1. Chronic right first MTP region pain and effusion
2. Bipartite tibial sesamoiditis
3. Medial hallucal neuritis without neuroma
At initial evaluation, the patient already received three weeks of immobilization with a CAM boot, metal shank insertion, topical ice, non-guided corticosteroid injection, and activity modifications.
We opted to resume immobilization in her CAM boot to further offload her forefoot and decrease inflammation. We employed regular ice massage and a short course of oral anti-inflammatory medication.
At initial follow-up, we performed an ultrasound-guided right first MTP intra-articular corticosteroid injection. She was instructed to continue icing and offloading with her CAM boot and axillary crutches. We recommended non-weight bearing for four weeks. We considered orthopedic referral to discuss sesamoidectomy if symptoms progressed.
The patient tolerated ultrasound- guided injection well. She successfully off-loaded her affected right foot with non-weight bearing status for four weeks duration. She was able to successfully discontinue the CAM boot and crutches with complete symptom resolution. She reported successful increase in her activities including use of an elliptical, bicycling, and light jogging for 1/2 mile intervals without recurrence of her pain. She was successfully released for gradual return to her strength and conditioning program and sport-specific activities per her collegiate athletic training staff.
At follow-up, we recommended gradual increase in treadmill jogging until reaching ideal mileage, followed by a progressive increase in running distance and intensity. Subsequently, she was to jog intermixed with lower-impact elliptical or bicycling for five days per week until resuming Spring lacrosse practice. We recommended a motion-control/stability shoe, topical ice for new-onset pain, and immediate decrease in activity for recurrence of previous symptoms.
- Tibial sesamoiditis and medial hallucal neuritis can both result in forefoot and great toe pain in athletes.
- Non-operative management is the mainstay treatment for
- Diagnostic and/or therapeutic injections can provide a
management option for refractory cases prior to surgical
- Ultrasonography provides a high yield modality for both
diagnostic and interventional management of forefoot pain in the athlete.
As the old adage says, "sesamoiditis is a diagnosis of exclusion." The authors ruled out fracture/diastasis of the bipartate sesamoid prior to ultrasound-guided injection. Consider medial hallucal nerve injury in the athlete with paresthesia to the medial great toe.
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