Current Insights On Treating Second MPJ Dysfunction

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Molly Judge, DPM, FACFAS

In Conclusion

I am reporting this technique as a preliminary pilot project. There has not been a prospective controlled trial evaluating this technique. Further investigation and clinical follow-up is ongoing and I will report on this as new information becomes available.

   Dr. Judge is a Fellow of the American College of Foot and Ankle Surgeons. She is in private practice at North West Ohio Foot and Ankle Institute, serving Ohio and Michigan. Dr. Judge is an adjunct faculty member at Ohio University and the Ohio College of Podiatric Medicine. She is also on the faculty for graduate medical education at Mercy Health Partners in Toldeo, Ohio.


1. Yu GV, Judge MS, Hudson JR, et al. Predislocation syndrome: progressive subluxation/dislocation of the lesser metatarsophalangeal joint. J Am Pod Med Assoc 2002; 92(4):182-99.
2. Personal communication with Luke Cicchinelli, DPM.
3. Banks AS, Downey MS, Martin DE, et al. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, third edition. Lippincott, Williams and Wilkins, Philadelphia, 2001.
4. Personal communication with Lawrence Karlock, DPM.
5. Zgonis T, Jolly GP, Kanuck DM. Interpositional free tendon graft for lesser metatarsophalangeal joint arthropathy. J Foot Ankle Surg. 2005;44(6):490-2.
6. Bouché RT, Heit EJ. Combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: preliminary observations. J Foot Ankle Surg. 2008;47(2):125-37.
7. Weil L Jr., Weil LS Sr. Emerging concepts in treating second crossover toe deformity. Podiatry Today 2009; 22(10):52-58.
8. Judge MS, LaPointe S, Yu GV, et al. The effect of hallux abducto valgus surgery on the sesamoid apparatus position. J Am Podiatr Med Assoc. 1999;89(11-12):551-9.

   For further reading, see “How To Detect Second Metatarsal Pain” in the January 2002 issue of Podiatry Today or “How To Address Key Biomechanical Issues With Second MPJ Injuries” in the April 2008 issue. To access the archives, visit

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Jeff A. Hallsays: February 6, 2011 at 9:58 am

Later this week, we'll be posting a follow-up blog from Molly Judge, DPM, FACFAS. Dr. Judge will expound upon the suture and button technique for plantar plate stabilization and share some questions on the technique from colleagues at a recent seminar.

Jeff A. Hall
Executive Editor
Podiatry Today

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Paul Jones, DPMsays: February 23, 2011 at 7:40 am

Is there results from the seminar yet?

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Mark Nellermoe DPMsays: February 24, 2011 at 5:39 pm

I liked the direct approach your procedure takes to this pathology. My question is how the suture affects the extensor digitorum longus (EDL). Does the tension of the suture cause damage to the tendon? How do you get motion in the joint postoperatively with the tendon tied down with the suture?

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Ed Davis, DPMsays: February 27, 2011 at 8:30 pm

The underlying biomechanical cause of many cases of 2nd MTP joint dysfunction is first ray inadequacy. Most patients in the earlier stages of 2nd MTP joint dysfunction can be treated with orthotics, not surgery. Hypermobile first ray, forefoot supinatus can be treated via a first metatarsal head cut out, forefoot valgus posting when appropriate and a metatarsal elevation in the device.

Yes, orthotics are often not covered by insurance and surgery is.

Reply to this comment »
Molly S. Judge, DPMsays: March 1, 2011 at 12:44 pm

Dr. Davis,

I appreciate your input regarding 2nd MTPJ dysfunction. I agree with you wholeheartedly regarding the potential success of treating HAV with the benefit of orthotic devices. However, the 2nd MTPJ dysfunction has not responded equally well to that therapy. Once the instability has progressed and subtle subluxation and pain has developed, the need for an external splint and accommodative support of the MTPJ predictably provides pain reduction and stability to the affected joint. In my experience, stabilizing the 2nd MTPJ via metatarsal sling pad is far and away the best way to approach this lesser MTPJ instability and pain. The ADDED benefit of a formal orthotic device is an important one but doe not preclude the use of the metatarsal sling pad.

You make a valid point regarding the benefit of orthotic devices in the face of hallux abducto valgus and I agree with you that long-term management includes providing forefoot balancing. In my opinion, treating 2nd MTPJ dysfunction is a conservative issue by and large.

Unfortunately when patients are misdiagnosed, they often present to my office LATER having undergone numerous forms of treatment failures that include surgery. In my article, I emphasize the importance of the clinical and radiographic examination, and the need to exhaust conservative therapy. Only a few patients in my practice have ever required surgical intervention for this condition and I share that experience with the readers. The cases that I discuss in the cover story article on 2nd MTPJ dysfunction are the exception to the rule. In fact, the conservative method is very effective for 2nd MTPJ dysfunction in many cases.

Best regards,
Molly S. Judge, DPM

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