osteochondrosis of the metatarsal head (Freiberg Disease) - Stage 4
TREATMENT AND OUTCOMES:
1. Placed in short leg walking boot with protected weight-bearing, ice 1-2 times daily, Foot/Ankle Surgery consultation with discussion of conservative care vs surgical (chondral drilling and/or chondroplasty). Patient opted for conservative care.
2. At 4-week follow-up, patient’s pain significantly reduced. Continued walking boot additional 4 weeks with transition into stiff-soled shoe.
3. At 8-weeks post treatment, follow-up MRI showed no progression of disease. Clinically with almost complete resolution of pain.
4. By 10 weeks, transitioned into a custom foot orthotic with added support to float 2nd MTP joint. Restrictions included low impact sports only with plan for repeat MRI at 6 months.
Collapse
