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A 40+ male with variable activity attended my clinic recently with transient forefoot pain, with primary site in the 4th and 5th MTPJ's of both feet.
No history of trauma was recorded.
I noticed a butterfly rash across his nose and upper cheeks (he is convinced that he doesn't have lupus!!)

1st MTPJ ROM was slightly restricted, non weightbearing.
Rearfoot to forefoot was normal.
Slight convexity of the forefoot.

Ultrasound by Dr Julie Gregg revealed tearing to the articular cartilage of both 4th and 5th toes. I suspect related joint synovitis, effusions and possible transverse ligament disruption and mild fibrous of the intermet nerves. I'm yet to see the report however.

Thus far activity has been heavily reduced, due to pain, yet at times he feels like he could run a marathon. footwear mod's have not given too much symptomatic relief. joint mobilisation, ice, NSAID's etc have been suggested but i feel it wasn't totally taken of board.

Any ideas how to manage this pathology, taking into account that surgery or scoping the joints are out of the question at the moment?

Manys thanks