Disorders of the Forefoot and Toes

Disorders of the forefoot and toes

CHAPTER CONTENTS The forefoot e302 The forefoot Short first metatarsal bone ...... e302 March fractures ...... e302 Short first metatarsal bone Fractures of the fifth metatarsal e303 This is known as Morton’s syndrome. Sometimes a short first Splay foot ...... e304 metatarsal is related to pain, sometimes it is not. If the first The first metatarsophalangeal joint e304 metatarsal is too short and hypermobile, most of the body The capsular pattern ...... e304 weight will be borne by the second metatarsal. Because of the Gout ...... e305 hypermobility and shortening, the transverse arch becomes Arthritis .in .adolescence ...... e305 depressed and metatarsalgia results (p. e308 of this chapter). Traumatic .arthritis ...... e305 Arthrosis .in .middle .age ...... e306 March fractures Rheumatoid .arthritis ...... e306 Non-capsular patterns e306 This condition was first described in 1855 by Breithaupt,1 a Metatarsalgia ...... e306 Prussian military doctor, who stated that many soldiers devel- Sesamometatarsal .lesions ...... e307 oped painful swellings at the dorsum of their feet after long Hallux .valgus ...... e307 marches. He called this Schwellfuss but the cause remained The outer four metatarsophalangeal joints e308 unclear until Stechow2 proved that the condition is caused by The capsular pattern ...... e308 stress fracture. Rheumatoid .arthritis .and .gout ...... e308 Stress fractures of the metatarsal bones comprise 3.7% of Freiberg’s .osteochondritis ...... e308 all sport-related injuries, with the second and third metatarsal Traumatic .arthritis ...... e308 accounting for 80–90% of the fractures.3–5 Stress fractures of Osteoarthrosis ...... e308 the metatarsals are also common in military recruits and in Non-capsular patterns e309 long-distance runners. It has been reported that up to 20% of Chronic .metatarsalgia ...... e309 stress fractures in athletes6 and 23% of stress fractures in mili- Interdigital .ganglion ...... e309 tary recruits7 are located in the metatarsals. Pressure .on .the .nerves .in .the .forefoot ...... e310 The lesion should be suspected when a patient presents with Bruising .of .the .second .digital .nerve ...... e310 unilateral and localized warmth and oedema at the dorsum of Morton’s .metatarsalgia ...... e310 the foot. Often the symptoms appear after a long walk but sometimes there is no specific precipitating activity. It is surprising that children are almost as liable to marching fractures as adults. Cyriax’s8 (his p. 440) youngest patient was a 6-year- old boy. During the first weeks after the onset of pain, there is local warmth and oedema over the dorsum of the forefoot. The

© Copyright 2013 Elsevier, Ltd. All rights reserved. Disorders of the forefoot and toes normal findings on functional examination of the ankle and midfoot contrast with tenderness at the forefoot. Because not only the bone but also the interosseous muscles at both sides are involved, the tenderness is more extensive than might be expected from the fracture itself. During the first few days, the fracture (usually a hair-line crack) may not be revealed by routine radiography. The diagnosis is confirmed after a few weeks, when the callus formation around the fracture becomes radiologically apparent. Earlier confirmation of the diagnosis is obtainable by either radionuclide bone imaging,9,10 or ultrasound examination.11–13

Differential diagnosis

Localized swelling, warmth and tenderness in the forefoot can also occur in: Fig 1 • .Friction .to .the .interosseus .muscles . • Gout in one of the tarsometatarsal joints. A history of recurrent acute attacks of arthritis at the same joint or in other joints is helpful. is deep transverse friction for 15 minutes, three times a week, • Rheumatic forms of arthritis, such as rheumatoid arthritis, for about 2–4 weeks. After the massage, faradic and resisted psoriasis and reactive arthritis. These disorders affect flexor exercises are given to the toes. The results of this com- multiple joints. The history is also longer than the usual bined treatment are excellent. 6 weeks of that of a march fracture. Technique: friction • Freiberg’s arthritis at the second metatarsophalangeal joint. The patient lies supine on the couch. The therapist sits facing Although ischaemic epiphyseal necrosis of the base of the the foot and with the ipsilateral hand encircles the toes in such second metatarsal bone occurs in adolescence, the disease a way that the thumb lies at the dorsal aspect and the proximal may be asymptomatic until adult life, when the deformity interphalangeal joint of the flexed index finger presses under of the joint and the degenerative arthritis produce pain. the metatarsophalangeal joints. The big toe is left free. The • Ringworm and erysipelas. Local cellulitis, caused by an thumb keeps the toes flexed and the index finger presses infection of β-haemolytic Streptococci spp. or fungi, can upwards, so as to render the metatarsus convex. The shafts cause considerable redness, thickening and tenderness. In move apart and the muscle bellies lie closer to the surface. The erisypelas, there is malaise, chills and fever, together with middle finger of the other hand, reinforced by the index finger, an increased erythrocyte sedimentation rate. In ringworm, is now placed in the groove between the two metacarpal bones there is considerable itching and inspection of the (Fig. 1). Fingers, wrist and forearm are kept in one line and interdigital clefts very often reveals a small localized parallel to the metatarsal bones. Deep friction is imparted by infection between two toes. rotating the fingers through an alternate pronation and supina- tion movement of the forearm, so that the muscle is moved between the fingertip and the metatarsal shaft. Treatment

