Disorders of the forefoot and toes

Disorders of the forefoot and toes CHAPTER CONTENTS
The forefoot . . . . . . . . . . . . . . . . . . . . . . . . e302
Short first metatarsal bone . . . . . . . . . . . . . e302
March fractures . . . . . . . . . . . . . . . . . . . e302
Fractures of the fifth metatarsal . . . . . . . . . . e303
Splay foot . . . . . . . . . . . . . . . . . . . . . . e304
The first metatarsophalangeal joint . . . . . . . . . . . e304
The capsular pattern . . . . . . . . . . . . . . . . e304
Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . e305
Arthritis in adolescence . . . . . . . . . . . . . . . . . e305
Traumatic arthritis . . . . . . . . . . . . . . . . . . . . e305
Arthrosis in middle age . . . . . . . . . . . . . . . . . e306
Rheumatoid arthritis . . . . . . . . . . . . . . . . . . . e306
Non-capsular patterns . . . . . . . . . . . . . . . e306
Metatarsalgia . . . . . . . . . . . . . . . . . . . . . . e306
Sesamometatarsal lesions . . . . . . . . . . . . . . . . e307
Hallux valgus . . . . . . . . . . . . . . . . . . . . . . . e307
The outer four metatarsophalangeal joints . . . . . . . e308
The capsular pattern . . . . . . . . . . . . . . . . e308
Rheumatoid arthritis and gout .
Freiberg’s osteochondritis . . .
Traumatic arthritis . . . . . . .
Osteoarthrosis . . . . . . . . .
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e308
e308
e308
e308
Non-capsular patterns . . . . . . . . . . . . . . . e309
Chronic metatarsalgia . . . . . . . . . . . . . . . . . . e309
Interdigital ganglion . . . . . . . . . . . . . . . . . . . e309
Pressure on the nerves in the forefoot . . . . . . . . . . e310
Bruising of the second digital nerve . . . . . . . . . . . e310
Morton’s metatarsalgia . . . . . . . . . . . . . . . . . e310
© Copyright 2013 Elsevier, Ltd. All rights reserved.
The forefoot
Short first metatarsal bone
This is known as Morton’s syndrome. Sometimes a short first
metatarsal is related to pain, sometimes it is not. If the first
metatarsal is too short and hypermobile, most of the body
weight will be borne by the second metatarsal. Because of the
hypermobility and shortening, the transverse arch becomes
depressed and metatarsalgia results (p. e308 of this chapter).
March fractures
This condition was first described in 1855 by Breithaupt,1 a
Prussian military doctor, who stated that many soldiers developed painful swellings at the dorsum of their feet after long
marches. He called this Schwellfuss but the cause remained
unclear until Stechow2 proved that the condition is caused by
stress fracture.
Stress fractures of the metatarsal bones comprise 3.7% of
all sport-related injuries, with the second and third metatarsal
accounting for 80–90% of the fractures.3–5 Stress fractures of
the metatarsals are also common in military recruits and in
long-distance runners. It has been reported that up to 20% of
stress fractures in athletes6 and 23% of stress fractures in military recruits7 are located in the metatarsals.
The lesion should be suspected when a patient presents with
unilateral and localized warmth and oedema at the dorsum of
the foot. Often the symptoms appear after a long walk but
sometimes there is no specific precipitating activity. It is surprising that children are almost as liable to marching fractures
as adults. Cyriax’s8 (his p. 440) youngest patient was a 6-yearold boy.
During the first weeks after the onset of pain, there is local
warmth and oedema over the dorsum of the forefoot. The
Disorders of the forefoot and toes normal findings on functional examination of the ankle and
midfoot contrast with tenderness at the forefoot. Because not
only the bone but also the interosseous muscles at both sides
are involved, the tenderness is more extensive than might be
expected from the fracture itself.
During the first few days, the fracture (usually a hair-line
crack) may not be revealed by routine radiography. The diagnosis is confirmed after a few weeks, when the callus formation
around the fracture becomes radiologically apparent. Earlier
confirmation of the diagnosis is obtainable by either radionuclide bone imaging,9,10 or ultrasound examination.11–13
Differential diagnosis
Localized swelling, warmth and tenderness in the forefoot can
also occur in:
• Gout in one of the tarsometatarsal joints. A history of
recurrent acute attacks of arthritis at the same joint or in
other joints is helpful.
• Rheumatic forms of arthritis, such as rheumatoid arthritis,
psoriasis and reactive arthritis. These disorders affect
multiple joints. The history is also longer than the usual
6 weeks of that of a march fracture.
