Author: Joshua Sole, MD
Co Author #1: Jay Smith, MD
Co Author #2: Elena Jelsing, MD
Editor: David Edwards, MD
A 20 year-old female collegiate lacrosse player presented to an academic sports medicine center with chronic right forefoot pain.
She endorsed eight months of right plantar forefoot pain and medial great toe pain. Her symptoms began insidiously during the Spring lacrosse season. She denied trauma or injury. She reported progressive pain in the medial plantar first MTP region. She was initially diagnosed with turf toe, which her athletic trainers managed with taping. She was able to complete her season, yet her symptoms continued to worsen. Radiographs were eventually obtained revealing a right first sesamoid bone fracture. She was placed in a CAM boot for three weeks. Her pain continued despite immobilization, and a palpation-guided corticosteroid injection was recommended. This injection relieved her pain for one week with symptoms gradually recurring. Complete rest from sports participation during her Summer break resulted in symptom improvement. Upon resuming lacrosse in the Fall, her typical pain returned. An outside MRI was obtained, and she presented to our institution for a second opinion regarding management.
She was a fit-appearing female in no acute distress. There was slight erythema over the medial MTP region without pallor or dystrophic changes. She demonstrated full range of motion of bilateral ankle joints and no appreciable ankle effusion was present. Manual muscle testing revealed normal strength, but pain was reproduced with great toe extension. Metatarsal squeeze did not produce pain. A palpable Morton's click was appreciated in the lateral foot distal to the 1st MTP region. However, this did not reproduce her paresthesias. The patient had exquisite tenderness to palpation over the medial, plantar aspect of her first MTP and sesamoid bone. Her gait was antalgic, walking preferentially on her lateral right foot. Toe walking reproduced first MTP pain. Normal sensation was present throughout the bilateral feet, with exception of subjective paresthesia to the medial, plantar first toe.
Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.