March fractures, whether partial or complete, always heal Fractures of the fifth metatarsal spontaneously in about 6 weeks. By that time, the bone is usually firm enough to be painless and mis-union need not be Three distinct fracture patterns occur in the fifth metatarsal: feared. tuberosity avulsion fractures, Jones fractures, and diaphyseal Treatment consists of relative rest. Normal walking need not stress fractures. be forbidden during the period of union. Immobilization is Tuberosity avulsion fractures are the most common and achieved when the forefoot is firmly bound, so that the other usually complicate an inversion sprain (see p. 776). The major- metatarsals splint the broken bone. Because, even with a ity heal with symptomatic care in a hard-soled shoe. splinted fracture, weight bearing still hurts a little, it is up to The true Jones fracture is defined as an acute fracture at the patient to do as much as can be tolerated. If the pain is the junction between the proximal diaphysis and metaphysis too severe, a plaster cast can be applied for 4 weeks. of the fifth metatarsal without distal extension beyond the If there is persistent pain after 6 weeks have elapsed, the fourth to fifth intermetatarsal articulation.14 The mechanism interosseous muscles must be at fault. It is obvious that when of injury is believed to be an abduction force applied to the there is a broken bone, the interosseous muscles will suffer forefoot with simultaneous ankle plantar flexion.15 A Jones abnormal stresses and become strained. Such a strain, whether fracture can be treated with 6 to 8 weeks of non-weight- the cause is a direct injury, a march fracture or an overstrain, bearing immobilization resulting in fair to good outcomes.16,17 hardly ever undergoes spontaneous cure and chronic pain can Operative treatment is selected if the patient is a high- last for years. The only effective treatment for this condition performance athlete or nonoperative treatment fails.18

A proximal diaphyseal fifth metatarsal stress fracture is defined as a stress fracture in the zone of the proximal fifth metatarsal immediately distal to the Jones fracture’s anatomic area.19 The mechanism of this injury is believed to be a repetitive load applied under the metatarsal head over a relatively short time, resulting in an overuse phenomenon. A proximal diaphyseal fifth metatarsal fracture may have a very long healing time and non-union can develop in as much as 25% of cases. For this reason, operative treatment is usually recommended.20

Splay foot

A splay foot is a broadened forefoot, with weakness of the intermetatarsal ligaments, associated with weakness of the intrinsic muscles. Very often splay foot starts with excessive dorsiflexion movement of Lisfranc’s joint, which occurs when too much weight falls on the midfoot. This is particularly likely to occur Fig 2 • .The .first .metatarsophalangeal .joint; .colour .indicates .the . in women who wear high heels. When excessive weight falls location .of .the .sesamoid .bones .within .the .tendons .of .the .flexor . on the midfoot, the talus is pressed downwards, and the meta- hallucis .brevis . tarsals undergo an upwards pressure, so that they are given excessive horizontal play and the transverse arch flattens. The result is a painful overstretching of the transverse interosseus ligament and an increase in weight on the middle metatarsal heads. Calluses will form on the plantar surfaces of the heads and bruising of the plantar aspect of the capsule of the metatarsophalangeal joints (so-called chronic metatarsalgia) results. In practice, splay foot is not a specific entity but usually accom- panies a midtarsal strain. Treatment includes a high heel with a horizontal upper surface, which prevents the forwards gliding of the talus and thus releases the forefoot (see Ch. 59), and energetic training of the short plantiflexor muscles of the toes. Localized splaying indicates a ganglion lying between two metatarsal heads. When the patient stands, an excessive interval is seen between two toes and palpation reveals a semisolid tumour keeping the heads apart (see p. e309 of this chapter).

