An unusual stress fracture of the proximal phalanx of the great toe: A ...

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An unusual stress fracture of the proximal phalanx of the great toe: A case report G.C. Pitsis* & J.P. Best Eastern Suburbs Sports Medicine Centre, Sydney, Australia INTRODUCTION: Stress fracture of the proximal phalanx of the great toe is rare. A medline search was conducted using the key words “stress fracture” and “great toe” resulting in three specific references. Yokoe and Mannoji in 1986 published a case series of a sprinter, a Kendo player (Japanese fencer), and a rugby player with this injury (1). Similarly, Shiraishi and colleagues in 1993 reported 3 cases of this injury in a long distance runner, a volleyball player, and a soccer player (2). Matsusue and colleagues in 1992 reported this injury in a shot-putter (3). Interestingly, these stress fractures have only been reported among adolescent athletes. Most stress fractures were associated with halux valgus deformity. The pathophysiology involves running and jumping activities inducing vertical ground reaction forces several times that of body weight. This results in large repetitive truncation forces on the base of the proximal phalanx from the windlass action of the plantar aponeurosis and muscle action, in addition to axial compressive forces (4). Hallux valgus is a postulated associated biomechanical predisposing factor to this injury due to the bowstring effect of extensor hallucis longus and adductor hallucis acting on the great toe. This may increase abduction forces on the first metatarsophalangeal joint. The resulting tensile strain on the medial collateral ligament and the medial head of the flexor hallucis brevis may predispose to an avulsion type stress fracture of the medial base of the proximal phalanx of the great toe (1,2,3,5,6). It is expected this type of stress fracture would heal with conservative treatment of 4 – 6 weeks non weightbearing rest. A graduated return to activity over a further 4 – 6 weeks is usually required. Biomechanical factors need to be addressed appropriately. CASE REPORT: The patient is a 41-year-old nulliparous non-professional triathlete who was clinically diagnosed with a stress fracture of the medial base of the proximal phalanx of the left great toe confirmed by x-ray (Figure 1). Radiologically the stress fracture was undisplaced and involved approximately one third of the articular surface. Pain in the left great toe was experienced after progressive moderate increased training load over a 12-week period leading into a triathlon. This included 20 kilometers of running per week. A mild ache was felt 2 weeks before competition. After completing the 65-kilometer cycle and 500-meter swim of the triathlon uneventfully, moderately severe pain was experienced during the first 500 meters of the 4.5-kilometer run. On completion of the race the patient could not fully weight-bear due to severe pain. The patient has a past history of multiple stress fractures over the last 4 years including the left fibula in June 1997, the left calcaneus in October 1998, and the right fibula in April 2000, suggesting a low threshold for stress fractures. A Dual Energy X-ray Absorptiometry (DEXA) scan in November 1998 revealed osteopenia. At the time of scanning the patient had 14 months of amenorrhoea. Following treatment with Alendronate (Fosamax), hormone replacement therapy (Ogen 1.25 mg and Provera 2.5mg), and calcium, follow-up DEXA scans in July 2000 and May 2001 were normal (Table 1). The patient continues to use hormone replacement therapy and reports normal menstruation.
Figure 1. Radiograph at diagnosis Table 1: DEXA scan results Nov 1998 July 2000 May 2001 Lumbar age-matched (Z) score: -1.4 -1.1 -0.6 Lumbar young-adult (T) score: -1.8 -1.2 -1.1 Proximal femur age-matched (Z) score: -1.0 -0.8 -0.4 Proximal femur young-adult (T) score: -1.4 -1.0 -0.9 The patient has asthma well controlled on regular Pulmicort and Brycanyl as required. She has needed a short coarse of oral prednisone on 2 occasions for severe exacerbation of her asthma at a younger age. She has a family history of ischaemic heart disease and hypertension. Initial clinical examination revealed point tenderness over the medial base of the proximal phalanx of the left great toe. There was no associated hallux valgus. She has been wearing orthotics for the last 15 years to correct hyper-pronation. They were last renewed 2 years ago and are in satisfactory condition. Excellent clinical and radiological union was achieved with 6 weeks non weight-bearing rest with crutches. A graduated return to activity was achieved over a further 6 weeks. A 2 nd – 5 th metatarsal bar was used to off-load stress from the great toe.
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An unusual stress fracture of the proximal phalanx of the great toe: A ...

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