• Freiberg’s arthritis at the second metatarsophalangeal joint.
Although ischaemic epiphyseal necrosis of the base of the
second metatarsal bone occurs in adolescence, the disease
may be asymptomatic until adult life, when the deformity
of the joint and the degenerative arthritis produce pain.
• Ringworm and erysipelas. Local cellulitis, caused by an
infection of β-haemolytic Streptococci spp. or fungi, can
cause considerable redness, thickening and tenderness. In
erisypelas, there is malaise, chills and fever, together with
an increased erythrocyte sedimentation rate. In ringworm,
there is considerable itching and inspection of the
interdigital clefts very often reveals a small localized
infection between two toes.
Treatment
March fractures, whether partial or complete, always heal
spontaneously in about 6 weeks. By that time, the bone is
usually firm enough to be painless and mis-union need not be
feared.
Treatment consists of relative rest. Normal walking need not
be forbidden during the period of union. Immobilization is
achieved when the forefoot is firmly bound, so that the other
metatarsals splint the broken bone. Because, even with a
splinted fracture, weight bearing still hurts a little, it is up to
the patient to do as much as can be tolerated. If the pain is
too severe, a plaster cast can be applied for 4 weeks.
If there is persistent pain after 6 weeks have elapsed, the
interosseous muscles must be at fault. It is obvious that when
there is a broken bone, the interosseous muscles will suffer
abnormal stresses and become strained. Such a strain, whether
the cause is a direct injury, a march fracture or an overstrain,
hardly ever undergoes spontaneous cure and chronic pain can
last for years. The only effective treatment for this condition
© Copyright 2013 Elsevier, Ltd. All rights reserved.
Fig 1 • Friction to the interosseus muscles. is deep transverse friction for 15 minutes, three times a week,
for about 2–4 weeks. After the massage, faradic and resisted
flexor exercises are given to the toes. The results of this combined treatment are excellent.
Technique: friction
The patient lies supine on the couch. The therapist sits facing
the foot and with the ipsilateral hand encircles the toes in such
a way that the thumb lies at the dorsal aspect and the proximal
interphalangeal joint of the flexed index finger presses under
the metatarsophalangeal joints. The big toe is left free. The
thumb keeps the toes flexed and the index finger presses
upwards, so as to render the metatarsus convex. The shafts
move apart and the muscle bellies lie closer to the surface. The
middle finger of the other hand, reinforced by the index finger,
is now placed in the groove between the two metacarpal bones
(Fig. 1). Fingers, wrist and forearm are kept in one line and
parallel to the metatarsal bones. Deep friction is imparted by
rotating the fingers through an alternate pronation and supination movement of the forearm, so that the muscle is moved
between the fingertip and the metatarsal shaft.
Fractures of the fifth metatarsal
Three distinct fracture patterns occur in the fifth metatarsal:
tuberosity avulsion fractures, Jones fractures, and diaphyseal
stress fractures.
Tuberosity avulsion fractures are the most common and
usually complicate an inversion sprain (see p. 776). The majority heal with symptomatic care in a hard-soled shoe.
The true Jones fracture is defined as an acute fracture at
the junction between the proximal diaphysis and metaphysis
of the fifth metatarsal without distal extension beyond the
fourth to fifth intermetatarsal articulation.14 The mechanism
of injury is believed to be an abduction force applied to the
forefoot with simultaneous ankle plantar flexion.15 A Jones
fracture can be treated with 6 to 8 weeks of non-weightbearing immobilization resulting in fair to good outcomes.16,17
Operative treatment is selected if the patient is a highperformance athlete or nonoperative treatment fails.18
e303
The Lower Leg, Ankle and Foot
A proximal diaphyseal fifth metatarsal stress fracture is
defined as a stress fracture in the zone of the proximal fifth
metatarsal immediately distal to the Jones fracture’s anatomic
area.19 The mechanism of this injury is believed to be a repetitive load applied under the metatarsal head over a relatively
short time, resulting in an overuse phenomenon. A proximal
diaphyseal fifth metatarsal fracture may have a very long
healing time and non-union can develop in as much as 25%
of cases. For this reason, operative treatment is usually
recommended.20
Splay foot
A splay foot is a broadened forefoot, with weakness of the
intermetatarsal ligaments, associated with weakness of the
intrinsic muscles.
