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Diagnosis and Treatment of Forefoot Disorders. Section 2. Central Metatarsalgia

      This clinical practice guideline (CPG) is based upon consensus of current clinical practice and review of the clinical literature. The guideline was developed by the Clinical Practice Guideline Forefoot Disorders Panel of the American College of Foot and Ankle Surgeons. The guideline and references annotate each node of the corresponding pathways.

      Central Metatarsalgia (Pathway 3)

      Central metatarsalgia involves pathology of the second, third, and fourth metatarsals and their respective metatarsophalangeal joints (MPJs). Metatarsal pathology may be secondary to a variety of problems including trauma, length abnormalities, structural deformity, and others. Pathology of the central MPJs is also secondary to numerous different etiologies and encompasses both osseous and soft tissue conditions. Osseous changes may be secondary to arthritis, whereas soft tissue conditions can be complex, often leading to instability of the MPJ and resultant multiplanar deformities. Systemic inflammatory conditions may produce both osseous and soft tissue abnormalities in the areas of the central MPJs.

      Significant History (Pathway 3, Node 1)

      Patients presenting with complaints related to the second, third, and fourth metatarsals and their respective MPJs typically relate a history of pain in the area of the ball of the foot, with or without swelling and/or discoloration. They may report a history of partial or complete stiffness of the affected joint(s). Symptoms are usually of gradual onset, tend to be progressive in nature, and may have been aggravated by a recent change in activity or footwear. Frequently there is no history of trauma (
      • Brunet J.A.
      • Tubin S.
      Traumatic dislocations of the lesser toes.
      ,
      • Goldner J.L.
      • Ward W.G.
      Traumatic horizontal deviation of the second toe: mechanism of deformity, diagnosis, and treatment.
      ). Related complaints may include the development of plantar calluses in the area of where symptoms occur as well as a gradual change in appearance or position of one or more toes (
      • Menz H.B.
      • Zammit G.V.
      • Munteanu S.E.
      Plantar pressures are higher under callused regions of the foot in older people.
      ).

      Significant Findings (Pathway 3, Node 2)

      Examination of the patient with central metatarsalgia symptoms may reveal edema and or inflammation in the area of the involved metatarsal(s) or MPJs. Pain on palpation of the affected metatarsal or joint is typically present (
      • Mendicino R.W.
      • Statler T.K.
      • Saltrick K.R.
      • Catanzariti A.R.
      Predislocation syndrome: a review and retrospective analysis of eight patients.
      ). Pain involving the MPJ usually is exacerbated upon reaching end range of motion with manual testing. Decreased range of motion or crepitus may indicate arthrosis or other osseous changes at the MPJ. Alternatively chronic hyperextension of the MPJ may predispose the plantar plate and collateral ligaments to attenuate and rupture (
      • Johnston III, R.B.
      • Smith J.
      • Daniels T.
      The plantar plate of the lesser toes: an anatomical study in human cadavers.
      ). In these joints, manual stress testing of the lesser MPJ may demonstrate instability as evidenced by dorsal translocation of the digit at the metatarsal head (
      • Thompson F.M.
      • Hamilton W.G.
      Problems of the second metatarsophalangeal joint.
      ). Typically patients with plantar plate rupture have pain with palpation plantarly at the metatarsal head or flexor crease of the affected MPJ (
      • Mandell G.A.
      • Harcke H.T.
      Scintigraphic manifestations of infraction of the second metatarsal (Freiberg's disease).
      ).
      Change in position or alignment of the toe may or may not be seen in central metatarsalgia, as patients may present with complaints of pain at the MPJ prior to the development of associated digital deformities. If digital deformities are present, they may be multiplanar, flexible, or nonflexible. A hyperkeratotic lesion plantar to the affected metatarsal or MPJ may be present and may contribute to the patient's symptomatology (Fig. 1). Diagnostic blocks often are of great help in localizing the area of the patient's symptoms and establishing an accurate diagnosis.
      Figure thumbnail gr1
      FIGURE 1Forefoot submetatarsal hyperkeratotic lesions vary considerably from (A) a localized discrete one to (B) a diffuse lesion under an isolated metatarsal or (C) under multiple metatarsals. (D) Biomechanical evaluation with Harris mat or computer force plate analysis may provide useful clinical information regarding pressure distribution or loading points. Soft tissue pathology such as ganglia, (E) bursa, and (F) skin pathology such as verruca and porokeratoses must be considered.

