When Second MPJ Overload Occurs Without Hammertoe Deformity

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When patients present with pain in the second metatarsophalangeal joint, the author says they often experience pain with high heels (as shown above) and hard-soled shoes, but can also report pain with flat shoes as well.
When Second MPJ Overload Occurs Without Hammertoe Deformity
By Babak Baravarian, DPM

   It is very easy to check the plantar plate and one must treat a tear or partial tear accordingly. However, in most cases, one will not see a tear and the only finding is laxity of the joint with easy dorsal motion of the digit to 80 or 90 degrees dorsiflexion.

Addressing The Possible Treatment Options

   Treatment options are very dependent on the findings. Accordingly, let us consider the following findings and subsequent treatment.

   Laxity of the first ray and hallux valgus causing overload of the second MPJ with no length issues of either ray. The treatment option for such a case includes orthotic therapy with a second ray cutout and physical therapy for pain relief. If conservative care does not work, consider performing a midfoot fusion Lapidus type bunion surgery to stabilize the medial column and relieve stress on the second ray.

   Forefoot overload due to equinus of the Achilles tendon or gastrocnemius complex. The treatment for such a case includes physical therapy for a stretching program and relief of forefoot pressure and pain. One would subsequently emphasize orthotics therapy and stretching by the patient at home. If this treatment course proves unsuccessful, consider a gastrocnemius recession or Achilles tendon lengthening.

   Long second metatarsal compared to the overall length of the first and third metatarsals. Conservative treatment should include physical therapy to calm down swelling and pain, and orthotic therapy that employs a cutout below the second metatarsal head to relieve stress on the region. In my experience, these cases are rare and surgical treatment is rarely indicated. However, in the rare case of a grossly long second metatarsal, consider a shortening procedure if conservative care fails.

   If there is any extensor contracture of the second MPJ, one may use a Weil type osteotomy. However, if the ray is stable, performing a distal shaft osteotomy will allow one to shorten the ray without opening the capsule. This procedure also facilitates better preservation of the joint.

   A stable but short first ray. This finding is fairly common and also very difficult to treat. In these cases, the first ray is not unstable but is short in comparison to the lateral rays. There may be a slight hallux valgus but not enough to warrant surgery. I see most of these cases after attempted surgeries with shortening of the ray leading to lateral overload.

   Conservative care in these cases includes physical therapy to calm down the joint and forefoot pain. One would subsequently use orthotics with a metatarsal pad, adding a Morton’s extension below the great toe to add stress to the region and incorporating a possible second MPJ cutout or added forefoot padding.

   I try to avoid any form of surgery in these cases as it usually does not work well. In my experience, bunion correction is truly not much help as performing a head osteotomy often leads to further shortening. I have also noted transfer lesions with the second metatarsal osteotomy and do not recommend such a procedure. As a last resort treatment, performing a Lapidus style hallux valgus correction with bone graft offers moderate to good outcomes for at least keeping if not lengthening the first ray. I also try to plantarflex the first ray slightly in order to take mildly added pressure away from the second ray and MPJ.

   Laxity of the second MPJ in a normal forefoot. This is fairly rare by itself but one may commonly note this with other findings. Utilizing orthotic therapy with a second MPJ cutout can be useful in addition to physical therapy to calm the region.

   With these cases, I treat this problem as a pre-dislocation syndrome with plantar plate overload. I often will consider a flexor to extensor transfer with or without fusion of the digit. The digital fusion is not necessary if the ray is stable without a hammertoe deformity. The flexor transfer allows more stability of the ray and joint, and limits the abnormal dorsal motion.

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