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2nd MTP Joint Pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by dawesy, Apr 27, 2005.

  1. dawesy

    dawesy Member

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    I know everyone out there has no doubt had this problem very frequently. There are many Ddx for this, but excluding major pathologies, im hoping to hear from people their treatment regiemes as i know this can often be treated with ease, however there is always those few that linger around.

    Im talking about that dull pain (not stress#etc..) that is no doubt a capsulitis/synovitis, painful directly on the joint, end ROM. Basically pre-dislocation syndrome.

    Sometimes a simple pad will work, sometimes i progress to a full functional orthotic (W or WO FF pads) if it is biomechanically related (eg 1st MTP Joint problems resulting in overload of the 2nd). Stiffer shoes often a helpful adjunct.

    Curious for others input as sometimes these measures can not get the success I and my patient desires. Im aware of other DDx, but assuming this diagnosis is correct, do others have helpful adjucts to the above measures?

  2. footdoctor

    footdoctor Active Member

    orthotic additions for 2nd met pathology

    hi there,

    I guess you have to zone in on the specific pathology and biomechanical abnormality.

    Is the 2nd met prominent?-'U' to 2nd PMP

    Is the 1st incompetent (FHL or metatarsus primus elevatus)

    For this 1st ray cut out and dancers pad or 2-5 reverse mortons extension.

    M.P.E - mortons extension

    retracted lesser toes- silicone 2-5 interdigital wedge to prevent excessive p/f of mets.

    Hallux rigidus- rigid extension.

    Personally i always ask myself when the problem has occured and not directly treating the site itself.

    Small orthotic modification and additions usually work for me.


  3. FunGuy

    FunGuy Member

    Gday Dawsey

    Good to hear from you and should catch up soon if possible. Should just call really.

    Good topic. See heaps of this stuff.

    Best for me so far is the plantarflexion taping of the 2nd digit to reduce dorsiflexion and mobilise the toe. This with some simple plantar padding (u-ed or met dome both work for some reason) often works a treat.

    And yeah orthotics to offload the 2 MPJ and redistribute pressure. Was wondering also if people see this as often as i do with a mild met adductus?

    That's my two bob.


  4. davidh

    davidh Podiatry Arena Veteran

    I see lots of this too.
    With symptoms which persist after orthosis therapy, it is worth trying cross-frictional massage applied to the plantar and just proximal to the MTP joint.
    In my experience, if adhesions are present symptoms will not tend to clear, and this simple non-invasive technique can have great results.
  5. admin

    admin Administrator Staff Member

    From Podiatry Today:
    Full text of article
  6. I am curious where this name of "second metartarsophalangeal joint stress syndrome" came from. Does anyone know of any previous articles, or references that discuss this disease that Josh Gerbert, DPM discusses in his article that Admin lists above?

    I was taught that this same clinical entity was called "second metartarsophalangeal joint capsulitis" 20 years ago. Yu et al have called the disease "predislocation syndrome" (Yu, G.V., Judge, M.S., Hudson, J.R. and F.E. Seidelmann: Predislocation syndrome: Progressive subluxation/dislocation of the lesser metatarsophalangeal joint. JAPMA, 92: 182-199, 2002). Are there any other names for this very common clinical entity that I see approximately 10 times per week in my practice?

    I tend to prefer "second metartarsophalangeal joint stress syndrome" but would like to have the original reference for when this term was originally coined in the medical literature. Maybe it should be called "plantar plate stress syndrome" or "plantar plate dysfunction"??

    Thanks in advance for your responses.
  7. Craig Payne

    Craig Payne Moderator

    That article is the only time I recall it being referred to as that.
  8. FunGuy

    FunGuy Member

    Gday again

    Perhaps a bit off the original topic but.....