      Diagnostic Testing: Radiographic Evaluation (Pathway 3, Node 3)

      Radiographic evaluation of the patient with central metatarsalgia symptoms should include weightbearing anterior-posterior (AP), lateral, and oblique views. A plantar axial view may also be beneficial in evaluating the structure and position of the central metatarsal heads.
      Radiographs are evaluated for both soft tissue and osseous changes. Soft tissue is investigated for edema, foreign bodies, and other abnormalities. Joint dislocation, subluxation, or irregularities of the metatarsal head or phalangeal base may be seen. Alignment of the second, third, and fourth MPJs as well as any abnormalities of the metatarsal parabola are assessed on the AP radiograph (Fig. 2). The presence of degenerative and/or avascular changes may be indicated by erosions, joint space narrowing, subchondral cysts, osteophyte formation, sclerosis, and alteration in the normal contour of the metatarsal head. A metatarsal stress fracture may or may not be radiographically apparent. Indeed, the first radiographic evidence of a stress fracture may be reflected by healing bone callus several weeks after the fracture had occurred (Fig. 3).
      Figure thumbnail gr2
      FIGURE 2Metatarsal deformities are often correlated with length relationships to each other on standard weightbearing radiographs. (A) Parabola have been described as well as (B) metatarsal tangents. Certainly, osseous relationships vary from patient to patient, but weightbearing radiographs have been used as an objective parameter to explain the forefoot pathologies discussed in this document. (Metatarsal tangents from ACFAS Scoring Scale, 2006.)
      Figure thumbnail gr3
      FIGURE 3Metatarsal stress fractures are common. This patient had (A) radiographs taken 2 weeks prior in the emergency room that were negative and now show complete fracture with displacement of the second metatarsal. (B) A follow-up radiograph 3 weeks later shows exuberant bone callus indicative of the unstable nature of the fracture.

      Additional Diagnostic Imaging Studies (Pathway 3, Node 4)

      Evidence of pathology at the MPJ joint or metatarsal may be further substantiated with the use of magnetic resonance imaging (MRI), computed tomography (CT), diagnostic ultrasound, radionucleotide scanning, and arthrography. These more advanced imaging techniques may assist in determining the presence and extent of both soft tissue and osseous damage in this area of the foot.
      MRI, CT, and radionucleotide scanning are helpful in determining the presence of metatarsal stress fracture or articular pathology such as an arthritide, Freiberg's infraction, or plantar plate rupture not appreciated radiographically (
      • Mandell G.A.
      • Harcke H.T.
      Scintigraphic manifestations of infraction of the second metatarsal (Freiberg's disease).
      ). Ultrasound may support clinical evidence of soft tissue trauma/edema and may offer an alternative diagnostic aid for suspected plantar plate ruptures (
      • Gregg J.
      • Silverstein M.
      • Schneider T.
      • Marks P.
      Sonographic and MRI evaluation of the plantar plate: a prospective study.
      ). The use of intra-articular radio-opaque dye is beneficial in documenting a plantar plate rupture if extravasation of the dye is found to be present (
      • Blitz N.M.
      • Ford L.A.
      • Christensen J.C.
      Second metatarsophalangeal joint arthrography: a cadaveric correlation study.
      ). Plantar pressure studies may be helpful in identifying weightbearing anomalies of the forefoot.

