HISTORY: A 21-year-old female college dancer presented with right great toe injury that occurred in February 2017 when she twisted the toe while pivoting then felt a pop and severe pain. Xrays at the ED were negative for fracture. She was able to continue dancing despite pain and had multiple episodes of re-injury. She was first evaluated in the Sports Medicine clinic in April 2017 after a recent episode of re-injury of first toe medial deviation while dancing with a pop sensation and swelling. Xrays were negative for fracture and she was diagnosed with a first MTP joint sprain treated with a walking boot for 1 month, dancing with buddy taping, and intrinsic foot exercises. By the end of May 2017, she reported near-full recovery with progression back into dancing until suffering the same injury while dancing with subsequent 1st MTP pain and instability.
EXAM: Right foot: Normal alignment. No edema. Painful passive end-range 1st MTP joint flexion & extension. Significant laxity with 1st MTP joint varus stress, asymmetric compared to contralateral MTP joint. Discomfort but no dorsal subluxation with 1st MTP joint drawer test. 5/5 great toe dorsiflexion & plantarflexion strength with discomfort. Lateral 1st MTP joint tenderness to palpation. Minimal fibular sesamoid tenderness to palpation. Intact distal sensation & dorsalis pedis pulse.
1. 1st MTP lateral capsule tear
2. 1st MTP lateral collateral ligament tear
3. Adductor hallucis brevis tear
IMAGING: MRI right foot: Complete lateral collateral ligament tear of the first MTP joint at the metatarsal attachment. No bony avulsion, normal alignment, normal plantar plate.
FINAL DIAGNOSIS: Tear of the first MTP lateral collateral ligament in a dancer with resultant joint instability
-Walking boot for 5-6 weeks, without dancing, and improvement of symptoms at follow-up in July 2017
-Weaned out of boot, started physical therapy, progressed back into dancing with buddy taping
-August 2017, noted 60% improvement of pain but continued 1st MTP joint instability
-Referred to Orthopedic Surgeon Dr. Lyle Micheli for surgical opinion with consultation from Dr. William Hamilton, dance medicine expert in New York City
-Per recommendations, she underwent two series of PRP injections of the LCL in August and October 2017, follow-up is pending