Description of patient (type of occupation, indication of age, intensity of sport):
34-year-old healthy very active female. She likes to travel a lot.
History and previous treatment:
Six years of recurrent pain in the right big toe joint. Two years ago, a small ganglion cyst was removed from lateral side. After that she was pain free for 6 months then the pain came back. All the Lab results are normal. Treatment was done with insoles, anti-inflammatories and physiotherapy.
Pain in the big toe joint when she is weight bearing. She can not walk longer distances.
Right foot: normal alignment. Tenderness over first MTP joint from the plantar side. No redness. 40% limited ROM in the MTP joint compared to the healthy side.
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X-rays show a normal bone status.
Additional investigation (CT/MRI):
MRI shows an inflammatory reaction in the forefoot. No osteochondral lesion seen. No evidence for sesamoiditis or reocurrance of ganglion.
Therapy resistant right Hallux rigidus.
Question(s) to this case:
After 6 years of pain would you:
1) continue conservative treatment
2) do an arthroscopy
3) do an open release with inspection of the cartilage to rule out cartilage defect which might not be visible in the MRI.
If there is no area of bone marrow oedema, I would not go for arthroscopy or open surgery. I can only advice to continue conservative treatment.