      Diagnosis (#3; Node 5)

      Establishment of the correct diagnosis may be very challenging as quite a variety of pathologies may be etiologic of pain in this anatomic location. These include:
      • Capsulitis (mechanical, arthritic, or secondary to second MPJ instability)
      • Metatarsal abnormalities (dorsiflexed, elongated, plantarflexed, shortened, hypertrophic plantar condyles and first ray hypermobility)
      • Metatarsal stress fracture
      • Second MPJ Instability
      • Other (avascular necrosis, tumor, foreign body, infection)

      Capsulitis (Pathway 3, Node 6)

      Capsulitis of the central MPJs may be secondary to mechanical or arthritic etiologies (Fig 4). Mechanical causes include any condition that results in increased forces through the joint itself as well as overload to the plantar metatarsal head. This may be associated with tears of the plantar plate or ligament disruption. Arthritic conditions include any of the inflammatory arthritidies such as rheumatoid arthritis and many of the seronegative arthritidies. Laboratory testing often is indicated in the establishment of an arthritic process. In the case of a mechanical etiology of capsulitis, treatment includes offloading and management of any contributing biomechanical abnormality with padding and/or orthotic therapy. Oral anti-inflammatory medication as well as local injection of a corticosteroid also may be beneficial. If the patient fails to respond appropriately to these measures, surgical treatment may be necessary. This would include synovectomy along with correction of any contributing pathology (eg, metatarsal abnormality) and repair of any capsuloligamentous tears if present (see Node 9).
      Figure thumbnail gr4
      FIGURE 4(A) Lesser metatarsalgia or localized inflammation of a lesser MPJ is a symptom that is commonly associated with hallux valgus deformities with involvement of the second MPJ. (B) Forefoot derangements frequently include hammertoe deformities with progressive contracture of lesser MTP joints that may lead to complete joint subluxation in the sagittal plane or (C) with a multiplanar deformity with “cross-over” toe. Inflamed or stiff MTP joints may represent (D) a feature of diabetic Charcot foot or (E) an inflammatory arthritis with involvement of the third MPJ with significant metatarsal head erosions.
      When arthritis of the MPJ is the cause of capsulitis, attempts should be made to establish an accurate diagnosis of the arthritic process involved. These attempts include the previously-mentioned laboratory testing, as well as joint aspiration and rheumatologic consultation/referral if indicated. Treatment for an inflammatory arthritic condition of the central MPJs includes all of the nonsurgical and surgical alternatives previously listed for mechanically-induced capsulitis. In addition, arthroplasty-type procedures may be necessary to remove painful ostephytes, remove loose bodies, perform other procedures such as chondroplasty or joint implantation. In some cases, metatarsal head resection may at times also be considered, but this usually is done only in the presence of significant deformity, such as in the performance of pan metatarsal head resection in the setting of rheumatoid arthritis (Fig 5).
      Figure thumbnail gr5
      FIGURE 5(A) The MPJs are a target area for rheumatoid arthritis and this patient exhibits severe deformity (B) with dislocation of the first, second, and third MPJs. (C) This patient underwent forefoot arthroplasty with first MPJ fusion and panmetatarsal head resections. (D and E) Shown are the foot and a radiograph at 1 year postsurgery.

      Metatarsal Abnormality (Pathway 3, Node 7)

