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4th MTP Extreme Pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Brandon Maggen, Jul 9, 2009.

  1. Brandon Maggen

    Brandon Maggen Active Member

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    Any ideas as to what I'm missing or should look for in this interesting and challenging patient.

    26 year old healthy female with acute and rapid onset pain 4 weeks ago at the approximate area of the 4th MTP joint of the left foot.

    There was no recollection of trauma, tripping, stumbling or injury.

    The dorsum of the area of the 4th MTP joint was swollen and too painful to examine properly. There was no deviation of the 4th digit and patient could bear weight and ambulate, albeit an antalgic gait.

    Xrays reveal absolutely nothing of interest, with specific and detailed viewing and opinion on the 3rd, 4th and 5th metatarsal shafts, necks and heads and their respective proximal phalanges. Also the MTP joints were scrutinized purposefully, without any findings.

    Blood work also show nothing of interest.

    The only lead I have, is that she wears safety boots, which I did not see and is on building sites daily. I suspected Neuritis, neuroma or even infraction, but all intermet spaces are normal and met heads perfect.

    Looking for plantar plate rupture is possible, but still too painful for a vertical stress test.

    I have referred for an MRI in the mean time and eagerly await the results.

    Any advice? Any further test? Any thoughts? All welcomed.

    Thanks in advance

  2. MelbPod

    MelbPod Active Member

    Hi Brandon,

    Sounds a complex case. Has she gone 4 weeks with the same level of pain? has it increased or decreased, has she tried previous treatments, icing? footwear change?
    What makes it better/ Worse?
    What activity does she do? any sports?
    You mentioned she wears safety boots..is she on her feet all day? what surface?
    Does she go barefoot at home?
    Is this in relation to blood tests? ie. no infection?

    My inclination without seeing the patient and this further information would be toward stress fracture, which will not show on plain radiograph, or planter plate injury.

    Look forward to the follow up.

  3. Brandon Maggen

    Brandon Maggen Active Member

    Hi Sally

    Thank you for your thoughts so far.
    Yes, she has gone 4 weeks with progressivively worsening pain.
    She has tried OTC NSAIDs with partial relief.
    She wears safey boots and is on building sites daily which is a mixture of sand, concrete and irregular surfaces.
    She usually goes to gym for free-weights and circuit - no aerobics/ treadmill etc.
    And yes, she normally goes barefeet at home.
    Blood work included, FBC, ESR, CRP, S-Urate - NAD.

    And I agree re stress #/ Plantar plate rupture. MRI has been ordered.

    Will advise on the results.

    Thank you again

  4. Graham

    Graham RIP

    I agree,

    Sounds like a stress fracture. Bone scan would help.
    I put mine in an ankle height air/cast for 6-12 weeks and reassess every 4.

    Good luck
  5. Stress fracture possible but why is the joint inflammed? Intraarticular stress fracture? MRI would be most helpful.
  6. Brandon:

    Acute onset of dorsal forefoot swelling with no history of trauma should be considered to be either a metatarsal stress fracture or metatarsal stress reaction (i.e. pre-stress fracture) until proven otherwise. Plantar plate injuries will first cause plantar swelling at the metatarsophalangeal joint and, in some cases, also cause dorsal swelling, but the dorsal swelling is not present in most plantar plate injuries. I tend to doubt this is a plantar plate injury from the information you have given us.

    The MRI will likely show marrow edema within the distal metatarsal shaft and may or may not have a fracture line. If a fracture line is visible, the diagnosis would be a metatarsal stress fracture. If a fracture line is not visible on MRI, the diagnosis would be a metatarsal stress reaction (i.e. pre-stress fracture). I put these patients into a cam-walker style boot-brace walker, tell them to not walk barefoot and have them ice the foot 20 minutes 2-3 times a day. She will probably need to be in the boot-brace walker for 2-6 weeks depending on whether it is a stress-reaction (about 2 weeks) or stress fracture (about 4-6 weeks).

    And by the way, Brandon, this would not be described as a metatarsophalangeal joint injury if it is a stress fracture or stress reaction of the metatarsal. Nearly all metatarsal stress injuries are extra-articular in nature, occurring at the location within the metatarsal where the greatest bending stresses are located, generally at the metatarsal neck level, where the moment area of inertia is the smallest for the metatarsal shaft.

    Hope this helps.
    Last edited: Jul 11, 2009

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