The first metatarsophalangeal joint Fig 3 • .The .final .stage .of .forefoot .contact .during .walking . During extension, the sesamoids are drawn from the head– The capsule of the first metatarsophalangeal joint is reinforced neck junction of the first metatarsal to the distal head area. on the plantar surface by a fibrocartilaginous plate that is The average range of motion is 50°.24 Apart from their function attached distally to the proximal phalanx and proximally to the in weight bearing, the sesamoids also serve as a fulcrum that plantar aspect of the neck of the first metatarsal. This volar increases the mechanical advantage of the flexor hallucis brevis plate contains the two sesamoid bones, inserted in the tendons tendon. of the flexor hallucis brevis (Fig. 2). The flexion–extension The clinical examination of the big toe is summarized in movement is a rolling and sliding of the metatarsal head within Box 1. the stable support made up of the base of the proximal phalanx and the volar plate.21 The joint is extremely important for normal gait. There The capsular pattern must be 60–70% of extension with the first metatarsal to allow the hallux to function normally during the stance phase of The capsular pattern at the first metatarsophalangeal joint is gait.22 In the final stage of forefoot contact, 40% of body weight slight limitation of flexion, together with marked limitation of is imposed on the joint and the big toe23 (Fig. 3). extension (Fig. 4).

Pivot point

Fig 5 • .A .‘rocker’ .fitted .to .the .shoe .

Fig 4 • .The .capsular .pattern .at .the .first .metatarsophalangeal .joint . Arthritis in adolescence

Early osteoarthrosis at the first metatarsophalangeal joint, mostly bilateral, occurs in adolescence and is the result of Box 1 osteochondritis dissecans.30 It leads to the formation of a hallux rigidus in young adults. Clinical examination of the big toe The teenage patient, nearly always male, develops large osteophytes at the dorsum of both first metatarsophalangeal Inspection joints. The onset is slow and there is no history of overuse or Redness and swelling: gout of injury. Initially the pain appears only during hyperextension Gross osteophytes: arthrosis of the big toe. Later, the joint gradually fixes in the neutral Valgus deformity and enlarged medial portion of the metatarsal position, leading to a hallux rigidus. Pain at every step is inevi- head: hallux valgus table from stress on the rigid joint. Ingrowing toe nails Clinical examination shows the big toe to be fixed in a Dermatological conditions neutral position. There is only a small range of extension and Functional examination flexion. The end-feel is hard and large osteophytes can be Passive extension and flexion palpated on the dorsum of the joint. Normally the big toe can be extended to a right angle with the Because the patient is unable to extend the big toe during forefoot, whereas flexion is only 30–45°. Both end-feels are elastic the foot-off phase, treatment must aim to introduce a forefoot Passive abduction, adduction and rotations movement that does not interfere with the mobility of the Resisted extension: extensor hallucis longus and brevis joint but nevertheless enables the heel to move upwards while Resisted flexion: flexor hallucis longus and brevis the forefoot is on the ground. To do this, a ‘rocker’ is placed Palpation in or under a thick and solid sole of a shoe, at the joint line (Fig. 5). For tenderness, fluid and osteophytes Instead of extending at the first metatarsophalangeal joint, the forefoot will now rock during a normal gait. If this is not adequate, a steel plate in the sole prevents further stress on the rigid joint, but the resulting gait is less natural.31 Gout Surgery for hallux rigidus consists of resection of osteophytes and metatarsal head (cheilectomy)32 or resection The first metatarsophalangeal joint is usually the first joint to arthroplasty.33–35 be affected in gout. The attack is characterized by a sudden onset of intense pain, frequently at night. The joint is swollen and exquisitely tender. The overlying skin is tense, warm and Traumatic arthritis dusky red. The attack lasts 1–2 weeks, and asymptomatic periods of months or years commonly follow the initial acute This results from a direct trauma or forceful hyperextension attack.25 of the joint. This is the case in osteoarthrosis, in which a super- An acute attack can frequently be aborted by colchicine or imposed post-traumatic arthritis easily occurs. It is also encoun- by one of the non-steroidal anti-inflammatory drugs.26–28 When tered in certain sports, such as soccer and American football.36–39 attacks are frequent or other gouty complications such as tophi Treatment consists of an intra-articular injection of 10 mg of occur, lowering of blood uric acid is indicated.29 triamcinolone and prevention of further overstretching.