      Sagittal plane abnormalities of the central metatarsals may be the result of anatomical variations that are congenital, developmental, or acquired (perhaps from trauma or prior surgery). These abnormalities can manifest themselves as dorsiflexed (elevated), elongated, plantarflexed, and shortened metatarsals, or as hypertrophic plantar condyles. Hypermobility of the first ray may result in a lateral transfer of stress away from the first metatarsal, with resultant symptoms. Any of these conditions, either alone or in combination, can cause increased load or pressure around one or more of the central metatarsals, producing pain, bursal formation, and/or a hyperkeratotic lesion.
      Although an elevated (dorsiflexed) metatarsal may be congenital, more frequently it is a result of trauma or a surgical procedure. Consequently, the adjacent metatarsal heads bear more weight, which may result in pain or plantar hyperkeratotic lesions.
      An elongated central metatarsal extends beyond the “normal” metatarsal parabola. The developmental form may be a result of delayed closure of the growth center for that particular metatarsal. However, the elongation may be only relative if adjacent metatarsals have been shortened from either trauma or surgery. During the gait cycle, particularly at the push-off phase, the elongated metatarsal tends to bear more weight for a longer period of time, resulting in symptoms of increased stress under the involved metatarsal head.
      A structurally plantarflexed metatarsal results in a more plantar location of its respective metatarsal head in comparison to the adjacent metatarsals. Congenital plantarflexed metatarsal is rare, but if present it is commonly associated with an anterior cavus foot deformity. The condition of an isolated plantarflexed metatarsal most often exists as a result of trauma or prior surgery. A clinical plantar prominence of the metatarsal head may also be the result of increased retrograde force from an associated digital deformity with dorsal contraction of the MPJ. This results in increased weightbearing stress, which may result in pain or a hyperkeratotic lesion beneath the metatarsal.
      A shortened metatarsal may be associated with a congenital or acquired syndromic condition (
      • Schimizzi A.
      • Brage M.
      Brachymetatarsia.
      ) or iatrogenically induced secondary to a surgical procedure. In addition to the decreased length of the metatarsal, relative elevation to the adjacent metatarsals results due to the inherent declination of the metatarsals. This shortening may increase the load or pressure to the adjacent metatarsal heads as they bear more weight, at times producing pain and/or hyperkeratotic lesions. Congenital shortening of a metatarsal (brachymetatarsia) usually becomes clinically evident between the ages of 4 and 15 years. Brachymetatarsia is relatively rare, with a reported incidence of 0.022% or 1 in 4586, and affects females more commonly than males in an approximate 25:1 ratio (
      • Davidison R.S.
      Metatarsal lengthening.
      ,
      • Urano Y.
      • Kobayashi A.
      Bone-lengthening for shortness of the fourth toe.
      ). Several retrospective studies report the fourth ray being the most commonly affected (
      • Schimizzi A.
      • Brage M.
      Brachymetatarsia.
      ). A congenitally short metatarsal may also result in metatarsalgia secondary to increased weightbearing forces around the adjacent metatarsal(s). An elevated toe can cause footwear difficulties and painful hyperkeratotic lesions. Physeal abnormalities and other changes may indicate associated syndromic conditions. Complaints from patients seeking treatment for a congenitally short fourth metatarsal may be only for cosmetic concerns.
      Congenital hypertrophy of the plantar condyles of the metatarsal heads is rare. The condition is most commonly the result of exostosis formation secondary to an arthritic condition or a degenerative process. Inflammatory joint disease with or without bursitis may also be a significant contributing factor. Patients with atrophy or anterior displacement of the plantar fat pad will appear to have this condition and may increase weightbearing stress under the involved metatarsal head(s). The lateral plantar condyle is most commonly involved.