Very often splay foot starts with excessive dorsiflexion
movement of Lisfranc’s joint, which occurs when too much
weight falls on the midfoot. This is particularly likely to occur
in women who wear high heels. When excessive weight falls
on the midfoot, the talus is pressed downwards, and the metatarsals undergo an upwards pressure, so that they are given
excessive horizontal play and the transverse arch flattens. The
result is a painful overstretching of the transverse interosseus
ligament and an increase in weight on the middle metatarsal
heads. Calluses will form on the plantar surfaces of the heads
and bruising of the plantar aspect of the capsule of the metatarsophalangeal joints (so-called chronic metatarsalgia) results.
In practice, splay foot is not a specific entity but usually accompanies a midtarsal strain.
Treatment includes a high heel with a horizontal upper
surface, which prevents the forwards gliding of the talus and
thus releases the forefoot (see Ch. 59), and energetic training
of the short plantiflexor muscles of the toes.
Localized splaying indicates a ganglion lying between two
metatarsal heads. When the patient stands, an excessive interval is seen between two toes and palpation reveals a semisolid
tumour keeping the heads apart (see p. e309 of this chapter).
The first metatarsophalangeal
joint
The capsule of the first metatarsophalangeal joint is reinforced
on the plantar surface by a fibrocartilaginous plate that is
attached distally to the proximal phalanx and proximally to the
plantar aspect of the neck of the first metatarsal. This volar
plate contains the two sesamoid bones, inserted in the tendons
of the flexor hallucis brevis (Fig. 2). The flexion–extension
movement is a rolling and sliding of the metatarsal head within
the stable support made up of the base of the proximal phalanx
and the volar plate.21
The joint is extremely important for normal gait. There
must be 60–70% of extension with the first metatarsal to allow
the hallux to function normally during the stance phase of
gait.22 In the final stage of forefoot contact, 40% of body weight
is imposed on the joint and the big toe23 (Fig. 3).
e304
Fig 2 • The first metatarsophalangeal joint; colour indicates the
location of the sesamoid bones within the tendons of the flexor
hallucis brevis. Fig 3 • The final stage of forefoot contact during walking. During extension, the sesamoids are drawn from the head–
neck junction of the first metatarsal to the distal head area.
The average range of motion is 50°.24 Apart from their function
in weight bearing, the sesamoids also serve as a fulcrum that
increases the mechanical advantage of the flexor hallucis brevis
tendon.
The clinical examination of the big toe is summarized in
Box 1.
The capsular pattern
The capsular pattern at the first metatarsophalangeal joint is
slight limitation of flexion, together with marked limitation of
extension (Fig. 4).
© Copyright 2013 Elsevier, Ltd. All rights reserved.
Disorders of the forefoot and toes Pivot point
Fig 5 • A ‘rocker’ fitted to the shoe. Fig 4 • The capsular pattern at the first metatarsophalangeal joint. Box 1 Clinical examination of the big toe
Inspection
Redness and swelling: gout
Gross osteophytes: arthrosis
Valgus deformity and enlarged medial portion of the metatarsal
head: hallux valgus
Ingrowing toe nails
Dermatological conditions
Functional examination
Passive extension and flexion
Normally the big toe can be extended to a right angle with the
forefoot, whereas flexion is only 30–45°. Both end-feels are elastic
Passive abduction, adduction and rotations
Resisted extension: extensor hallucis longus and brevis
Resisted flexion: flexor hallucis longus and brevis
Palpation
For tenderness, fluid and osteophytes
Gout
The first metatarsophalangeal joint is usually the first joint to
be affected in gout. The attack is characterized by a sudden
onset of intense pain, frequently at night. The joint is swollen
and exquisitely tender. The overlying skin is tense, warm and
dusky red. The attack lasts 1–2 weeks, and asymptomatic
periods of months or years commonly follow the initial acute
attack.25
An acute attack can frequently be aborted by colchicine or
by one of the non-steroidal anti-inflammatory drugs.26–28 When
attacks are frequent or other gouty complications such as tophi
occur, lowering of blood uric acid is indicated.29
© Copyright 2013 Elsevier, Ltd. All rights reserved.
Arthritis in adolescence
Early osteoarthrosis at the first metatarsophalangeal joint,
mostly bilateral, occurs in adolescence and is the result of
osteochondritis dissecans.30 It leads to the formation of a hallux
rigidus in young adults.
