Assistant Professor Indiana University Health Indianapolis, Indiana, United States
Case Diagnosis: Trigger Toe/ Hallux Saltans
Case Description: A 22-year-old collegiate ballet dancer with history of right plantar great toe pain due to sesamoid stress reactions and 1st metatarsophalangeal joint osteoarthritis presented with worsening right plantar great toe pain during mid season performances. Pain was worse with demi-pointe position in Pointe shoes and had feeling like her toe would get stuck in flexion. Exam revealed tenderness over plantar distal portion of flexor hallucis longus (FHL) tendon, pain with resisted great toe flexion and passive extension, catching of her great toe in flexion. Diagnostic ultrasound performed demonstrated thickening with peritendinous edema of FHL tendon and triggering at the A1 pulley.
Discussions: Trigger toe is an uncommon diagnosis with a paucity of literature surrounding it. It most often presents in elite ballet dancers who spend significant time bearing weight on excessive plantar flexion. While the condition can affect any toe, it often affects the FHL in a condition called Hallux Saltans. Treatment of the condition follows a similar approach to trigger finger with conservative measures such as rest, NSAIDs, and physical therapy being first line, while surgery is used for refractory cases. The current published data on surgical intervention appears to favor an endoscopic approach.
Conclusions: Plantar toe and foot pain can be a daunting presenting concern, particularly in ballet dancers whose actions predispose them to a variety of possible injuries. Coming to an appropriate diagnosis requires a thorough history and physical exam and possibly the use of point of care tools such as ultrasound for real time evaluation of soft tissue structures in the region of patient's pain. A thorough knowledge of relevant anatomy and a high index of suspicion is also necessary in diagnosing uncommon causes of pain.
