A painful swollen toe

A 31 year old man presented to his family doctor with a one year history of painful swelling of his left second toe. The swelling was persistent, did not improve with rest or leg elevation, and was exacerbated by prolonged walking and working. The pain was worse at night. He thought the symptoms were related to tight footwear. There was no history of preceding trauma or fever.

On clinical examination, the patient was afebrile. The proximal aspect of his second toe was swollen and tender (fig 1). No definite mass was palpated, and the passive motion of the proximal interphalangeal joint was similar to that of the contralateral toe, with pain at the end range of flexion and extension of the joint. The patient’s erythrocyte sedimentation rate, C-reactive protein (CRP), and white cell count were all within the normal ranges. Radiography showed a radiolucent lesion in the plantar cortex of …