    Just wondering also if any of these people we see in their later years may once have had Freibergs (diagnosed or undiagnosed) as a teenager and are having problems associated with the previous trauma and metatarsal head degeneration.
    Obviously with friebergs there is a degree of avascular necrosis of the metatarsal head. And possibly do these persitent cases lack the blood flow to the met heads. I have read in one study that 33% of the cadaver feet (200 in total) studied lacked a 2nd metatarsal artery (Don't know the name sorry). Does this implicate treatment that no matter how much we offload the area, if the blood flow is compromised to the 2nd met head, healing will always be delayed and in theory may never be 100%.
    Interested to hear any comments and if anyone has found this to be relevant in treating 2nd MPJ pain.


  9. joshua gerbert

    joshua gerbert Welcome New Poster

    2nd MTPJ stress syndrome


    I am not certain who first "coined" the term "2nd MTPJ stress syndrome; however the first time I ever saw it in the literature was in chapter (29) that William Jenkin, DPM wrote for the textbook by Lawrence Oloff - "Musculoskeletal Disorders of the Lower Extremity" in 1994. In talking with Dr. Jenkin he stated that he had been using that term for some years but does not recall ever seeing it in print. He had submitted his chapter for the textbook in 1992. I know that I have been using that term for at least 15 years and probably got it from Dr. Jenkin since we both teach in the surgery department at the California School of Podiatric Medicine. I wish that I could have been more helpful to your inquiry.

    Last edited by a moderator: May 22, 2005
  10. Josh:

    Thanks for the prompt reply. I'll be seeing Larry Oloff on Saturday and I'll ask him about this. I've been hearing some of the Kaiser Sacramento residents use the term "2nd MTPJ stress syndrome" for the past few years and I was told that you and Bill Jenkin frequently used the term. I do like the term "2nd MTPJ stress syndrome" better than "2nd MPJ capsulitis" which is the term I learned somewhere along the way...but can't remember where. I know that "2nd MTPJ stress syndrome" was not being used at CCPM during my student years from '79-'83. Can you believe it's been that long since the "Motley Crew" (Class of '83) graduated from CCPM?

    Maybe Bill Jenkin can contribute to the discussion since he seems to have given this topic considerable thought.
  11. LCG

    LCG Active Member

    Some good articles out there relating to this topic try

    Dilnot,MC. plantar plate rupture . Australian journal of Pod. Med. 2003; vol 37(2) pp43-46

    Thompson FM. Problems of the 2nd MTP joint . Orthopedics 1987. 10(1) 83-89

    Last edited: May 22, 2005
  12. Vanessa Hadchiti

    Vanessa Hadchiti Welcome New Poster

    This is my first message, so i'll keep it simple or i might dig a hole for myself, but if the toe is malaligned in an adducted and hyperextended position, then the dignostic name i refer to is, plantar plate tear. But if the toe is not mal-aligned and there is persistent pain, then it could be early grade 1 stage of a plantar plate tear. One must rule out howver, any sero-negative arthropathies.
  13. John Spina

    John Spina Active Member

    Vanessa makes sense.One should look out for seronegative arthridities in this case.If capsulitis I read an article by Dr.Robert Kornfeld re holistic medicine and treatments for this.While I myself do not do holistic medicine,I will admit it opened up my eyes.That could be a treatment.More traditional treatments include padding and physical therapy.
  14. footdoctor

    footdoctor Active Member

    2nd met issue


    I agree,sero-negative arthroscopies must be ruled out.However,the symptoms and positive diagnostics of my patient have pointed to plantar-plate disruption.I arrived at my conclusion from the folllowing.

    1) pain in 2nd mpj on plantarflexion.

    2) Direct loading on forefoot produce plantar 2nd met discomfort.

    3) WB produced 2nc pipj d/f and adduction

    4) passive d/f and p/f produced no discomfort

    5) dorsal palpation of mpj & extensor digitorums' course,no symptoms.

    Patient so far has responded well to a 2-4 7mm felt toe prop and pmp with long 2nd cut out.

    If you can, download this article from japma on predislocation syndrome.

    It gives all the clinacal features of this deformity,tests and treatments.

    I found it extremely useful.

    predislocation syndrome-progressive subluxation/dislocation of the lesser metetarsophalangeal joints

    Gerald v yu.et al

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