Case Report: A 36-year-old runner with 1st MTP joint pain

A 36-year-old runner presented to me yesterday complaining of pain on the bottom of the great toe in the region of the first MTP joint.  The problem began one week prior when he mis-judged a curb height during one of his runs and struck it with the foot forcefully dorsiflexing the toes.  The patient felt mild pain immediately that became more severe several hours later.

Symptomatically the patient complained of pain with dorsiflexion of the great toe during gait as well as tenderness to palpation in the region of the metatarsal heads.

Physical examination revealed pain with passive dorsiflexion of the first MTP, which was slightly exacerbated when performed with the ankle in plantarflexion.  Active resisted flexion of the toe was also painful, again made worse in ankle plantar flexion.  No pain was noted with passive flexion, and only mild pain was produced with adduction of the great toe.  Joint compression was unremarkable.  Palpation of the dorsal and lateral sides of the joint capsule did not cause pain.  Palpation of the inferior capsule produced pain.  More specifically, palpation of medial sesamoid bone produced a complete reproduction of the pain symptoms (figure 1).

A diagnosis of Sesamoiditis was made using the following functional anatomic considerations:

–       In common with other sesamoid bones in the body, the sesamoids of the foot are situated within a tendon, namely the medial tendon of flexor hallucis brevis (FHB) (Figure 2 & 3). Additionally, the medial sesamoid receives some fibers from the abductor hallucis tendon, the lateral sesamoid from the adductor hallucis, and both from the most medial digitation of the plantar aponeurosis.  Because they are situated within the substance of the FHB, passive extension of the great toe with the ankle in dorsiflexion would decress stress on the structures, as tension contributed from the flexor hallucis longus would relieve tension on the symptomatic sesamoids themselves.  Thus the finding of increased pain with passive dorsiflexion with the ankle in a plantar flexed position.

–       Similarly to the point above, the finding of increased pain with active resisted flexion with the ankle in a plantar flexed position is a result of the same anatomic consideration.

–       The completed lack of tenderness with palpation of the dorsal and lateral capsular surfaces helps to rule out capsular sprain as this would tend to cause at lease mild tenderness throughout the joint due to swelling of the synovial layer.  As well, we would have expected to find tenderness with plantar flexion, and also with joint compression.

–       As noted above, the medial sesamoid receive fibers from the abductor hallucis, this would explain the pain felt with passive adduction of the great toe.

Functional Anatomy:

–       The sesamoid bones serve as anchors and help to form the pulley for the flexor hallucis longus in addition to being attachment points for the FHB, Adductor hallucis, and abductor hallucis

Clinical Anatomy:

–       Predisposition to sesamoiditis appears related to coexistent hallux valgus, overly flexible footwear, and repetitive running or walking on hard surfaces.

–       These small bones may also suffer from local bursitis, OA/chondromalacia, fracture, stress fracture, bipartite development, and secondary involvement with collagen/vascular, rheumatoid, or gouty processes.  They can also complicate the prognosis with dislocation of the first MTP joint.

Treatment:

The plan for treatment will be to control the inflammatory process using anti-inflammatory meds, medical acupuncture, and ice baths.  In addition, Functional Range Release™ technique will be applied to relieve tension on the structure.  Taping of the great toe restricting (but not blocking) dorsiflexion will be done during the immediate inflammatory phase.  At the tail end of the inflammatory phase, the application of P.A.I.L.’s (Progressive Angular Isometric Loading)™ will begin for two reasons: first to expand the patients functional ROM simultaneously developing strength at increasing angles, and second influence proper collagen alignment deposition by the fibroblasts as some minimal tearing is expected to have occurred due to the mechanism of injury.  The next step in the rehabilitative process with involve more proprioceptive/balance training to ensure proper motor program remain intact following the injury, as well as a progressive walk/run program to get the athlete back to training.

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