Medical Analysis Report

I. Imaging Findings

Based on the provided X-ray and ultrasound images:

• The lesion is located on the dorsomedial side of the left great toe, presenting as a distinct solitary prominence.
• X-ray shows a bony protrusion extending outward from the dorsal edge of the distal phalanx, appearing quasi-circular or irregular in shape, without a clearly defined separate cortical layer. A cancellous (spongy) bone-like structure is visible, consistent with cancellous bone hyperplasia.
• Ultrasound indicates a region of high-echo signals (bony structure) below the soft tissue, covered by soft tissue or fibrocartilage-like tissue on top, forming a noticeable local protrusion.
• The protrusion may be continuous with the main body of the distal phalanx, suggesting a bony extension or newly formed bone.

II. Potential Diagnoses

Based on the clinical history and imaging findings, the following differential diagnoses are considered:

1. Subungual Exostosis: Commonly found on toes, especially on the dorsomedial side of the great toe. It may be associated with trauma or chronic irritation, presenting as a painful nodule and nail plate elevation. Imaging typically shows a protrusion that is continuous with the subungual bone.
2. Osteochondroma: Also appears as a bony outgrowth with a continuous cortex, often near the growth plate, covered by a cartilage cap. However, it usually presents more prominently with a distinct bony cortex continuity.
3. Enchondroma: Often found within the bone, commonly in the fingers rather than toes, showing characteristic cartilaginous matrix calcifications. It does not typically present as a pronounced bony protrusion.
4. Glomus Tumor: Generally presents as a soft tissue mass with marked pain, sensitivity to cold, and tenderness. Imaging would show a soft tissue lesion rather than a bony overgrowth.
5. Squamous Cell Carcinoma: May exhibit ulceration and epithelial invasion, typically showing bone destruction or soft tissue masses on imaging, rather than a distinct bony protrusion as in this case.

Among the above conditions, the clinical and imaging characteristics most closely match a subungual exostosis.

III. Final Diagnosis

Considering the patient’s age (29 years old), a year-long progressive enlargement leading to pain, imaging findings (a cancellous bony outgrowth continuous with the distal phalanx), and the typical location on the dorsomedial aspect of the great toe, the most likely diagnosis is:

Subungual Exostosis.

If there is any doubt, further histopathological examination can be undertaken to exclude other rare malignant or special lesions.

IV. Treatment Plan and Rehabilitation

1. Treatment Strategies:
• Conservative Treatment: If pain is mild and does not affect daily activities, a short period of symptomatic management (e.g., local padding, decompression, choosing wider shoes/socks to reduce friction) can be considered. However, due to the tendency of the lesion to grow, causing pressure or pain, surgery is often ultimately required.
• Surgical Treatment:
  • Surgically remove the exostosis and, if necessary, excise part of the involved nail plate to relieve pain and correct nail deformity.
  • During surgery, evaluate the connection between the bony outgrowth and the main phalanx to ensure complete removal of the lesion and reduce recurrence.
  • Preserve the nail bed to maintain normal nail growth function.
2. Postoperative Rehabilitation and Exercise Prescription:

The rehabilitation program should be gradual and individualized, following the FITT-VP principles (Frequency, Intensity, Time, Type, Volume, Progression).

• Early Stage (1–2 weeks post-op):
  • The main goals are wound healing and reduction of local swelling, avoiding vigorous pressure or friction.
  • Perform gentle passive and active exercises of the toes, such as 2–3 sessions per day, each lasting 5–10 minutes, limiting the range of motion to avoid pain.
• Mid Stage (2–4 weeks post-op):
  • Increase active flexion and extension exercises of the toes. Warm foot soaks and light massage can enhance local circulation.
  • Gradually attempt wearing properly fitting, soft-soled shoes, avoiding high heels or tight footwear.
  • Depending on pain and healing status, increase exercise frequency to 2–3 times a day, each session 10–15 minutes.
• Late Stage (after 4 weeks post-op):
  • If bone healing is satisfactory, progressively return to normal gait and daily activities, slowly introducing low-intensity walking or jogging.
  • Increase activity by about 10% per week while monitoring local pain or swelling to adjust training intensity.
  • If necessary, add foot muscle strengthening exercises (e.g., toe towel-grabbing exercises, resistance band training) to help maintain foot stability.

If the patient has low baseline fitness or conditions like osteoporosis, it is crucial to modify exercise methods and intensity under the guidance of professional physicians and rehabilitation therapists to ensure safety.

V. Disclaimer

This analysis report is for reference only and cannot replace in-person clinical diagnosis and medical advice. Specific treatment and rehabilitation plans should be made by qualified medical professionals based on the patient’s actual condition.