1. Great Toe Pain: An Unexpected Finding Kennieth McCollough, MD American Sports Medicine Institute SEACSM February 10, 2012

2. History 17 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 running Activity modification has not helped

3. History No medications or allergies No past medical history No past surgical history Lives with family, NS/ND Family history unremarkable ROS otherwise negative

4. Physical Exam Swelling noted over medial aspect of right first MTP Swelling and tenderness on palpation Active 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 ankle Calcaneal valgus and pronation of bilateral feet on standing, but lateralizes on right to avoid toe-off Normal alignment of 1st ray, MTP and proximal phalynx

5. Questions?

6. Differential Diagnosis First MTP sprain Stress Reaction/Fracture Arthritis(OA, Septic, Gouty) Sesamoiditis Tendinitis(Flexor, Extensor tendons of great toe) Bursitis Neoplasm

7. Imaging Initial Radiographs Working Diganosis: Calicific Peri-arthritis

8. Initial Treatment Placed in Cam Boot,started NSAIDS and restricted from running Became acutely more inflamed and swollen over the next five days Consult was made to Foot and Ankle specialist MRI was performed

9. Magnetic Resonance Imaging Radiology report read as focus of calcification medial to the first metatarsal with surrounding soft tissue edema

10. Treatment Surgical resection of soft tissue mass on medical aspect of right first metatarsal joint secondary to worsening clinical picture and poor response to conservative management

11. Pathology Described as fibrous tissue with dystrophic calcification

12. Final Diagnosis and Outcome Acute Calcific Peri-arthritis Un-remarkable post operative course Resumed running in six weeks

13. Questions?

14. Thank You