Irina Antipova: A 72-Year-Old Violinist With Right Great Toe Pain

Learning Objectives

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Learn the common causes of toe pain.
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Develop an understanding of the unique anatomy of the interphalangeal joint of the toes.
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Develop an understanding of the causes of arthritis of the toe.
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Learn the clinical presentation of osteoarthritis of the toe.
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Learn how to use physical examination to identify pathology of the interphalangeal joint of the toes.
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Develop an understanding of the treatment options for osteoarthritis of the interphalangeal joint of the toes.
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Learn the appropriate testing options to help diagnose osteoarthritis of the interphalangeal joint of the toes.
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Learn to identify red flags in patients who present with toe pain.
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Develop an understanding of the role in interventional pain management in the treatment of toe pain.

Irina Antipova

Irina Antipova is a 72-year-old violinist with the chief complaint of, “I can’t walk up or down the stairs to my house because of my toe.” Irina went on to say that she wouldn’t have bothered me, but it was becoming harder and harder to make it up her front steps after coming home from work. Irina said that 50 years of hard winters had finally caught up with her. “Doc, I don’t know what I would do if I didn’t go to teach my students every day, but the getting up and down the stairs and getting up again is getting harder and harder. I try to use a cane, but it really doesn’t help. It takes me forever to get up the stairs. I’m afraid of falling, and my toe hurts so bad.”

I asked Irina if anything like this has happened before. She shook her head no, and said that she was in pretty good shape for the shape she was in, but her toes were really hurting, and “walking is getting harder and harder. I never have been a sound sleeper, but that big toe must be waking me up 20 times a night. I have been using my heating pad, but as you know I live alone, and I am afraid to leave it on at night.”

I asked Irina about any antecedent trauma to the toes, and she thought about it for a minute. She said that she really couldn’t remember any injuries, but back in the “old country,” she walked many miles each day and thought nothing of it. “Everyone did, Doc. You worked hard or you starved. The happiest day of my life was when I first laid eyes on the Statue of Liberty.”

I asked Irina to point with one finger to show me where it hurt the most. Irina pointed to her right great toe, and then began to rub it. She said, “The whole toe hurts. And the other thing is, sometimes I feel this grating sensation, especially when I first get up in the morning.” She denied popping or catching with flexion and extension. I asked if she had any fever or chills, and she shook her head no. “What about steroids?” I asked. “Did you ever take any cortisone or drugs like that?” Irina again shook her head no and said, “Doc, you know me, I’m a tough old bird, and I wouldn’t bother you if it didn’t really hurt. I love my job—it’s my life—but this pain has really got me worried. I have to be able to get up the stairs to get into my house. What will become of me? I am all alone!” And with that, she started crying. I reassured her that we would do all we could to get her better and suggested that we take a look at the toe to figure out what was going on.

On physical examination, Irina was afebrile. Her respirations were 18, and her pulse was 74 and regular. Her blood pressure was normal at 122/74. Her head, eyes, ears, nose, throat (HEENT) exam revealed mild cataract formation on the right. Her cardiopulmonary examination was normal, as was her thyroid exam. Irina’s abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. Visual inspection of the toes revealed no cutaneous lesions or deformity other than findings consistent with osteoarthritis. I took a look at her hands and they were not much better, with both Heberden and Bouchard nodes visible ( Fig. 8.1 ). The skin overlying the right great toe was warm to touch, but there was no evidence of infection or rubor that might suggest podogra ( Fig. 8.2 ). Palpation of the right great toe revealed mild diffuse tenderness, with no obvious synovitis or point tenderness. Range of motion was decreased, with pain exacerbated with active and passive range of motion. The left foot examination was normal, other than findings consistent with osteoarthritis of all the joints of the feet. A careful neurologic examination of the upper and lower extremities revealed no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not

The History

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No history of toe trauma
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No fever or chills
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Gradual onset of right great toe pain with exacerbation of pain with use
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Grating sensation in the right toe
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Sleep disturbance
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Difficulty walking up or down stairs due to pain
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Pain on walking

The Physical Examination

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Patient is afebrile
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Normal visual inspection of toe
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Palpation of right great toe reveals diffuse tenderness
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No point tenderness
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Mild warmth of right great toe
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Pain with range of motion
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No evidence of infection
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No active synovitis

Other Findings of Note

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Normal blood pressure
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Normal HEENT examination other than mild cataract formation on the right
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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No CVA tenderness
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Normal upper extremity neurologic examination, motor and sensory examination

What Tests Would You Like to Order?

The following tests were ordered:

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Plain radiographs of the right toe

Test Results

The plain radiographs of the right great toe revealed significant joint space narrowing and osteophyte formation of the first metatarsophalangeal joint consistent with severe osteoarthritis ( Fig. 8.3 ).