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

Introduction
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
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 weight-bearing 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.
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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
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
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An unusual stress fracture of the proximal phalanx of the great toe: A case report
Table 1. DEXA scan results
Table 1: DEXA scan results
G.C. Pitsis* & J.P. Best Eastern Suburbs Sports Medicine Centre, Sydney, Australia
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 case report
G.C. Pitsis* & J.P. Best Eastern Suburbs Sports Medicine Centre, Sydney, Australia
Figure 2. Radiograph 4 weeks
post-diagnosis
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Discussion
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
The patient’s stress fracture was unusual as it occurred simply with relatively low levels of stress and normal bone mineral density. In addition,
there was no associated hallux valgus, and was not consistent with the previously documented age group of adolescence.
Stress fractures are more common in female athletes with menstrual disturbances (7). Alendronate (Fosamax) is used for treatment in
osteoporosis. Hormone replacement therapy with Ogen 1.25 mg and Provera 2.5mg may be effective in reducing the negative effects of
menstrual disturbances on bone mineral density (8). The addition of calcium in the exercising individual may also promote increase bone
mineralisation (9). She is currently being investigated from an endocrinological viewpoint.
This case report supports the opinion that stress fractures of the proximal phalanx of the great toe respond well to non weight-bearing rest with
graduated return to activity. This has been recorded previously (1,2). In addition, Shiraishi and colleagues (1) found one of the patients
proceeded to non-union as a result of continued training. Biomechanical factors need to be addressed appropriately (10).
Evidence of clinical union occurred before radiological union at 4 weeks post-injury. This supports current understanding of the temporal
relationship of clinical and radiological union. Thus clinical status of the fracture is of paramount importance when assessing progress of union
of the fracture. Radiological investigations will confirm fracture position, and document evidence of union after 4 weeks.
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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
Figure 3. Radiograph 8 weeks
post-diagnosis
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References
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
Yokoe K. and Mannoji T. Stress fracture of the proximal phalanx of the great toe: a report of three cases. American Journal of Sports Medicine
1986; 14 (3): 240-242.
Shiraishi M, Mizuta H, Kubota K, et al. Stress fracture of the proximal phalanx of the great toe. Foot and Ankle 1993; 14 (1): 28-34.
Matsusue Y, Yamamuro T, Nakagawa Y, et al. Stress fracture of the proximal phalanx of the great toe: the case report of a shot-putter. Clinical
Journal of Sports Medicine 1992; 2(4): 279-282
Brukner P, Bennell K and Matheson G. Stress fractures. Blackwell Science, 2000. pp 183-184.
Eisele S and Sammarco G. Fatigue fractures of the foot and ankle in athletes. Journal of Bone and Joint Surgery – American volume 1993 Feb.
75 (2): 290-298.
Hershman E and Mailly T. Stress fractures. Clinics in Sports Medicine 1990 Jan. 9 (1): 183-214
Brukner P and Bennell K. Stress fractures in female athletes. Diagnosis, management and rehabilitation. Sports Medicine 1997 Dec. 24
(6):419-429
Fields C and Fricker P. Medical problems in athletes. Blackwell Science, 1997.
Brukner P and Khan K. Clinical sports medicine, second edition. McGraw Hill 2000.
Knapp T and Garrett W. Stress fractures: general concepts. Clinics in Sports Medicine 1997 Apr. 16(2): 339-356.
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Table of Contents
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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.

Figure 2. Radiograph 4 weeks post-diagnosis
DISCUSSION: The patient’s stress fracture was unusual as it occurred simply with relatively low levels of
stress and normal bone mineral density. In addition, there was no associated hallux valgus, and was not
consistent with the previously documented age group of adolescence.
Stress fractures are more common in female athletes with menstrual disturbances (7). Alendronate (Fosamax)
is used for treatment in osteoporosis. Hormone replacement therapy with Ogen 1.25 mg and Provera 2.5mg may
be effective in reducing the negative effects of menstrual disturbances on bone mineral density (8). The addition of
calcium in the exercising individual may also promote increase bone mineralisation (9). She is currently being
investigated from an endocrinological viewpoint.
This case report supports the opinion that stress fractures of the proximal phalanx of the great toe respond
well to non weight-bearing rest with graduated return to activity. This has been recorded previously (1,2). In
addition, Shiraishi and colleagues (1) found one of the patients proceeded to non-union as a result of continued
training. Biomechanical factors need to be addressed appropriately (10).
Evidence of clinical union occurred before radiological union at 4 weeks post-injury. This supports current
understanding of the temporal relationship of clinical and radiological union. Thus clinical status of the fracture is
of paramount importance when assessing progress of union of the fracture. Radiological investigations will confirm
fracture position, and document evidence of union after 4 weeks.

Figure 3. Radiograph 8 weeks post-diagnosis
REFERENCES:
1. Yokoe K. and Mannoji T. Stress fracture of the proximal phalanx of the great toe: a report of three cases.
American Journal of Sports Medicine 1986; 14 (3): 240-242.
2. Shiraishi M, Mizuta H, Kubota K, et al. Stress fracture of the proximal phalanx of the great toe. Foot and
Ankle 1993; 14 (1): 28-34.
3. Matsusue Y, Yamamuro T, Nakagawa Y, et al. Stress fracture of the proximal phalanx of the great toe:
the case report of a shot-putter. Clinical Journal of Sports Medicine 1992; 2(4): 279-282
4. Brukner P, Bennell K and Matheson G. Stress fractures. Blackwell Science, 2000. pp 183-184.
5. Eisele S and Sammarco G. Fatigue fractures of the foot and ankle in athletes. Journal of Bone and Joint
Surgery – American volume 1993 Feb. 75 (2): 290-298.
6. Hershman E and Mailly T. Stress fractures. Clinics in Sports Medicine 1990 Jan. 9 (1): 183-214
7. Brukner P and Bennell K. Stress fractures in female athletes. Diagnosis, management and rehabilitation.
Sports Medicine 1997 Dec. 24 (6):419-429
8. Fields C and Fricker P. Medical problems in athletes. Blackwell Science, 1997.
9. Brukner P and Khan K. Clinical sports medicine, second edition. McGraw Hill 2000.
10. Knapp T and Garrett W. Stress fractures: general concepts. Clinics in Sports Medicine 1997 Apr. 16(2):
339-356.