The teenage patient, nearly always male, develops large
osteophytes at the dorsum of both first metatarsophalangeal
joints. The onset is slow and there is no history of overuse or
of injury. Initially the pain appears only during hyperextension
of the big toe. Later, the joint gradually fixes in the neutral
position, leading to a hallux rigidus. Pain at every step is inevitable from stress on the rigid joint.
Clinical examination shows the big toe to be fixed in a
neutral position. There is only a small range of extension and
flexion. The end-feel is hard and large osteophytes can be
palpated on the dorsum of the joint.
Because the patient is unable to extend the big toe during
the foot-off phase, treatment must aim to introduce a forefoot
movement that does not interfere with the mobility of the
joint but nevertheless enables the heel to move upwards while
the forefoot is on the ground. To do this, a ‘rocker’ is placed
in or under a thick and solid sole of a shoe, at the joint line
(Fig. 5).
Instead of extending at the first metatarsophalangeal joint,
the forefoot will now rock during a normal gait. If this is not
adequate, a steel plate in the sole prevents further stress on
the rigid joint, but the resulting gait is less natural.31
Surgery for hallux rigidus consists of resection of osteophytes and metatarsal head (cheilectomy)32 or resection
arthroplasty.33–35
Traumatic arthritis
This results from a direct trauma or forceful hyperextension
of the joint. This is the case in osteoarthrosis, in which a superimposed post-traumatic arthritis easily occurs. It is also encountered in certain sports, such as soccer and American football.36–39
Treatment consists of an intra-articular injection of 10 mg of
triamcinolone and prevention of further overstretching.
e305
The Lower Leg, Ankle and Foot
Arthrosis in middle age
Osteoarthrosis at the first metatarsophalangeal joint (MPJ) is
the second most common disorder affecting the foot after
hallux valgus. The prevalence of the condition increases with
age, and it has been reported that radiographic changes in the
first MPJ are evident in approximately 46% of women and 32%
of men at 60 years of age.40 The degeneration and stiffness is
not the result of a previous aseptic necrosis but has probably
been induced by trauma or repetitive stresses. Sometimes a
heavy weight falling on the joint or a fracture is the precipitating cause. Repetitive stresses during extension (as in women
wearing high heels) can influence the degeneration.
Deterioration is slow and insidious, and therefore symptoms
may not arise for years. They appear only when the joint
becomes overstrained.41 In other words, the source of the
pain is not the osteoarthrosis as such but the superimposed
post-traumatic arthritis. Symptoms therefore start when some
dorsiflexion is lost: in men when 45° of extension range has
been lost, in women who wear high heels when only 20 or 30°
has been lost. The typical case is consequently a middle-aged
man or woman who has pain at the big toe during and after
walking.
Clinical examination shows a painful and markedly limited
extension of the big toe, together with slight limitation of
flexion. The end-feel is hard. Osteophyte formation and
some local tenderness can be palpated at the dorsum of
the joint.42
Because the pain is the result of a post-traumatic arthritis,
it can be abolished by one intra-articular injection of triamcinolone. If the patient is careful in the future, wears appropriate
shoes with thick, solid soles and avoids high heels, relapses are
not to be expected. During the last decade an alternative treatment termed ‘viscosupplementation’ – the intra-articular injection of hyaluronan with the aim of restoring the viscoelasticity
of the synovial fluid – has been proposed and studies show
promising results.43,44 Good results can also be achieved by
traction. Alternatively, mobilization, using traction–translation
techniques can be used.45 In advanced cases, in which there is
hallux rigidus, the use of a ‘rocker’ and a steel sole must be
advised (Fig. 5). If all conservative treatment fails, surgery can
be undertaken.46,47
Technique: injection
The patient sits with the foot flat on the couch. The physician
grasps the distal phalanx and pulls it in an axial direction, with
a slight flexion component. This distracts the joint surfaces
and enables the joint line to be identified, which is not always
easy to do in patients with large osteophytes: the depression
between the osteophyte and the bone should not be mistaken
for the joint line. A 1 ml syringe is filled with steroid suspension and fitted with a thin 2 cm needle. After identifying the
joint line and the tendon of the long extensor, the needle is
passed into the space between the two bones, medially to the
tendon (Fig. 6) and the steroid is injected.
The patient should be warned of severe after-pain for 12–24
hours but will be pain free afterwards. If care is taken in the
future, a second injection will not be necessary.
e306
Fig 6 • Intra-articular injection of the first metatarsophalangeal joint. Rheumatoid arthritis
This disease often affects the metatarsophalangeal joints.48 The
usual signs and symptoms of an inflamed joint are seen. The
patient has nocturnal pain and morning stiffness. Clinical
examination reveals a capsular pattern and a capsular thickening at a warm and swollen joint. Treatment is causative.
