2nd MPJ pain

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Hello all,

As a new member this is my first entry and I write in need of help my fellow pods!! I have a woman late 30's who has had unilateral 2nd MPJ for 4mths. Pain is exacerbated in WB and by direct plantar pressure on the 2nd MPJ. Pain is not present with df or pf the toes. Strapping of the foot with met dome worked initailly and still continues to give relief though this is not really a suitable long term option. No hx of trauma and no symptomatic signs of neuroma. No swelling is or has been present and no palpable 'thickness' of tendons etc Orthoses are currently in use. Shoes are not a factor, gait is good and feet are stable, mechanics are very much in 'normal' range. Have tried periods with met domes, met pads, u-shaped pads, in association with massage, traumheel and local into the area. Posterior leg stretches, anti-inflamms etc have all been attempted but with little effect.

She is slightly overweight though the foot itself looks quite normal in appearnace eg no splaying of toes etc. Mild varus in FF with some RF, midfoot eversion but no apparent hypermobility or stiffness in 1st Ray etc.
Out of desperation x-ray and ultrasound but both came back negative.

i am very interested in some further suggestions, if others have come across something similar. Some help my fellow foot lovers??

 

Benjamin

Pathology affecting the 2nd MTPJ is amongst the most common problems we all treat, and usually a tissue/anatomical approach to the diagnosis will usually lead to your answer.

I find the most important and least expensive piece of equipment for assessing the 2nd MTPJ is your index finger. WHERE is the most painful area/s of the joint? Usually, once you can define the area that is most inflamed, treating is becomes easier.

Your main options for differential diagnosis should include;
* plantar plate/capsule tear
* adventitious bursitis
* stress fracture of the neck of the 2nd MT
* neuroma
* undifferentiated systemic arthritis
* old Freidberg's/DJD

Assess a weight-bearing x-ray carefully. What is the relative length of the 2nd MT? Is it too long, relative to the 1st and/or 3rd MT? Do you have access to plantar pressure testing equipment? Is it worth doing an MRI? Have you requested blood work?

At the end of the day, if you have exhausted all of the conservative options, you should consider a podiatric surgeon referral to get assistance and a 2nd opinion.

Hope this helps in some way.

LL

 

Benjamin,

Did you do a dorsal draw test to r/o plantar plate rupture/attenuation? Compare pain /laxity to adjacent lesser toes and contralateral side. If positive, try taping the toe in slignt plantarflexion and test if this decreases her walking pain. If so, immobilize in a Budin splint or Darco shoe.

I can't believe how many of these I find as a second opinion.

Nick

 

We attempted taping toes as suggested but with no improvement. X Ray (following a few weeks of pain) show no signs of Freiberg's, Stress #, any form of arthritis. Ultrasound has shown no sign of neuroma, or disturbance to plantar plate. No deviation of toes in WB. Affected met head ( and others) show no sign of laxity, hypermobility etc. with movement and draw tests.

I suppose my concern is the many number of DD that It does not seem to be and the fact that as mentioned in 1st post, we have tried numerous forms of tx and the only other thing that has helped is strapping. Perhaps this means some form of immobilisation may be the answer. I am considering 2nd opinion by pod surgeon and therfore possible MRI investigation however would love to know exactly what the "pain" itself may be.

Benjamin

 

G'Day Benjamin,
I have just had a dx of partial plantar plate rupture, confirmed by MRI of my own foot. The pain that was described to me by a Pod Surgeon was the leakage of synovial fluid into the joint causing increased pressure in the joint capsule. Whether this is correct or not I am unsure.
I suppose you have tried a 'U' plantar cover or increased medial ILA support to move pressure laterally?
Keep us posted.
Mark.

 

Hi Benjamin

Have you tried to modify/improve the functioning of the foot around the CC i.e. increase the windlass effect of the 1st? say using a cluffy wedge attached directly to the big toe to see if that will off load the 2nd Met? further invert the foot and 1st ray cutouts??

regards

 

Hi Benjamin

Have you tried to modify/improve the functioning of the foot around the CC i.e. increase the windlass effect of the 1st? say using a cluffy wedge attached directly to the big toe to see if that will off load the 2nd Met? further invert the foot and 1st ray cutouts??

regards
Mark

 

Double check that the first ray is not dorsiflexed compared to the contralateral side. If it is I find a soft pad along the first mpj and ray instead of a dome type application can help markedly in this situation to balance up the weight bearing.
Also check if the subtalar joint is in any way supinated/ing into and through midstance as this locks the midtarsal joints and puts pressure on the second as the first ray dorsiflexes its way out of its responsibilities.
Good luck

 

Have you tried these additions (met-dome) in conjunction with the orthotic, or independent of it.

 

To try and answer all questions briefly, I have tried various additions such as met-dome, U shape padding etc without great improvements. There doesn't seem to be any 'splaying' of toes that is so often synonymous with plantar plate disturbance. In previous patients ultrasound has been enough to diagnose such plantar plate problems and this proved negative for this patient, though an MRI would be interesting.

As often the case when trying to compensate for soreness, the patient is now moving the rear and midfoot into a supinated position excessively during gait (causing a new array of problems, peroneal soreness etc). Whilst not displaying any obvious degree of 1st ray pf, or hypermobility, I agree that a 1st MPJ cut out is worth a try. There did appear to be a litle of that compensatory 1st ray df during gait, but it is difficult to accurately assess this due to the fact that she is trying to take pressure off FF. I have made this modification to the orthoses thus far and will keep you posted when I review her next week. Fingers (and toes) crossed.

Benjamin

 

Hey Benjamin

Obviously hard to help via email but I agree with Mark at looking at the function of the first ray as well (reverse mortons extension), however you are now not only dealing with a patient with 2nd MPJ pain, other sites are now symptomatic probably due to her defensive gait pattern. Depending on the time frame (how long she has been in pain) perhaps a second opinion and MRI is a good idea if your latest mods are not successful.

 

Hi there,
insofar as making a device, I have found this to be helpful...cast with the midtarsal joint fully loaded is very important, and then plantarflexing the first whilst maintaining a subtalarneutral has helped me avoid further problems or deficiencies in orthotic manufacture. Scoop the lateral column in the positive cast if the foot is fleshy. I generally do a 2-5 out of cork and add a met pad, not glueing down the top cover till the patient has worn it for a week or two. Look at the bottom of existing shoes to see if there is a "high pressure area" (like a hurricane on the weather channel) under the second. Loosen the lacing across the 1st to 5th to ensure optimal function. If the best mechanical fixes don't appear to help..it may well be a capsular problem.

Best wishes
Freeman Churchill

 

Just a quick end note to all. Following 3 weeks of continual taping of the foot plus a 1st MPJ cut out of the orthoses, patient has reported over 60 % improvement in symptoms. Each time I reduce the amount of taping used (to prevent reliance on that support) and therfore maximise use of the orthoses. At this stage the 1st MPJ cut out seems to have provided significant relief and hopefully symptoms will continue to resolve.

Regards,

Benjamin

 

The latest Podiatry Today has this article:
An Alternative Approach To Plantar Plate Derangement