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3 MTP joint synovitis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by srd, Jul 7, 2009.

  1. srd

    srd Active Member

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    I have a 34yo woman with left forefoot pain at area of 3/4MTP joints.

    Assesment shows bilateral pronation L>R. Left HAV. Good ROM of lesser MTP joints -no pain on joint movement. Minor lateral deviation of 4th digit. "Click" elicited on compression and traction of 3rd digit.

    I have been treating this as mortons neuroma including orthotic therapy for improving medial and transverse arches.

    Follow up 4 weeks later showed no improvement to pain levels. Orthotics were comfortable and pt was compliant with treatment. Small increase in 4th digit deviation on weight bearing. No increase on pain on palpation.

    I sent for ultrasound which found ' no evidence of morton's neuroma', 'no evidence of bursitis', 'flexor tendons and sheaths are normal', 'Small joint effusion at the 3rd MTP joint may indicate the presence of some synovitis'.

    Any ideas on further treatment or references would be appreciated. I haven't seen this before.

  2. Peter

    Peter Well-Known Member

    for relief of symptoms short-term, consider icing, rest, nsaids, short-leg walker if debilitating.
    long term, rocker sole with stiffener if shoes flexible.

    Any bloods done?
  3. Griff

    Griff Moderator

    There is no transverse arch


  4. srd

    srd Active Member

    Sorry - you're right. no transverse arch.
  5. David Singleton

    David Singleton Active Member

    could try taping the affected toe in to plantar flexion, to see if this reduces symptoms!
  6. CraigT

    CraigT Well-Known Member

    ...which would suggest plantar/flexor plate tear / pre-dislocation syndrome
  7. Brandon Maggen

    Brandon Maggen Active Member


    Have you tried a Vertical Stress test of both the 3rd and 4th digits? If you have more than +- 2mm vertical displacement, a plantar plate rupture nees to be considered. An MRI would be conclusive.

    Try 'cross-over' taping: with a loop around the dorsum of the affected digit, crossing over each other on the plantar aspect and adhered to the foot. This displaces the digit plantarly which promotes better apposition of the articular surfaces between the metatarsal and the phalange.


    Brandon Maggen
  8. Mart

    Mart Well-Known Member

    I would try and narrow the diagnosis a bit. Can you give us more info on frequency,location and nature of pain; it might then be easier to speculate?

    Occupation, foot-wear, agrevating/mitigating factors, cardio-vascular exercise level and type, recent change in weight-bearing activity, any concurrent mechanical issues, you mention hallux valgus. Do you have access to gait evaluation which might help visualise compensatory overload or elevated ray stiffness, any plantar lesion pattern. How is joint alignment?. Diagnostic ultrasound exam should have picked up any plantar plate issues if you have a decent machine. Was foot painful during Diagnostic ultrasound exam – synovitis may have been quiescent, was power doppler used to visualise synovial flow?

    If I suspected joint pain I would carefully inject about 0.1 mls plain lidocaine with an insulin syringe into dorsal joint space. Careful not to affect digital nerves and check no sensory loss outside of joint space ie joint isolated. If I suspected metatarsal head compression overload then shift force proximally and see affect. I find inter-metatarsal space bursae/neuromas can be tricky to rule out on US sometimes they are really obvious other times the exam can be ambiguous, it depends on subject. Again careful targeted small vol dx injection at site helpful

    Please give is some more meat and potatoes



    The St. James Foot Clinic
    1749 Portage Ave.
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
  9. You mentioned a "click" or Muelder's Sign. What do think is the cause of this? Is there sensory alterations of the adjacent sides of the involved toes? If so, likely a Morton's Neuroma. I must admit, these can be difficult diagnostic dilemmas. What do you suppose causes the toes to seperate?
  10. srd

    srd Active Member

    Thanks to all replies,

    Pt is a dental nurse and so spends a lot of time on feet. She has not had any recent changes to weight bearing loads. Her only exercise regime is a walk around the block with the dog. The pain started about 8-9 weeks ago, but pt can not remember any activity that would have triggered this. Pain is not constant but is aggravated by poor footwear and is worse in evenings. Passive Joint mobility seemed normal and not painful. HAV was the only bony deformity apparent in chair. Deviation of 4th digit was only noticed upon weight bearing.

    When I got the 'click' I was sure it was Muelder's sign - I have heard this several times before and it sounded and felt the same. I have always believed this to be diagnostic. (please correct me if I'm wrong). Which is why I have been treating it as Morton's Neuroma.

    I sent pt for ultrasound after symptoms were not alleviated and digit displacement increased. (which I thought must be due to some interdigital swelling but I haven't seen this with Morton's neuroma before).

    With the results I am thinking more of plantar plate rupture so I spoke to sonographer who didn't believe plantar plate rupture could be diagnosed successfully with ultrasound and an MRI would be a better diagnostic tool.

    In the mean time I have altered orthotics and am doing taping as suggested.

    Thanks again for your help and suggestions.

  11. Mart

    Mart Well-Known Member

    I am curious regarding comments that PP rupture could not be Dx on US. With hight res (14Mhx) probe the PP is beautifully imaged and can be observed dynamically with dorsiflexion of phallanx.

    If there is rupture then the FDL tendon is seen touchng the metatarso-phalangeal joint, if partial rupture the tear can be seen to "open up" when stressed". If your search podarena for PP you will see some images demonstrating this which I posted last year.

    The only patients I have seen with complete rupture have rheumatoid arthritis and sequellae in foot.

    I believe that inter-metatarsal space bursa/neuroma may be missed if not having "textbook" appearance" on US. This is my personal anecdotal impression based on my own experince and is not supported by the literature which I have read.

    Foot-wear (which you allude to) in my experience has a large impact on pain associated with inter-metatarsal space lesions seems often neglected as part of others treatment plans. I have seen many patients wanting second opinion regarding neuromas who have failed to respond to steroid, and offered surgery.

    Often when checking foot-wear (patient self report is often misleading) it is frequently contrictive at forefoot and with modification of footwear habits problem resolved if lesion is in early stages of disorganisation (and not obvious on US).

    good luck with this



    The St. James Foot Clinic
    1749 Portage Ave.
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
  12. LHM

    LHM Member

    Hi srd
    With MPjt synovitis it might be worth checking for signs of rheumatoid arthritis, can be a very early indicator and worth trying to rule out.
  13. Sammo

    Sammo Active Member

    Just a quick thought.. If she has HAV then the 1st ray will be likely to not be loading as much as it should = extra force being distibuted across the lesser metatarsals.. could cause both the Capsulitis or PP rupture and possible some intermetatarsal injury (Neuroma, Interossei strain etc..)?

    Also, i'm guessing you have a pre met dome on the orthoses.. where exactly is this placed.. photos of orthoses would be a great help :-D

    Kindest regards,


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