Non-capsular patterns
Metatarsalgia
Metatarsalgia at the first metatarsophalangeal joint is not as
frequent as at the outer four toes. When it occurs, it is usually
the result of an increase in the angle between the forefoot and
the hindfoot. This is the case in a pes cavus deformity and also
in osteoarthrosis at the cuneiform–first metatarsal joint (after
a previous osteochondritis), which fixes this joint in plantiflexion and therefore increases the pressure on the plantar aspect
of the first metatarsophalangeal joint during walking.
The clinical signs are pes cavus deformity of the foot, with
normal mobility and painless resisted flexion of the big toe.
However, there is significant tenderness at the plantar aspect
of the capsule of the first metatarsophalangeal joint.
Treatment consists of an intra-articular injection of 10 mg
of triamcinolone (see earlier). In a pes cavus deformity, the
patient must also wear a raised heel with a horizontal upper
surface (see Ch. 59). This measure relieves the excessive stress
on the joint and prevents recurrences.
© Copyright 2013 Elsevier, Ltd. All rights reserved.
Disorders of the forefoot and toes Sesamometatarsal lesions
Halux valgus
Traumatic periostitis of the sesamoid bone of the flexor hallucis
longus usually results from local trauma, such as stepping barefoot on a sharp pebblestone or landing on the medial side of
the extended joint.49,50 After the accident the patient feels pain
at the inner aspect of the forefoot with each step.
Clinical examination shows a full range of movement, sometimes with pain at the end of extension. Resisted flexion hurts
at the plantar aspect and the sesamoid bone is tender to the
touch, the exact point shifting with the position of the hallux.24
Clinical diagnosis can be confirmed with conventional radio­
graphy and MRI imaging.51,52
Treatment consists of infiltration of the correct area with
10 mg of triamcinolone. Usually one infiltration is sufficient.
Some authors advise orthotics53 as a prophylactic measure but
experience shows that this is never necessary. If conservative
treatment is not followed by quick recovery, fracture54,55 or
post-traumatic osteochondritis56 should be suspected. Immobilization in a plaster cast or surgical intervention is then
required. Surgical treatment may include partial or complete
resection of the sesamoid, shaving of a prominent tibial sesamoid or autogenous bone grafting for non-union.49
Alternatively, the pain can be caused by overuse, which
sets up a traumatic arthritis at the sesamoid–first metatarsal
joint.57,58 This condition is similar to metatarsalgia of the big
toe. Treatment is an infiltration with 10 mg of triamcinolone
between the sesamoid and the first metatarsal, together with
prevention by use of a raised horizontal heel.
This is the most common deformity of the big toe. It has been
estimated that about 25% of the population have it to some
degree.59 There is no parallel between the degree of valgus and
the severity of the symptoms, and many patients with severe
deformity are free of symptoms.
Much has been written about the aetiology of hallux
valgus.60–62 Because hallux valgus also occurs in barefooted
people who never wear shoes, there must be congenital factors
predisposing to the deformity. The causative components seem
to be multiple: the first metatarsal shaft is shorter than the
second, there is a hypermobility of the first ray and the first
intermetatarsal angle is enlarged.63,64 All these factors contribute to the origin of a widely splayed forefoot (A in Fig. 8).65,66
Because of the shortness of the first metatarsal, the second toe
takes most of the weight during the final phase of the step. If
there is a muscular imbalance between the adductor hallucis
and abductor hallucis, the big toe will deviate laterally (B) and
undergoes a pronation movement (C).67 This is accentuated by
the contractions of the flexors and long extensor of the toe,
which act like a bowstring and shift the tip of the big toe
further into adduction (D). When this predisposed splayed
forefoot is now forced into a high-heeled pointed shoe, excessive weight is added and the first toe deviates increasingly and
rapidly in a lateral direction. The pointed shoe increases the
pressure at the medial aspect of the metatarsophalangeal joint,
which results in an inflamed and painful bursa (tailor’s
bunion).68, 69
The diagnosis is made on the typical appearance:
Technique: infiltration and injection
The patient lies supine on a high couch. The tender point is
identified. Because the skin is usually thick and difficult to
sterilize, the medial side of the metatarsophalangeal region
must be scraped until the epidermis is clean. A 1 ml syringe is
fitted to a thin needle and filled with 10 mg of triamcinolone.