      Hypermobility of the first ray has been reported to result in overload of the second metatarsal head with resultant pathology in this area. Treatment of associated first ray hypermobility may be necessary in the treatment of central metatarsalgia.
      Each of these conditions creates similar symptomatology in the area of the metatarsal with the deformity or in the area of adjacent metatarsals. Elongated or plantarflexed metatarsals as well as metatarsals adjacent to an elevated metatarsal sustain increased weightbearing forces. In addition, metatarsals with hypertrophy of the plantar condyles show a similar pattern of increased forces and possible focal keratoses at the level of the condyles.
      Nonsurgical treatment involves medications, offloading the painful joint or metatarsal head, and treating any associated biomechanical pathology. Treatment includes padding, orthoses, and rocker-bottom shoe modifications. Nonsteroidal anti-inflammatory drugs and corticosteroid injections may also be used (
      • Co A.Y.
      • Ruch J.A.
      • Malay D.S.
      Radiographic analysis of transverse plane digital alignment after surgical repair of the second metatarsophalangeal joint.
      ).
      Surgical treatment is indicated for those patients who fail to respond to nonsurgical care or for patients in whom nonsurgical care would not be considered beneficial.
      Dorsiflexed (elevated) metatarsals are surgically treated by an osteotomy at either the proximal or distal aspect of the metatarsal to plantarflex the metatarsal with the goal of reestablishing the normal weight bearing pattern of the forefoot. Care must be taken to avoid over- or under-correction of the deformity.
      Structurally plantarflexed metatarsals are surgically treated by an elevating osteotomy at either the proximal or the distal aspect of the metatarsal to re-establish the sagittal plane alignment of the bone and a normal metatarsal parabola (
      • Feibel J.B.
      • Tisdel C.L.
      • Donley B.G.
      Lesser metatarsal osteotomies A biomechanical approach to metatarsalgia.
      ) (Fig 6). Care must be taken to prevent common complications of excessive elevation or shortening resulting in transfer lesions or metatarsalgia. Painful dorsal exostosis or prominence secondary to excessive elevation and floating toe/lack of toe purchase may also occur (
      • Migues A.
      • Slullitel G.
      • Bilbao F.
      • Carrasco M.
      • Solari G.
      Floating-toe deformity as a complication of the Weil osteotomy.
      ).
      Figure thumbnail gr6
      FIGURE 6(A) Management of metatarsalgia associated with an elongated third metatarsal and a discrete keratotic lesion. (B). This patient underwent a shortening third metatarsal osteotomy to reduce localized pressures and a discrete sub-third metatarsal head lesion.
      Surgical procedures for a shortened metatarsal include acute or gradual lengthening of the metatarsal, soft tissue release, correction of associated digital deformity, and in some cases syndactyly. Specific techniques used for metatarsal lengthening include metatarsal osteotomy, bone grafting, and distraction osteogenesis, (Fig. 7). Potential complications include under- or over-correction, decreased joint motion, delayed union, nonunion, malunion, or graft failure. Amputation at the MTP joint should be avoided because of the risk of subsequent adjacent toe deformity (
      • Ferrandez L.
      • Yubero J.
      • Usabiaga J.
      • Ramos L.
      Congenital brachymetatarsia: three cases.
      ).
      Figure thumbnail gr7
      FIGURE 7(A) Brachymetatarsia most often involves the fourth metatarsal. This patient was surgically treated with distraction osteogenesis. (B) Fixator is in place. (C) Radiography at 1-year postsurgery shows very nice reconstitution of metatarsal length and morphology. (Courtesy Alan Banks, DPM, Atlanta, GA)
      Surgical treatment of enlarged plantar condyles is performed when the symptoms of metatarsalgia are due to the prominence and resultant increased pressure or load caused by this abnormality. Surgical treatment of enlarged plantar condyles involves remodeling or resection (condylectomy) of the involved metatarsal condyles. If other etiologic factors such as those described previously are determined to exist, consideration should be given to other procedures to treat the coexisting deformity.
      Operative treatment of first ray hypermobility may be necessary in some instances. This is usually done via medial column arthrodesis.

