Lesser Metatarsalgia: Are Lesser Metatarsal Osteotomies Necessary?

Ramy Fahim, DPM, and Lawrence DiDomenico, DPM, FACFAS

Carefully considering the biomechanical factors that contribute to lesser metatarsalgia, these authors advocate and offer insights on combining a modified Hibbs procedure and a Girdlestone-Taylor procedure to maximize outcomes without the complications of a metatarsal osteotomy.

Metatarsalgia refers to localized and generalized pain at the forefoot, specifically at the plantar aspect of the metatarsal heads with either mechanical or iatrogenic etiology.1 The surgical management of this pathology remains an area of debate as various authors have described multiple procedures and approaches.

   Accordingly, it is of utmost importance to identify the biomechanical factors and different etiologies influencing the pathology. Treatments include digital procedures, various metatarsal osteotomies, lesser metatarsophalangeal joint (MPJ) arthrodesis, metatarsal head resections, ancillary posterior muscle group lengthening and medial column procedures.2

   We will explore the avenue of a surgical approach in addressing lesser metatarsalgia, including second MPJ instability, without the need to perform a metatarsal osteotomy. In doing so, we are able to avoid some of the inherent complications that include recurrence of symptomatic intractable plantar keratoses, transfer metatarsalgia, a stiff metatarsophalangeal joint, scar tissue, neuritis, lesser MPJ instability, floating toes, recurrence, malunions, non-unions and overall unpredictable outcomes.1

A Guide To Metatarsalgia Classification

In order to appropriately analyze and formulate treatment strategies adequately, it is important to classify the etiology behind the pathology accurately. This can be subclassified into primary, secondary and iatrogenic metatarsalgia.

   Primary metatarsalgia. Primary metatarsalgia refers to pathology resulting from direct abnormalities in the patient’s anatomy (such as a plantar plate tear, hammertoe conditions that involve extensor recruitment and flexion contracture, etc.). This would include a tight heel cord and hypermobile first ray, which would result in excess loading and propulsion at the level of the lesser MPJs.3 Greisberg and colleagues in 2010 confirmed through their case series of 352 patients that patients with metatarsalgia have a higher dynamic metatarsal elevation (first ray hypermobility) in comparison to those patients without metatarsalgia.4

   Secondary metatarsalgia. Secondary metatarsalgia is a result of systemic conditions such as inflammatory arthropathy, gout, Freiberg’s infraction, tarsal tunnel syndrome and Morton’s neuroma. Additionally, symptoms of post-traumatic injury can shift the plantar pressure and lead to fat pad atrophy, which may exacerbate the symptoms. In addition, the effect of those conditions can result in hyperextension of the MPJ and result in pain similar to mechanical metatarsalgia.2,5

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