The insertion is made from the medial aspect. The thumb of
the free hand is kept on the tender spot and the needle is
advanced in the direction of the palpating thumb (Fig. 7),
whether at the sesamoid bone or at the joint between sesamoid
and metatarsal. Depending on the lesion, an infiltration or an
injection is then made.
• The forefoot is broadened and the transverse arch
flattened.
C
D
B
A
Fig 7 • Infiltration of sesamoid lesions. © Copyright 2013 Elsevier, Ltd. All rights reserved.
{
Fig 8 • Aetiologies of hallux valgus (see text for details). e307
The Lower Leg, Ankle and Foot
• The big toe is angled towards the second toe and
frequently overlies it. The medial portion of the first
metatarsal head is enlarged.
• The skin and the bursa over the medial aspect of the first
metatarsophalangeal joint are inflamed and thickened.
Treatment depends on the degree of disability. It is as well to
remember that many patients with extreme deformities have
no pain at all. Because most of the pain stems from the compression of the enlarged forefoot in too narrow shoes, the
primary conservative treatment is appropriate shoes: a wide
shoe with a horizontal heel should be advised; sometimes a
‘pouch’ can be pressed out at the side of the metatarsal head.
Local tenderness at the skin or at the inflamed bursa can often
be treated successfully with ichthammol ointment. Surgery is
indicated when there is continuous pain or for cosmetic
reasons.70–73 There is a choice of several procedures depending
on the severity of the lesion and the age and mobility of the
patient.74,75
The outer four
metatarsophalangeal joints
The capsular pattern
The capsular pattern at the outer metatarsophalangeal joints is
more limitation of flexion than extension (Fig. 9).
Rheumatoid arthritis and gout
Rheumatoid arthritis affects the metatarsophalangeal joints
symmetrically. In advanced cases, the toes become fixed in the
clawed position of extension at the metatarsophalangeal joint
and flexion at the proximal interphalangeal joint.
Gout is less frequent at the outer toe joints than at the big
toe. The acute redness and tenderness should always be differentiated from a march fracture.
Freiberg’s osteochondritis
This is an ischaemic epiphyseal necrosis of the head of the
second metatarsal bone, first described by Freiburg in 1914,76
and later by Kohler,77,78 who showed that the third instead of
the second metatarsal is involved in about 20% of cases. The
disease occurs in adolescence, before the epiphyseal closure of
the metatarsal head has been completed.79
The precise aetiology is unknown but it is assumed that the
development is precipitated by an abnormally long second
metatarsal bone, indirect trauma and changes in bone marrow
pressure.80,81 Sometimes the disease is asymptomatic until
adulthood, when deformity of the involved metatarsal head
and osteoarthrosis supervene and cause symptoms.
If the condition itself causes symptoms, examination will
show localized arthritis of the second (or third) metatarsophalangeal joint, with local swelling and warmth and limitation of flexion and extension. It takes a month from the onset
of pain before the characteristic radiographic changes become
visible. Therefore, in its early stages the lesion is difficult to
diagnose and a scintigraph or MRI image may be needed to
distinguish it from a march fracture of the metatarsal shaft.82,83
Spontaneous recovery from this subacute stage takes up to
a year. By that time the metatarsal head is permanently enlarged
and palpation reveals a prominent ridge at the dorsal aspect of
the metatarsal shaft. There is also some painless limitation of
flexion and extension. Sometimes, and if no proper prophylactic measures are taken, metatarsalgia caused by the bony
enlargement may supervene.
Later on, when the patient is 40–50 years old, osteoarthrosis
may complicate the picture and the joint becomes fixed in a
manner analogous to hallux rigidus.
Treatment consists of using orthotic metatarsal platforms to
release pressure on the second metatarsal head. If there is
limitation of extension, a ‘rocker’, as in hallux rigidus, can be
prescribed. In advanced cases, surgery may be necessary.84
Traumatic arthritis
Traumatic arthritis at a metatarsophalangeal joint is rare. It can
result from a direct blow or from indirect trauma, for instance
during a hyperextension movement.85 Recently, hyperplantiflexion injuries to the great toe sustained in beach volleyball
players have been described. This injury is referred to as
‘sand toe’ and may result in significant functional disability.86
Untreated, the capsulitis can continue for months, whereas
one injection with 5 mg of triamcinolone can completely
relieve pain within 2 days.