      Metatarsal Stress Fracture (Pathway 3, Node 8)

      Stress fractures of the central metatarsals develop when the bone is subjected repetitively to sub-failure loads (
      • Milgrom C.
      • Finestone A.
      • Sharkey N.
      • Hamel A.
      • Mandes V.
      • Burr D.
      • et al.
      Metatarsal strains are sufficient to cause fatigue fracture during cyclic overloading.
      ,
      • Brukner P.
      • Bradshaw C.
      • Khan K.M.
      • White S.
      • Crossley K.
      Stress fractures: a review of 180 cases.
      ,
      • Arnd A.
      • Ekenman I.
      • Westblad P.
      • Lundberg A.
      Effects of fatigue and load variation on metatarsal deformation measured in vivo during barefoot walking.
      ). Stress fractures make up as much as 20% of all sports-related injuries (
      • Fredericson M.
      • Jennings F.
      • Beaulieu C.
      • Matheson G.O.
      Stress fractures in athletes.
      ). A greater incidence of these injuries among females has been reported (
      • Kaye R.A.
      Insufficiency stress fractures of the foot and ankle in postmenopausal women.
      ). Patients with chronic inflammatory arthropathies, severe osteoporosis, marked joint deformity, or receive chronic corticosteroid therapy are at high risk of developing stress fractures (
      • Maenpaa H.
      • Lehto M.U.
      • Belt E.A.
      Stress fractures of the ankle and forefoot in patients with inflammatory arthritides.
      ). Stress fractures of the second metatarsal base are most commonly seen in dancers (
      • Hardaker Jr, W.T.
      Foot and ankle injuries in classical ballet dancers.
      ,
      • Sarimo J.
      • Orava S.
      • Alanen J.
      Operative treatment of stress fractures of the proximal second metatarsal.
      ,
      • Micheli L.J.
      • Sohn R.S.
      • Solomon R.
      Stress fractures of the second metatarsal involving Lisfranc's joint in ballet dancers:a new overuse injury of the foot.
      ,
      • O'Malley M.J.
      • Hamilton W.G.
      • Munyak J.
      • DeFranco M.J.
      Stress fractures at the base of the second metatarsal in ballet dancers.
      ). Although the length of the first metatarsal has been implicated as a risk factor for weight transference, equivalent rates of fracture in short, average, and long first metatarsal conditions have been reported (
      • Drez Jr, D.
      • Young J.C.
      • Johnston R.D.
      • Parker W.D.
      Metatarsal stress fractures.
      ). Numerous studies have shown that abnormal mechanics of the first ray may transfer weight to the adjacent metatarsals and lead to stress transference and fracture of the adjacent metatarsal (
      • Kitaoka H.B.
      • Cracchiolo III, A.
      Stress fracture of the lateral metatarsals following double-stem silicone implant arthroplasty of the hallux metatarsophalangeal joint.
      ,
      • Friend G.
      Sequential metatarsal stress fractures after Keller arthroplasty with implant.
      ,
      • Zechman J.S.
      Stress fracture of the second metatarsal after Keller bunionectomy.
      ).
      The majority of metatarsal stress fractures occur in the second and third metatarsals. Radiographic examination may be normal for several weeks after the onset of symptoms. In cases of uncertain diagnosis or in cases where more aggressive treatment might be indicated (ie, high performance athletes), a technetium bone scan, MRI, or CT scan may assist in the early detection of a stress fracture (
      • Santi M.
      • Sartoris D.J.
      • Resnick D.
      Diagnostic imaging of tarsal and metatarsal stress fractures Part II.
      ).
      The primary treatment of a central metatarsal stress fracture is immobilization and offloading with the use of a walking boot or surgical shoe along with activity modification (
      • Gehrmann R.M.
      • Renard R.L.
      Current concepts review: stress fractures of the foot.
      ,
      • Fetzer G.B.
      • Wright R.W.
      Metatarsal shaft fractures and fractures of the proximal fifth metatarsal.
      ). Proper shoes and orthoses are used to control abnormal biomechanical influences and may relieve symptoms. Failure to address pre-existing biomechanical abnormalities that result in metatarsal stress fractures can lead to complete fracture or possible recurrence (
      • Kaeding C.C.
      • Yu J.R.
      • Wright R.
      • Amendola A.
      • Spindler K.P.
      Management and return to play of stress fractures.
      ,
      • Heaslet M.W.
      • Kanda-Mehtani S.L.
      Return-to-activity levels in 96 athletes with stress fractures of the foot, ankle, and leg: a retrospective analysis.
      ). Return to regular activity or sport is allowed once adequate fracture healing has been accomplished. In the event of malunion, the metatarsal may become elevated, plantar-flexed, and/or shortened and this may increase the load to adjacent metatarsals. Surgical treatment of a metatarsal stress fracture is rarely necessary. However, surgery may be required in cases of complete fracture, failure to heal with usual nonsurgical measures, or in cases of malunion (
      • Sarimo J.
      • Orava S.
      • Alanen J.
      Operative treatment of stress fractures of the proximal second metatarsal.
      ).

      Other (Pathway 3, Node 9)

      Other causes of central metatarsalgia-related symptoms also exist. These include second MTP joint instability, avascular necrosis, tumor, foreign body, and infection.

