A Little (Toe) Problem - Ultimate Frisbee

HISTORY: A 29 year old male professional ultimate frisbee player presented with four weeks of tripping over the lateral aspect of his right foot and inability to move his 5th toe. The lateral aspect of his right forefoot was landed on as he and another player came down from a catch. He denies any pain or popping sensation at initial injury. Denies any sensation changes. He expressed considerable distress as he has been tripping frequently during aggressive cuts and feels the toe “gets stuck” in his cleat. PHYSICAL EXAMINATION: Right foot was without frank deformity, and the 5th ray was well aligned. No bruising, swelling or erythema on the dorsal or plantar surfaces. Complete extensor lag of the 5th digit at metatarsophalangeal joint during active extension while all other toes extend fully. Full active flexion of all digits. Ankle with full active and passive ROM. 5/5 strength in dorsiflexion, plantar flexion, inversion, eversion, and 5th toe flexion. No tenderness to palpation along the 5th digit or along the entirety of the 5th ray. DIFFERENTIAL DIAGNOSIS: 1. 5th toe extensor hood rupture. 2. 5th toe extensor tendon rupture, complete. 3. 5th toe dislocation. 4. Ankle eversion weakness. TEST AND RESULTS: Limited field side ultrasound notable for 5th toe extensor tendon discontinuity and resolving hematoma. The athlete declined further imaging workup as he elected to not pursue surgical intervention. FINAL WORKING DIAGNOSIS: Isolated 5th toe extensor hood rupture, complete TREATMENT AND OUTCOMES: 1. Buddy taping to 4th digit Due to the upcoming season, the player elected to not pursue further workup or invasive intervention. Following conservative buddy taping of the 5th ray to the 4th, the athlete had immediate relief of his tripping sensation. Use of a full-length carbon fiber shoe insert was discussed but not implemented. When reevaluated 6 months after injury, the athlete was not able to demonstrate active extension of his 5th ray. One year after the injury, the inability to extend the 5th ray remains; however, the player is without associated pain, gross functional limitation, or performance degradation.