Osteoarthrosis
Fig 9 • The capsular pattern at the outer four metatarsophalangeal
joints. e308
Local injury or a former Freiberg’s osteochondritis can cause
osteoarthrosis at the metatarsophalangeal joints. Limitation of
flexion and extension with a hard end-feel results.
© Copyright 2013 Elsevier, Ltd. All rights reserved.
Disorders of the forefoot and toes Treatment consists of prescribing shoes with hard and thick
soles, eventually fitted with a ‘rocker’ to render extension
asymptomatic.
Non-capsular patterns
Chronic metatarsalgia
Pain in the plantar aspect of the forefoot is called metatarsalgia.
Chronic metatarsalgia affects the middle three toes and arises
when the metatarsal heads have to bear a disproportionate
amount of the body’s weight.
Aetiology
Scranton87 differentiates secondary and primary metatarsalgia.
In the former, the lesion is the result of structural changes in
the joint (e.g. Freiberg’s disease, rheumatoid arthritis or gout).
The latter occurs if there is any incongruence between load
and load-bearing capacity.
The aetiology of primary metatarsalgia is as follows. In
a normal foot, only one-third of the body weight is borne
by the forefoot. The transverse arch and the contraction of
the long flexor muscles of the toes distribute the weight
between the pads of the toes and the metatarsophalangeal
joints. Because of the tautness of the anterior arch, the big toe
and the outer toe take most of the weight. When too much
weight falls on the forefoot, flattening of the anterior arch and
insufficiency of the flexor muscles of the toes results in abnormal pressure on the plantar aspects of the second, third and
fourth metatarsophalangeal joints.88,89 In due course, a local
capsulitis develops. This happens in the following conditions:
• Splay foot: the broadened forefoot, associated with
weakness of the intrinsic flexor muscles leads to flattening
of the anterior arch and some clawing of the toes.
• Plantar deformity: the dropped forefoot leads to
too much pressure at the plantar aspects of the
metatarsophalangeal capsules.
• High heels: if the shoe has a high heel with an oblique
upper surface, the patient will stand on an inclined plane,
sliding constantly downwards on the forefoot. Too much
weight is imposed on the forefoot, with chronic
metatarsalgia as a result. It is not the high heel itself but
the oblique upper surface which is the source of the
trouble. High heels with a horizontal upper surface do not
cause problems and are even beneficial to women with a
plantaris deformity of the forefoot. Unfortunately, no such
ready-made shoes exist.
• Pes cavus deformity: a pes cavus deformity is very
often accompanied by extreme hyperextension at the
metatarsophalangeal joints, caused by shortening of the
extensor digitorum muscles together with ineffective
intrinsic flexors, holding the toes clawed.90 In such cases,
the toes do not bear body weight at all and serious
metatarsalgia results, with large callosities under the
metatarsal heads, together with corns at the dorsal aspects
of the interphalangeal joints.
© Copyright 2013 Elsevier, Ltd. All rights reserved.
• Weak flexor muscles: sometimes the short muscles in the
sole of the foot are weakened after a long rest in bed
during an illness. If too much weight is borne too soon for
too long a time, metatarsalgia can result.
• Dancer’s metatarsalgia: a dancer working en pointe may
bruise the plantar aspect of the second, third and fourth
metatarsophalangeal joints.91 To prevent this, most ballet
shoes are fitted with a small semilunar pad, which ensures
that the joints are protected and the body weight
distributed as widely as possible.
Symptoms and signs
There is pain at the plantar aspect of the forefoot on standing
and walking, relieved by rest. Sometimes a callus will form,
which increases the pressure on the metatarsal head and aggravates the irritation.
Clinical examination shows pain at the end of dorsiflexion,
sometimes at the end of both dorsiflexion and plantiflexion.
Tenderness is noted under the metatarsal heads. Although the
tenderness is described as being of the metatarsal heads, it is
not the articular cartilage but the plantar aspect of the metatarsophalangeal joint that is at fault. The difference is important, because irreversible changes never take place and relief
of too much weight bearing will always lead to full recovery.
Treatment
The most important measure is to avoid excessive weight
bearing at the forefoot: the high heel must have a horizontal
surface. This brings more weight onto the hindfoot than the
forefoot and prevents the foot from sliding forwards. A support
with its thickest part stopping just behind the heads of the
metatarsals (metatarsal pad) must be fitted into the shoe. This
ensures that the shafts of the metatarsals bear more weight
than the joints themselves.