      Second MPJ Instability

      The second MPJ is most frequently implicated in MPJ instability. Second MPJ instability with or without inflammation of the articular and peri-articular structures can lead to multiplanar malalignment. Second MPJ instability has been described as predislocation syndrome (
      • Yu G.V.
      • Judge M.S.
      • Hudson J.R.
      • Seidelmann F.E.
      Predislocation syndrome Progressive subluxation/dislocation of the lesser metatarsophalangeal joint.
      ), plantar plate dysfunction (
      • Blitz N.M.
      • Ford L.A.
      • Christensen J.C.
      Plantar plate repair of the second metatarsophalangeal joint: technique and tips.
      ), mono-articular non-traumatic synovitis, MPJ capsulitis and synovitis, metatarsalgia, and crossover second toe deformity. Many factors that include both mechanical and inflammatory conditions have been described to contribute to this condition. Possible mechanical causes include trauma to the plantar plate and supporting ligaments and joint capsule; an elongated second metatarsal; Freiberg's infraction; prior surgical intervention; congenital deformities; and the forces produced on the second MTP joint by an adjacent hallux valgus deformity. Inflammatory conditions such as isolated synovitis or systemic inflammatory arthropathies may be causative factors as well.
      The confirmation of an unstable joint is determined by clinical and radiographic evaluations (Fig 8). This condition is characterized by pain and inflammation of the second MPJ and varying degrees of digital deviation in the transverse and sagittal plane. As the condition progresses a positive dorsal stress test on the digit at the MPJ (drawer test) reveals subluxation and, sometimes in later stages, dorsal dislocation (
      • Yu G.V.
      • Judge M.S.
      • Hudson J.R.
      • Seidelmann F.E.
      Predislocation syndrome Progressive subluxation/dislocation of the lesser metatarsophalangeal joint.
      ). Transverse plane deviation of the digit may be better appreciated on weightbearing examination and is commonly present with sagittal plane instability. It should be noted that clinical instability at the MPJ is not necessarily pathognomonic for a plantar plate rupture; rather it may be identified in patients with ligamentous laxity and chronic plantar plate attenuation (
      • Blitz N.M.
      • Ford L.A.
      • Christensen J.C.
      Plantar plate repair of the second metatarsophalangeal joint: technique and tips.
      ).
      Figure thumbnail gr8
      FIGURE 8(A) Plantar plate rupture leading to digital instability and chronic localized pain is the presenting symptom in this patient. (B) Lateral radiograph shows loss of toe purchase with a (C) positive MPJ stress test. (D) The MRI image shows discontinuity of the plantar plate and its phalangeal base insertion is confirmed by (E) an intraoperative photo illustrating rupture. (F and G) Postsurgically, this patient shows restoration of toe purchase, both clinically and radiographically. (Courtesy Craig Camasta, DPM, Douglasville, GA)
      Weightbearing radiographic evaluation reveals the joint alignment changes. MRI and arthrography may be beneficial in further delineating the competency of the plantar plate.
      Nonsurgical treatment may involve offloading of the second MPJ, splinting or taping of the second toe, orthoses, rocker-bottom shoe modifications and metatarsal padding. Nonsteroidal anti-inflammatory drugs and corticosteroid injections also may be used (
      • Co A.Y.
      • Ruch J.A.
      • Malay D.S.
      Radiographic analysis of transverse plane digital alignment after surgical repair of the second metatarsophalangeal joint.
      ).
      Surgical treatment is indicated for those patients who have failed nonsurgical care or for patients who are not candidates for nonsurgical treatment. Surgical correction is aimed at restoring the alignment and function of the second MPJ and any associated digital deformity. Surgical options include interphalangeal joint arthrodesis, flexor tendon transfer (
      • Myerson M.S.
      • Jung H.G.
      The role of toe flexor-to-extensor transfer in correcting metatarsophalangeal joint instability of the second toe.
      ), reefing of the plantar-lateral capsule, collateral ligament repair, plantar plate repair (
      • Blitz N.M.
      • Ford L.A.
      • Christensen J.C.
      Plantar plate repair of the second metatarsophalangeal joint: technique and tips.
      ), MPJ arthroplasty, and various metatarsal osteotomies (
      • Co A.Y.
      • Ruch J.A.
      • Malay D.S.
      Radiographic analysis of transverse plane digital alignment after surgical repair of the second metatarsophalangeal joint.
      ).

