Avascular necrosis of the first metatarsal head in a young female adult: A case report and review of literature

Table 1 Follow-up on the patient’s treatment

Timepoint	Remarks
First presentation (May 2017)	The patient first presented with right big toe pain. Physical examination revealed mild swelling of the first MTPJ, with failed IPJ flexion, but intact FHL tendon. Clinical appearance of the feet, sensation and local perfusion of toes were normal
	Pain NRS of 7-8/10 was noted. Patient was put on bilateral elbow crutches for walking aid
1 wk later (May 2017)	Physical examination and CT scan both showed unchanged condition with continued pain and swelling. Overall features still implied either diagnosis was healing AVN or healing fracture
	Pain NRS of 3-4/10 was noted. Patient was stepped down to partial weight bearing protocol with unilateral elbow crutch
2 mo later (July 2017)	Swelling subsided. CT scan revealed no serial changes. The abnormal linear signal within the marrow cavity of the first MTT head remained. Although mild joint effusion of the first MTPJ remained, no observable progression or regression of serpiginous line was seen
	Pain NRS of 1-2/10 was noted. Patient was allowed to conduct full weight bear
14 mo later (July 2018)	CT scan and MRI showed a reduction in bony oedema. The abnormal linear signal within marrow cavity of first MTT head, dorsal aspect of distal phalangeal base and proximal phalangeal head remained visible
18 mo later (November 2018)	Final follow-up: The patient reported slight improvement of her right toe pain, with slight tenderness observed upon palpation. Range of motion of the first MTPJ had improved with only a 10 degree deficit in flexion without swelling, redness or local heat
	Characterisation of the improvement of anatomical morphology by radiological assessments (CT scan and MRI) remained the same. The patient reported that she was able to undergo cross-training during the past ten months. However, she was not able to return to rugby activities. Thus, advise was given to the patient to continue cross-training as tolerated. Anatomical investigation of the toe remained unchanged
	Upon physical examination, tenderness continued to be experienced over the first MTT head. However, the patient was able to return to high-intensity training. She experienced no pain during rest or active flexion and extension, with only mild aching after training
Last follow-up (November 2018)	Mild tenderness remained, with full range of motion of first MTPJ achieved. Patient able to return to high-intensity training with mild aching after each session

MTPJ: Metatarsophalangeal joint; IPJ: Interphalangeal joint; FHL: Flexor Hallucis Longus; CT: Computed tomography; MTT: Metatarsal; MRI: Magnetic resonance imaging.