How To Detect Second Metatarsal Pain
Treating forefoot metatarsalgia can be very challenging. In these cases, you’ll often find several differing types of pain and it may be difficult to differentiate the pain according to the patient’s complaints. Be aware the region most often misdiagnosed is forefoot pain surrounding the second metatarsal region. With this in mind, let’s address differing complaints surrounding the second metatarsal region by considering the following case study.
A 40-year-old female patient comes into the office, complaining of pain in the region of the second metatarsal. She feels pain with ambulation and it worsens with increased ambulation. With continued walking or activity, she feels a chronic sharp pain in the region of the second metatarsal head and surrounding tissues. She also says she has increased pain at the ball of the foot when she wears high heels and you detect some numbness of the second toe at the distal tip.
The patient has no history of trauma and says the pain increased in the previous three to four months from a dull ache to a chronic state. The patient also notes an increased contracture of the second toe in the previous one to two weeks. She reports the pain is slightly better when she uses anti-inflammation medications.
What The Examination Reveals
During the physical examination of the patient, you see mild edema and erythema beneath the second metatarsal head and surrounding tissue. You don’t see any callus tissue and you note there is no fluctuance in the deep space of the second metatarsal head. Upon performing the vascular examination of the foot, you find normal dorsalis pedis and posterior tibial pulses. You also note the patient’s muscle strength to the foot is intact and normal with no loss of muscle function.
However, the second toe has a slight contracture at the metatarsal-phalangeal joint (MPJ) and the proximal interphalangeal joint. There is a slight length difference among the first, second and third metatarsals, as the second metatarsal is slightly longer than the first and third. You also see an associated hypermobility of the first metatarsal-cunieform joint. The patient has a positive Lachman’s dorsal drawer of the second MPJ with associated severe pain.
Palpating the second interspace causes pain with pressure and you notice the second interspace has a fullness. However, there is no palpable click. The pain in the second interspace does not radiate into the toes nor does it radiate proximally into the rest of the foot and ankle. Palpating the plantar surface of the second MPJ and interspace causes greater pain as you place pressure closer to the second MPJ. You note the pain is greater under the second MPJ as you progressively place pressure distally from the metatarsal head toward the attachment of the toe.
The patient’s gait pattern reveals mild pes planus. You notice an associated early heel off pattern secondary to a slight equinus deformity. The patient feels pain when you ask her to stand onto her tip toes but she relates no shooting pain.
When you examine radiographs, you see a slightly elevated first metatarsal and a slightly long second metatarsal. The patient has a mild hammertoe associated with the second toe proximal interphalangeal joint. You also note mild deviation of the second MPJ into an adductus position.
What Is The Differential Diagnosis?
1) Second interspace neuroma
2) Hammertoe contracture with second metatarsal contracture
3) Second metatarsal phalangeal joint synovitis
4) Long/plantarflexed second metatarsal
5) Plantar plate tear of the second MPJ
Key Tips On Adjunctive Tests
An MRI is my choice test in this situation. Although it’s hard to identify a neuroma on MRI, often, there is an associated interspace edema without involving the second MPJ that helps with a possible neuroma diagnosis. When it comes to a plantar plate rupture or partial tear, this is often visible on MRI and you can also diagnose it indirectly when your patient has increased signal in the plantar surface of the second metatarsal head and phalynx base. You can also use an MRI to visualize joint synovitis.