Perplexing sub second met pain

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I'd like some advice on a stubborn case.

Chief complaint: Aching at the ball of the right foot.

History of present illness: Patient is a 35-year-old white male with a gradual onset of an aching type of pain at the ball of the right foot of about 9 months duration. There was no change in his activity level or shoes prior to the onset. It has gotten progressively worse. It is aggravated by walking. He has treated this himself with ice, Epsom salts and ibuprofen which have provided no help. He also complained of chronic pain in both feet, indicating the heels and sub met head areas. Patient is a phys ed teacher and has a high activity level including basketball and golf. He admits to rare alcohol consumption but denies tobacco use.

Past medical history: Denies all major medical problems.

Physical exam: (Initial exam, approximately one month after onset of symptoms) neurovascular status was intact bilaterally. No edema, erythema or ecchymosis was seen. Skin temperature was moderately warm and symmetrical. Strength was 5/5 all muscle groups. Pain was produced with pressure under the metatarsal heads of the right foot. This was maximal under the second. Some pain was produced with passive dorsiflexion of the second right metatarsophalangeal joint. No crepitus or limitation of motion was noted. No deformity of the second toe or metatarsophalangeal joint was seen. In stance, the heels were everted. He was able to do a standing toe raise in which both heels invert however this maneuver aggravated the chief complaint.

Tests: Plain film x-rays were unremarkable. MRI demonstrated a focal tear at the musculotendinous junction of the medial flexor hallucis brevis proximal to the tibial sesamoid (patient has no pain upon clinical exam in this area).

Diagnosis: My initial diagnosis was sub second right metatarsal head bursitis.

Treatment: I recommended that he avoid going barefoot. A metatarsal raise pad was applied. He was instructed on rest, ice and elevation. I recommended that he continue with ibuprofen. When these measures fail to help, he was given a corticosteroid injection. Other treatment has included immobilization in a CAM walker, physical therapy and a Medrol Dosepak. None of these measures have provided relief any lasting.

Any help or advice would be greatly appreciated.

 

The most likely scenario is plantar plate tear, which can still be overlooked by MRI even when looking for it.

LL

 

have you considered referred pain for trigger points in adductor hallucis and flexor hallucis brevis (given MRI revealed a tear in FHB)?

 

Jhan:

Try reading this thread: http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=50748

 

I see several patients with metatarsalgia daily and have been trying to refine my diagnostic technique for recalcitrant cases. Because I have diagnostic ultrasound at hand in my exam rooms I use it a lot and try and glean as much as I can from appreciating the sonographic appearance and motion of soft tissues.

What I believe I am learning is that appearance from US imaging, whilst providing useful insight often requires addition of ultrasound guided diagnostic injections to improve specificity for root of pain.

As Kevin mentioned plantar plate defects are quite common and often an incidental finding.

If plantar plate injury is a pain generator then an intra articular injection will confirm this, sonographically the degenerated zone seems to be associated with signal detected with power Doppler imaging when symptomatic.

I have never seen an adventitious bursa under the 2nd metatarsal head, quite a few under the 1st where they are usually quite noticeable clinically because of swelling.

Plantar fibro-fatty pad oedema is a common finding at metatarsal heads especially when there is joint instability from overly compliant plantar plate which allows dorsal subluxation of proximal phalanx (predislocation syndrome).

I find that plantar digital neuritis is commonly missed by others as cause of metatarsalgia and can be quite confusing because it seems variable symptomatically.

My approach to diagnose root of pain for intractable metatarsalgia in addition to physical exam is;
Diagnostic ultrasound exam of:
metatarso-phalangeal joints for effusion and synovitis, inter-metatarsal space for inter-metatarsal space bursa enlargement adjacent to plantar digital nerve or signs of hyaluran degeneration at neurovascular bundle (so called neuroma), flexor digitorum brevis tendon and sheath for tenosynovitis, plantar plate for degeneration, tear or calcification, metatarsal head for cortical irregularity (OCD), of ganglion cyst or other mass. At metatarsal head 1 position and quality of sesamoids ( bipartite, absent, fragmented and degenerated), Flex Hall Long for degeneration or tenosynovitis, and adventitous bursa.

Mostly, provocative testing with single limb stance heel raise results in pain in which case I may then do sequentially ultrasound guided small volume diagnostic injections with lidocaine into

1 plantar fibro-fatty pad (test there is no sensory loss to digit, there can be nerve block if not done correctly)
2 joint (for joint and capsular nociceptors)
3 deep to neurovascular bundle at deep transverse intermetatarsal ligament for plantar digital neuritis ( I often find dorsal midfoot pain which had plantar digital neuritis as cause and can be very confounding).

This will differentiate roots of pain and there may be more than one. I think this is very important before administering corticosteroid injection; I believe corticosteroid injections often fail because they are put in the wrong place.

I still find it incredible how many people I see who have metatarsalgia which has confounded expensive imaging and multiple treatment options without improvement; root of pain is finally found to be plantar digital neuritis and cause is tight foot-wear.

Hope this helps

Cheers

Martin

The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com

 

I can't believe epsom salts didn't help!

Can you explain why this is perplexing?

Steve

 

Jhan

Does your patient have a clawed. retracted, second toe? if so make a toe prop and see what happens. I have a second met head pain that is extremely tender to walk on even tho I have made orthoses and very deep insoles with met head cut out and met raises etc. Nothing works except a toe prop which completely alleviates the pain.

BTW, what kind of rare alcohol does he drink, personally I like a nice 27 year old Glenfiddich when I want a treat.

Regards Dave Smith