A 14-year-old male patient, high-level skier, presented with recurrent painful swelling at the lateral part of his left foot complicating a quintus varus deformity while using ski boots. Clinically, he presented a wide forefoot with support areas on the lateral side of the fifth metatarsal head, along with mobile swelling.
First radiographs showed subcutaneous amorphous, poorly defined, cloud-like calcifications at the lateral part of the fifth MTP joint and a quintus varus deformity (Fig. 1). Magnetic resonance imaging was performed to exclude malignancy, showing subcutaneous tissue thickening associated with local enhancement after injection of contrast media and small hypointensities compatible with the heterotopic calcifications visible on the radiographs (Fig. 2 a-c). There was no evidence of tumour lesions.
One year later, at the end of the ski season, the patient was seen again and found to have less inconvenience regarding the bunionette and partial resolution of the calcifications seen on the radiographs (Fig. 3).
Three years later the patient showed decreased ski performance due to the recurrence of pain. Physical examination and radiographs showed a wide forefoot with a bunionette deformity, swelling and calcifications near the fifth MTP joint (Fig. 4 a, b).
Periarticular ossification and myositis ossificans could appear after a major trauma such as surgery for hip prosthesis or extended burn [2] and present typical bone organisation with a distinct cortical and trabecular bone pattern along with calcifications. Calcifications normally appear as mineralised densities with an attenuation coefficient higher than soft tissue but lower than bone [1].
Calcifications may arise in septic arthritis, crystal deposition diseases or acute calcific periarthritis (ACP) [3]. For septic arthritis, calcifications are a late manifestation and clinical manifestations are different (blush, heat, fever, etc.) [3]. In pseudogout, calcifications may present with acute symptoms and similar-appearing calcifications, but it is unusual to identify those calcifications without associated chondrocalcinosis. In gout, calcifications are only seen in the intermediate and late stages of chronic gout and are associated with erosions and cortical irregularities. Calcifications are typically associated with a soft-tissue tophus. During intermediate stages, joint space loss may also be seen. Patients have a history of recurrent attacks [3].
In basic phosphocalcic crystal deposition disease, mostly hydroxyapatite, calcifications may appear in either the periarticular tissues or in the intra-articular space. These calcifications are amorphous, dense, round or oval and may have a cloudy aspect while resorbing [4]. For typical phosphocalcic deposits in the supraspinous tendon the period of resorption of the calcifications is usually very painful, which is not the case for our patient. ACP must be considered a subset of hydroxyapatite deposition disease [3]. Calcifications of ACP appear without a triggering factor but early on in the disease and then are gradually adsorbed only with symptomatic treatment and splinting. Radiographs show dense, homogeneous, amorphous, cloud-like, generally round or oval calcific deposits with no cortex or internal trabecular pattern [3], periarticular, with no evidence of joint space narrowing or cortical lesion. Deposit may remain static for a long period, enlarge and change shape, or diminish in size and disappear. Recurrence is not usual for ACP [5].
We also should consider calcifications in systemic processes but where clinical presentation is different [3].
In our case, MRI excluded a tumoral lesion. Recurrent painful swelling when mechanical conflict exists without other symptoms rules out septic arthritis, crystal deposition diseases and systemic processes. The seasonal evolution of symptoms, association with a quintus varus and the absence of recurrence after surgery are in favour of a micro-traumatic origin associated with mechanical conflict.
Written informed patient consent for publication has been obtained.
Painful and recurrent soft tissues calcifications complicating a quintus varus.
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Based on the provided foot X-ray and MRI images, a localized calcification within the soft tissue is observed near the lateral aspect of the left fifth metatarsal head. On the X-ray, this appears as a dense shadow with no evident bone destruction, cartilage erosion, or significant bony deformity, and there is no marked narrowing of the surrounding joint space. MRI shows that the lesion area has a signal clearly different from the adjacent soft tissue, ruling out tumor-related changes. Mild inflammatory changes or edema signals are seen locally, suggesting chronic or repeated mechanical irritation.
Taking into account the patient’s age (14 years), clinical presentation (recurrent pain during skiing, swelling on the lateral aspect of the foot), and imaging findings (localized soft tissue calcification without obvious bone destruction or joint erosion), while excluding tumor, infection, and other crystal-induced arthropathies, the most probable diagnosis is:
“Periarticular soft tissue calcification due to microtrauma (mechanical impact)”
Treatment Strategies:
1) Conservative Management: In early stages or cases with mild symptoms, use physical therapy, anti-inflammatory analgesics (e.g., NSAIDs), and improved footwear design or foot orthotics to reduce localized pressure.
2) Surgical Intervention: In patients with recurrent pain or swelling that significantly impairs function, consider minimally invasive removal of the calcific focus and correction of any fifth metatarsal or foot deformity (e.g., bunionette, metatarsal misalignment) to reduce mechanical stress.
3) Postoperative Rehabilitation: If surgery is performed, postoperative recovery should include rehabilitation exercises and appropriate bracing or protective devices, with a gradual return to weight-bearing.
Rehabilitation/Exercise Prescription (FITT-VP principle):
• Frequency: Begin with 2–3 rehabilitation sessions per week, gradually increasing to 3–4 sessions as pain and swelling improve.
• Intensity: Employ light to moderate intensity, avoiding vigorous impact at the site of irritation. Low-load exercises such as swimming or stationary cycling may be used.
• Time: Start with sessions of around 20–30 minutes, gradually extending to 45 minutes depending on tolerance and symptom improvement.
• Type: Focus on improving foot strength and soft tissue elasticity through range-of-motion exercises, plantar muscle strengthening (e.g., elastic band exercises), and proprioception/balance training (e.g., balance board/soft pad training).
• Progression & Volume: Gradually increase weight-bearing and training volume, closely monitoring for local pain or swelling. Adjust the plan or reduce weight-bearing activities if significant discomfort or swelling recurs.
Special Considerations:
• As a 14-year-old in a growth and development stage, it is important to protect growth plates and avoid excessive or repetitive overuse activities.
• For skiing or other sports, ensure well-fitted footwear with adequate cushioning and support on the lateral aspect of the foot.
• If marked redness, swelling, heat, pain, or worsening functional impairment arises locally, seek medical review and update imaging or laboratory tests as needed.
This report provides a comprehensive analysis based on the current imaging and medical history, serving as a reference only. It should not replace in-person consultation or a professional physician’s diagnosis and treatment. If further questions arise or symptoms worsen, please visit a hospital promptly.
Painful and recurrent soft tissues calcifications complicating a quintus varus.