      Avascular Necrosis of the Metatarsal Head

      A unique finding of the lesser MTP joint (typically the second) is osteochondrosis. Commonly referred to as Freiberg's infraction, these cartilage and osseous changes represent an avascular necrosis of the metatarsal head (
      • Freiberg A.A.
      • Freiberg R.A.
      Core decompression as a novel treatment for early Freiberg's infraction of the second metatarsal head.
      ,
      • Binek R.
      • Levinsohn E.M.
      • Bersani F.
      • Rubenstein H.
      Freiberg disease complicating unrelated trauma.
      ,
      • Scartozzi G.
      • Schram A.
      • Janigian J.
      Freiberg's infraction of the second metatarsal head with formation of multiple loose bodies.
      ). Surgical management of this condition may include: distal metatarsal osteotomy (
      • Lee S.K.
      • Chung M.S.
      • Baek G.H.
      • Oh J.H.
      • Lee Y.H.
      • Gong H.S.
      Treatment of Freiberg disease with intra-articular dorsal wedge osteotomy and absorbable pin fixation.
      ,
      • Chao K.H.
      • Lee C.H.
      • Lin L.C.
      Surgery for symptomatic Freiberg's disease: extraarticular dorsal closing-wedge osteotomy in 13 patients followed for 2-4 years.
      ,
      • Katcherian D.A.
      Treatment of Freiberg's disease.
      ,
      • Smith T.W.
      • Stanley D.
      • Rowley D.I.
      Treatment of Freiberg's disease: a new operative technique.
      ,
      • Kinnard P.
      • Lirette R.
      Dorsiflexion osteotomy in Freiberg's disease.
      ), implant arthroplasty (
      • Bordelon R.L.
      Silicone implant for Freiberg's disease.
      ,
      • Miller M.L.
      • Lenet M.D.
      • Sherman M.
      Surgical treatment of Freiberg's infraction with the use of total joint replacement arthroplasty.
      ,
      • Scartozzi G.
      • Schram A.
      • Janigian J.
      Freiberg's infraction of the second metatarsal head with formation of multiple loose bodies.
      ,
      • Shih A.T.
      • Quint R.E.
      • Armstrong D.G.
      • Nixon B.P.
      Treatment of Freiberg's infraction with the titanium hemi-implant.
      ), resection arthroplasty (
      • Young M.C.
      • Fornasier V.L.
      • Cameron H.U.
      Osteochondral disruption of the second metatarsal: a variant of Freiberg's infraction?.
      ) and interpositional grafting (
      • Beito S.B.
      • Lavery L.A.
      Freiberg's disease and dislocation of the second metatarsophalangeal joint: etiology and treatment.
      ,
      • el-Tayeby H.M.
      Freiberg's infraction: a new surgical procedure.
      ), and interpositional soft tissue grafts (
      • Zgonis T.
      • Jolly G.P.
      • Kanuck D.M.
      Interpositional free tendon graft for lesser metatarsophalangeal joint arthropathy.
      ,
      • Roukis T.S.
      • Landsman A.S.
      • Ringstrom J.B.
      • Kirschner P.
      • Wuenschel M.
      Distally based capsule-periosteum interpositional arthroplasty for hallux rigidus Indications, operative technique, and short-term follow-up.
      ).

      Tumor

      Pain and/or swelling in the forefoot may be secondary to tumors of soft tissue or bone. Timely diagnosis and any indicated consultation and /or referral are important. Treatment is specific to the type of tumor present.

      Foreign Body

      Symptoms secondary to a foreign body in the forefoot are not uncommon. A symptomatic retained foreign body may be old or new and may be associated with a significant wound (laceration, gunshot or puncture wound) or show no discernable portal of entry. Excision of the offending foreign body is the treatment of choice. In the acute setting confirmation of tetanus prophylaxis is indicated.

      Infection

      Infection of the central metatarsal area may be secondary to a variety of etiologies including puncture wound, foreign bodies, diabetic ulceration (see Diabetic Foot Disorders: A Clinical Practice Guideline, 2006, supplement to Journal of the Foot and Ankle Surgeons), laceration, fungal infections etc. It may involve joint, soft tissue, bone or occur in combination. Identification of the anatomic structure(s) involved and the causative organism(s) will direct treatment.

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