Description of patient (type of occupation, indication of age, intensity of sport):
18 years old female student (height 176 cm and weight 72 kg) presents to office with a 7 month history of left forefoot pain centered at her second toe, which is increasing in severity. Pain at rest is minimal. Any attempt at weight bearing causes significant pain. Pain is somewhat controlled by a combination of analgesics.
History and previous treatment:
Two weeks before the symptoms began, the patient began track & field training. Patient did not do sports systematically before this. At the second week of training the patient attempted long jumps. By the end of the second week of training the patient complained of " something does not feel right in my left foot". The parents withdrew the patient from training. From that point onwards there a progression in the pain level especially during weightbearing. The patient has had no treatment besides occasional analgesia.
Current complaints:
Minimal pain at rest at the level of 2nd MTP of left foot. Painful to touch as well. Significant pain at any attempt to bear weight, especially when attempting to go up or down stairs. Overall patient is in quite distress as the pain is inhibiting activities of daily living.
Physical examination:
Antalgic gait. Severe pain in left fore foot on push-off phase. Examination of lower limbs from pelvis down is normal on both sides. Normal alignment for both hind foots and normal arches bilaterally.
Left foot: No significant change in appearance of 2nd Ray. No swelling or redness. Neurovascular status normal. Severe pain to palpation of 2nd MTP and metatarsal head.(Especially on dorsal and lateral surfaces). Passive ROM of the 2nd MTP is limited due to pain. Active ROM is very limited (10-20 degrees of PF). The proximal half of the second MTS is not painful to palpation. Proximal phalanx not painful to
Radiology:
X-ray:
[Picture1]
Changes in the 2nd MTS head of left foot that appear to be the result of an old fracture. We suggest further evaluation with CT/MRI.
Additional investigation (CT/MRI):
[Picture 2]
Patient had 2 MRIs within 4 months. The conclusion is the same on both reports. "Bone oedema in the second MTS head with oedema of the surrounding soft tissues." No comment is made in terms of the state of the overlying cartilage.
Remarks:
Patient has visited numerous Orthopaedic Surgeons. There appears to be a consensus on diagnosis of Freiberg's disease. The patient has been offered conservative treatment which include: 2nd MTP joint H.Acid injections, Hyperbaric Oxygen therapy in combination with Non- WB, analgesia. Other colleagues have offered surgical treatment (unspecified type of surgery).
Images:
Case summary:
Patient has visited numerous Orthopaedic Surgeons. There appears to be a consensus on diagnosis of Freiberg's disease. The patient has been offered conservative treatment which include: 2nd MTP joint H.Acid injections, Hyperbaric Oxygen therapy in combination with Non- WB, analgesia. Other colleagues have offered surgical treatment (unspecified type of surgery).
Question(s) to this case:
18 years old female with 7-month history of progressive pain if her left forefoot centered over 2nd MTP joint. Patient presents with significant pain on weight bearing that interferes with ADL. She has received no treatment besides analgesia.
Question(s) to this case:
1). Do you agree with the Diagnosis of Freiberg's Disease.
2.) If yes, can suggest treatment possibilities.
Expert:
I agree to the diagnosis Freiberg disease. My advice is a dorsal closing wedge osteotomy with screw fixation.