Medical Imaging Analysis Report

I. Imaging Findings

Based on the toe X-ray/ultrasound/MRI data provided by the patient, the following main imaging features can be observed:

1. Lesion Location: Located in the distal phalanx of the third toe of the right foot (near the nail bed or the base of the distal phalanx), close to the toe pad or under the nail.
2. Lesion Morphology and Size: The lesion is relatively small in volume and is confined to the soft tissue around the distal phalanx, with no obvious widespread swelling or bone destruction observed.
3. Ultrasound Findings: The lesion appears as a hypoechoic (or hypoechoic mass) structure, with a certain degree of blood flow signals on Color Doppler, suggesting a vascular-rich possibility.
4. MRI Findings: On T1-weighted images, the lesion shows low or isointense signals, and on T2-weighted images, it is hyperintense. Contrast-enhanced scans reveal marked enhancement. The dynamic contrast-enhanced sequence shows a significant “tumor blush” in the arterial phase. There may be mild compression or indentation of the surrounding bone cortex, but no obvious bone erosion is noted.
5. Relevant Clinical Signs: The patient complains of persistent pain and extreme sensitivity to cold stimulation (cold sensitivity), consistent with the characteristics of a vascular lesion on imaging.

II. Possible Diagnoses

Combining the above imaging findings and the patient’s history, the following differential diagnoses are considered:

1. Glomus Tumor (of the finger/toe): Typically presents as a small, highly vascular tumor that is painful and tender, often with pain exacerbated by cold. On MRI, it often shows low signal on T1, high signal on T2, and marked contrast enhancement, making it the primary diagnosis to consider.
2. Giant Cell Tumor of Tendon Sheath: Although commonly found around the fingers or hand joints, it can also appear in the toe. It usually shows mixed or low signal intensity on MRI, with less vascularity compared to a glomus tumor. Clinically, significant cold sensitivity is often absent.
3. Schwannoma: A peripheral nerve tumor that can cause local pain or tenderness, but rarely exhibits pronounced cold sensitivity. Its enhancement pattern also differs from that of a glomus tumor.
4. Other Soft Tissue Lesions: Such as hemangiomas or small benign soft tissue tumors. Although small in size and locally confined, they should still be included in the differential diagnosis. However, they can often be excluded based on clinical presentation and MRI features.

III. Final Diagnosis

Taking into account:

• the patient’s age (21 years), main symptoms (severe pain, tenderness, cold sensitivity lasting 4 years),
• imaging findings (low signal on T1, high signal on T2, vascular enhancement),
• the classic clinical triad (pain, tenderness, cold sensitivity).

The most likely diagnosis is: Glomus Tumor of the Toe.

If there is still doubt, surgical exploration and pathological examination can be considered to confirm the diagnosis.

IV. Treatment Plan and Rehabilitation

1. Treatment Strategy:
   • Surgical excision is the main treatment. Depending on the lesion’s exact location, removal can be performed through a nail approach or a lateral incision, ensuring complete resection of the tumor. Care should be taken to avoid damage to surrounding tissues and nerve bundles.
   • If the tumor is small and clearly localized, the surgical trauma is relatively minimal, and adverse reactions are generally minimal.
   • Regular follow-up after surgery is recommended to monitor for local recurrence.
2. Rehabilitation/Exercise Prescription (FITT-VP Principle):

   After surgical excision, the toe and foot require short-term protection and recovery. Once the soft tissue wound has healed, rehabilitation exercises can be progressively introduced:

   • Frequency (F): Start with gentle exercises 1-2 times a day, gradually increasing to 2-3 times a day as pain subsides.
   • Intensity (I): Ensure exercises do not cause significant pain. In the early postoperative phase, begin with seated or supine toe movements and ankle joint mobilization; avoid prolonged weight-bearing activities.
   • Time (T): Start with 5-10 minutes per session, gradually increasing to 15-20 minutes. If pain or swelling occurs, reduce or pause the exercise accordingly.
   • Type (T):
     1. Active ankle joint exercises: such as plantar flexion, dorsiflexion, inversion, and eversion to improve ankle and toe flexibility.
     2. Toe flexion and extension exercises: gradually increase range of motion to enhance soft tissue elasticity in the surgical area.
     3. Light balance training: for example, standing with support to train ankle coordination (only begin once the surgical wound has stabilized).
   • Volume/Progression (V/P): As pain decreases and function improves, each session can be extended to 20-30 minutes, and frequency increased to 3-4 times a day. Gradually introduce low-impact activities like walking or light jogging that do not place excessive pressure on the toe.

   If the patient has other medical conditions (e.g., osteoporosis, vascular or nerve issues), the rehabilitation program should be tailored to ensure safety.

Disclaimer: This report is a reference-based analysis derived from the provided information and cannot replace an in-person consultation or professional medical advice. If you have any doubts or if symptoms worsen, please seek medical attention promptly for further evaluation or treatment.