Big Toe Woes: The Root Of A Young Runner’s Foot Discomfort Uncovered With A Unique Radiological View

HISTORY: A 41yo female runner training for a half-marathon presented to the outpatient sports medicine clinic with pain and numbness for 4 months in the right medial great toe and first metatarsal. These symptoms were initially only present during longer runs; however, they are now present even with walking. Her symptoms improve with rest and did not change with pregabalin. She reports a purposeful change in running technique from heel strike to a forefoot strike about 2 months ago but has not participated in formal physical therapy or gait training. She has no history of injections or surgery. PHYSICAL EXAMINATION: 5/5 strength throughout bilateral lower extremities. Patellar and Achilles reflexes 2+ bilaterally. Diminished sensation to light touch and pinprick in right 1st toe primarily dorsal surface and some plantar surface. Full range of motion of the foot and ankle. Tenderness to palpation of right 1st toe proximal phalanx, MTP, and PIP. Pain with metatarsal squeeze. Negative Tinel’s at tarsal tunnel. Bilateral pes planus. Pain in right 1st toe with toe walking. DIFFERENTIAL DIAGNOSIS:1.Neuroma2.Tarsal Tunnel Syndrome3.First metatarsal stress fracture4.Sesamoiditis5.Digital plantar nerve entrapment TEST AND RESULTS:Right foot anterior-posterior, lateral, and sesamoid view radiographs: No acute fracture or osseous malalignment. Narrowing of the medial hallux sesamoid articulation suggestive of underlying cartilage loss. No soft tissue swelling or joint effusion. FINAL WORKING DIAGNOSIS:1. Sesamoiditis TREATMENT AND OUTCOMES:1.Referral to orthotics and patient received bilateral custom removable longitudinal arch supports with extended foot plate to increase stability during push-off.2.PT 1-2x weekly focused on ankle stability, plantar flexion stretching, and recruitment of plantar flexors including flexor hallucis longus and tibialis posterior to encourage great toe extension during terminal stance.3.Topical non-steroidal anti-inflammatory medication and ice as needed.4.At 8 week follow up patient reports significant reduction of pain when walking. PT reports improved great toe extension at terminal stance without symptom reproduction. She has normal strength and sensation and plans to begin jogging after a gradual increase in walking distance and speed over the next few weeks.