1st MPJ exostosis

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I have a patient, 24 year old female that has complained of irritation from lumps on the top of her big toes with particular shoes.

Previous history of ball room dancing for 5 years from age 13 - 18. Currently both 1st MPJ's (right > left) are seen to have a significant dorsal exostosis on the 1st met head reducing dorsiflexion available at the joint. Right allowing 0 degrees dorsiflexion and left approx 30 degrees.

There is no pain at all besides occasional irriatation with footwear. This is not a major problem for her at this stage although long term implications and outcomes are where we are focusing our attention.

I have discussed two different treatment options with this patient.

1. With currently healty 1st MPJ's, surgically assess and reduce exostosis growth in order to restore ROM. Use of footwear and orthoses in order to control foot alignment and function.

2. No intervention. Footwear and possible orthoses use in order to assist with foot mechanics and pressure distribution. Leave as is until (or if) symptoms present and then look at surgical options.

My thoughts are that with currently healthy joints as seen on x-ray's and the concerns being the dorsal exostosis and long term implications, that surgical opinion would be best. Reducing the exostosis, restoring function, improving shoe fit and mainting this with the required shoes and or orthoses will enable the best long term outcomes.

This is a situation I have come across on a few occasions. I have discussed this with a few other collegues and have been surprised at their hesitancy to advise or discuss the surgical option for a patient such as the above.

Your thoughts on this would be much appreciated.

Scott

 

Hi Scott,

This is a 24 year old female we are talking about - do you think you can successfully change her footwear?

Ian

 

Currently there are about 4 shoes she is predominantly wearing. 1 Brooks Adrenaline, Teva sandal, Boots (1.5 inch heel) and approx 1inch broad heeled shoe for work. She is very restricted currently even with the above shoes mentioned.

Shoe choice has been quite good in the past (all considered) and was previously allowing a good fit and outome with orthoses use.

We have currently got a number very successful shoes, however they are all now rubing on this dosal exstosis. With the very restricted dorsifexion at the MPJ current shoes have not exceeded heel heights of 1.5 - 2 inches (and times in those is rare).

Any surgical change has been discused in terms of long term maintenance and she is mianly focused towads being able to wear her current shoes with comfort.

 

And there was me thinking she presented complaining of pain only when in her 'party shoes'!

If she is restricted/symptomatic in trainers such as Brooks Adrenaline then I think I agree with you - I would probably seek a surgical opinion. Perhaps a relatively simple cheilectomy may do the trick?

Any chance of posting her x-rays on here?

 

Hi Samuzz:

"Right allowing 0 degrees dorsiflexion and left approx 30 degrees."

With this amount of ROM (or lack of) I'm sure her joints (especially the right) are rather degenerated. Rarely do the dorsal exostoses cause this amount of decreased ROM alone. Once a "ceilectomy" is performed the ROM may increase slightly, but don't give her high expectations.

Not seeing the Xray, I would assume there is decreased joint space with a long 1st Metatarsal.

Surgery (this type) always has the same indications - i.e., decrease pain and improve function. If you can fulfill those two criteria then perform the surgery. She can expect continued progression of her hallux limitus/rigidus as time goes on. Ceilectomies are RARELY (if ever) a definitive treatment.

Steve

 

Thanks for the advice. I have reviewed the x-rays (sorry I have no idea how I would attach the films to this post) with the patient and have discussed possible treatment options, but mainly discussing the long term outlook. She will be consulting with a surgeon in the next few weeks to get a better idea of this.

 

If, at the end of the day, it is just the exostosis which is the issue, a simple exostectomy should solve the issue very qucily and easily with minimal disruption to everyday life and minimal periods non-weightbearing. A chielectomy is a more invasive and aggressive procedure, which has good results, however will require a longer rehabilitation period. Either way, it is important to address why the exostoses have developed in the first instance (functional hallux limitus, metatarsus primus elevatus, unstable medial column, varus 1st ray etc.) and also address this to stop the reformation. Exostosis development is a secondary feature of hallux limitus, not an aetiology. But certainly surgery is a very vaible option, granted especially since the patient is a 24 year old female who has a life of shoes ahead of her.
Cheers!