Metatarsalgia is a common condition that we see on a regular basis. Pain under the second metatarsophalangeal joint (MPJ) is the most common area of pain. When performing a physical examination, it is critical to rule out other less common causes of pain such as neuromas, stress fractures, arthritic conditions of the MPJ, and skin conditions such as warts, calluses and porokeratoses.
An arthritic joint will have a crunchy feel to the dorsal MPJ, especially with range of motion (see Figure 1). The motion will not be fluid-like but rather stiff and with soft tissue crepitation. If there is pain with range of motion of the digit, then you know you are dealing with a joint problem and can rule out neuromas. If there is pain on the dorsal metatarsal neck with redness and swelling, you most likely are dealing with a stress syndrome or stress fracture.
Assuming that you have ruled out other causes of pain and your diagnosis is capsulitis/bursitis/synovitis/predislocation syndrome of the second MPJ (or whatever you like to call it), what do you do?
From a conservative standpoint, offloading of the joint with a metatarsal pad and sub-second MPJ accommodation pocket is in order. If there is instability of the toe with a painfully positive Lachman’s test, then digital splinting is effective. A Budin hammertoe splint may also be effective. Certainly, rest, stiff soled shoes, icing and nonsteroidal anti-inflammatory drugs (NSAIDs) are indicated.
What about surgery? Do you do a Weil osteotomy or another metatarsal osteotomy? Do you do a direct plantar plate repair? Do you do both? Personally, I have found that when there is a long second metatarsal, a Weil osteotomy (with hammertoe repair if needed) will provide resolution of sub-second metatarsal pain without a plantar plate repair (see Figure 2). Unfortunately, the patient will generally have a floating toe (see Figure 3). If that is going to be a problem for the patient (after discussing the scenario), then a plantar plate repair is necessary to obviate that problem.
So what do you do in the case of chronic sub-second metatarsal pain with a normal metatarsal parabola, no hammertoe and no dysfunctional first ray? Your patient has tried every conservative treatment protocol and he or she cannot live with it anymore.
What I have found to be effective is a direct plantar visualization of the plantar plate and performing radiofrequency Coblation (Topaz, Arthrocare). I feel this approach has some advantages. First, if there is a plantar plate tear, rent, defect, etc., then I can directly repair it. Secondly, it avoids altering normal osseous structures. Finally, if there is a plantar plate tear and I do find abnormality of the bone (i.e. hypertrophic condyle), then I can do a simple condylectomy from this approach.
I have a case to share with you. A 59-year-old female presented with the chief complaint of sub-second metatarsal pain. Her exam was consistent with capsulitis/bursitis of the second MPJ. She did not have any digital deformities. The patient had no gross instability of the second MPJ with a negative Lachman’s test. She had her greatest pain with plantarflexion of the toe and with direct palpation of the metatarsal head and plantar plate.
Her X-rays revealed a relatively normal metatarsal parabola without any deformity (see Figures 4-6). She had six months of conservative treatment with the conservative measures I described above. The patient pushed my hand to perform surgery.
I performed a plantar incision over the second MPJ and inspected the plantar plate and flexor tendons, all of which looked normal without a tear. I simply performed radiofrequency Coblation of the plantar plate (see Figures 7-9). Within two months following the surgery, she was pain-free.
This is yet another option for treating the sub-second metatarsalgia condition when there is not an osseous deformity or frank tear of the plantar plate.