In a splay foot or after a long stay in bed, vigorous strengthening of the short flexor muscles of the toes by exercises is
necessary, so that the toes flex properly at each step to take
most of the body weight during walking.
In long-standing cases, good results can be obtained by a
single intra-articular injection of triamcinolone into the joint.
Technique: injection
The patient lies supine. The joint is identified at the plantar and
dorsal aspect; usually the joint line is more proximal than might
be expected. A thin needle is fitted to a syringe filled with
0.5 ml of triamcinolone. By pulling at the toe and by moving the
proximal phalanx in slight plantar flexion, the joint line becomes
accessible to the needle. The needle is thrust downwards,
lateral to the long extensor tendon. After 1 cm the tip of the
needle is in the joint space and the steroid is injected.
Some soreness is to be expected for about 24 hours. Good
results follow after 2 days. If preventive measures are also
taken, the relief is permanent.
Interdigital ganglion
A ganglion arising from a flexor tendon sheath may arise
between the toes at the dorsum of the foot. It can cause painful
e309
The Lower Leg, Ankle and Foot
pressure, especially if small shoes are worn.92 The diagnosis is
obvious when a firm mass appears during standing. An excessive interval is then seen between the two toes and palpation
reveals a semisolid tumour. Lying down permits the ganglion
to recede. Because the mass is thick and composed of fibro­
lipomatous material, aspiration often fails. Excision is indicated
if problems persist.
Fig 10 • Orthotic device for Morton’s metatarsalgia. Morton’s metatarsalgia
Pressure on the nerves in
the forefoot
Symptoms caused by pressure on nerves at the forefoot are
very often regarded as metatarsalgia. The differential diagnosis
relies on the fact that the patient describes sharp, unexpected
and sudden twinges instead of continuous pain during walking
or running. During clinical examination, no signs of bruising of
the plantar capsule of the metatarsophalangeal joints are discernible. Sometimes the symptoms can be reproduced by local
pressure on a nerve.
Bruising of the second digital nerve
This is a rare condition, which is rather surprising, because the
nerve passes forwards on the lateral side of the plantar aspect
of the first metatarsophalangeal joint, close to the surface and
unprotected from external trauma. It can easily be palpated as
a thick band, before it bifurcates just distal to the joint, to
supply sensation at the adjacent borders of the first and the
second toes. If there is repetitive injury, bruising will persist.
Consequently, the patient gets sharp twinges during walking.
The twinges will be followed by pins and needles and by a
constant ache.
During clinical examination the symptoms can be reproduced by local pressure on the bruised nerve.
Treatment consists of wearing a thick rubber pad under the
forefoot for 3–6 months. An alternative is the injection of
triamcinolone suspension around the inflamed nerve: a needle
is introduced at the dorsum of the foot between the first and
second metatarsophalangeal joints and thrust in the direction
of the affected area, until it is felt to impinge against the
plantar skin, where 1 ml of the suspension is infiltrated.
This condition, first described in 1876,93 results from a neuroma
at the interdigital nerve between the fourth and fifth toes
(exceptionally between the third and fourth toes).
The history is characteristic. The patient, usually a middleaged woman, states that during walking she is suddenly seized
by a sharp and unexpected pain at the outer side of the forefoot. She has to stop walking and characteristically take the
weight off the foot and remove her shoe to rub and massage
the painful area. After some minutes the pain ceases and she
can continue to walk. The frequency of attacks is very difficult
to predict, because sometimes there may be several attacks a
day or none during a year. Usually recurrences tend to become
more frequent. Between the attacks the patient is unaware of
the condition and there are no symptoms at all.
Clinical examination is negative in most cases. Sometimes
the symptoms can be reproduced by moving the heads
of the adjacent metatarsal bones against each other during
compression. Recently, ultrasound examination has been
shown to be very sensitive in the detection of web-space
abnormalities.94,95
The cause was described by Betts in 1940,96 who stated that
the painful condition results from a fusiform neuroma, about
1 cm long, of the fourth digital nerve proximal to its point of
division.97 When the fibrous swelling is nipped between the
adjacent metatarsal heads, or pulled against a swollen transverse ligament,98 sudden ‘neuritic’ pain results.
Treatment consists of relieving the pressure on the neuroma
by alternating the alignment of the metatarsal heads. For
instance, the head of the fourth bone can be elevated by a small
support (Fig. 10). This will keep the bones slightly out of line
and prevent pressure on the nerve. Steroid infiltration seldom
succeeds. When conservative treatment fails, surgical excision
of the neuroma may be required.99,100
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