Arthrosis in middle age

Osteoarthrosis at the first metatarsophalangeal joint (MPJ) is the second most common disorder affecting the foot after hallux valgus. The prevalence of the condition increases with age, and it has been reported that radiographic changes in the first MPJ are evident in approximately 46% of women and 32% of men at 60 years of age.40 The degeneration and stiffness is not the result of a previous aseptic necrosis but has probably been induced by trauma or repetitive stresses. Sometimes a heavy weight falling on the joint or a fracture is the precipitating cause. Repetitive stresses during extension (as in women wearing high heels) can influence the degeneration. Deterioration is slow and insidious, and therefore symptoms may not arise for years. They appear only when the joint becomes overstrained.41 In other words, the source of the pain is not the osteoarthrosis as such but the superimposed post-traumatic arthritis. Symptoms therefore start when some dorsiflexion is lost: in men when 45° of extension range has been lost, in women who wear high heels when only 20 or 30° has been lost. The typical case is consequently a middle-aged man or woman who has pain at the big toe during and after walking. Clinical examination shows a painful and markedly limited extension of the big toe, together with slight limitation of Fig 6 • .Intra-articular .injection .of .the .first .metatarsophalangeal .joint . flexion. The end-feel is hard. Osteophyte formation and some local tenderness can be palpated at the dorsum of the joint.42 Because the pain is the result of a post-traumatic arthritis, Rheumatoid arthritis it can be abolished by one intra-articular injection of triamcinolone. If the patient is careful in the future, wears appropriate This disease often affects the metatarsophalangeal joints.48 The shoes with thick, solid soles and avoids high heels, relapses are usual signs and symptoms of an inflamed joint are seen. The not to be expected. During the last decade an alternative treat- patient has nocturnal pain and morning stiffness. Clinical ment termed ‘viscosupplementation’ – the intra-articular injec- examination reveals a capsular pattern and a capsular thicken- tion of hyaluronan with the aim of restoring the viscoelasticity ing at a warm and swollen joint. Treatment is causative. of the synovial fluid – has been proposed and studies show promising results.43,44 Good results can also be achieved by traction. Alternatively, mobilization, using traction–translation Non-capsular patterns techniques can be used.45 In advanced cases, in which there is hallux rigidus, the use of a ‘rocker’ and a steel sole must be advised (Fig. 5). If all conservative treatment fails, surgery can Metatarsalgia be undertaken.46,47 Metatarsalgia at the first metatarsophalangeal joint is not as frequent as at the outer four toes. When it occurs, it is usually Technique: injection the result of an increase in the angle between the forefoot and The patient sits with the foot flat on the couch. The physician the hindfoot. This is the case in a pes cavus deformity and also grasps the distal phalanx and pulls it in an axial direction, with in osteoarthrosis at the cuneiform–first metatarsal joint (after a slight flexion component. This distracts the joint surfaces a previous osteochondritis), which fixes this joint in plantiflex- and enables the joint line to be identified, which is not always ion and therefore increases the pressure on the plantar aspect easy to do in patients with large osteophytes: the depression of the first metatarsophalangeal joint during walking. between the osteophyte and the bone should not be mistaken The clinical signs are pes cavus deformity of the foot, with for the joint line. A 1 ml syringe is filled with steroid suspen- normal mobility and painless resisted flexion of the big toe. sion and fitted with a thin 2 cm needle. After identifying the However, there is significant tenderness at the plantar aspect joint line and the tendon of the long extensor, the needle is of the capsule of the first metatarsophalangeal joint. passed into the space between the two bones, medially to the Treatment consists of an intra-articular injection of 10 mg tendon (Fig. 6) and the steroid is injected. of triamcinolone (see earlier). In a pes cavus deformity, the The patient should be warned of severe after-pain for 12–24 patient must also wear a raised heel with a horizontal upper hours but will be pain free afterwards. If care is taken in the surface (see Ch. 59). This measure relieves the excessive stress future, a second injection will not be necessary. on the joint and prevents recurrences.

Sesamometatarsal lesions Halux valgus

Traumatic periostitis of the sesamoid bone of the flexor hallucis This is the most common deformity of the big toe. It has been longus usually results from local trauma, such as stepping bare- estimated that about 25% of the population have it to some foot on a sharp pebblestone or landing on the medial side of degree.59 There is no parallel between the degree of valgus and the extended joint.49,50 After the accident the patient feels pain the severity of the symptoms, and many patients with severe at the inner aspect of the forefoot with each step. deformity are free of symptoms. Clinical examination shows a full range of movement, some- Much has been written about the aetiology of hallux times with pain at the end of extension. Resisted flexion hurts valgus.60–62 Because hallux valgus also occurs in barefooted at the plantar aspect and the sesamoid bone is tender to the people who never wear shoes, there must be congenital factors touch, the exact point shifting with the position of the hallux.24 predisposing to the deformity. The causative components seem Clinical diagnosis can be confirmed with conventional radio to be multiple: the first metatarsal shaft is shorter than the graphy and MRI imaging.51,52 second, there is a hypermobility of the first ray and the first Treatment consists of infiltration of the correct area with intermetatarsal angle is enlarged.63,64 All these factors contrib- 10 mg of triamcinolone. Usually one infiltration is sufficient. ute to the origin of a widely splayed forefoot (A in Fig. 8).65,66 Some authors advise orthotics53 as a prophylactic measure but Because of the shortness of the first metatarsal, the second toe experience shows that this is never necessary. If conservative takes most of the weight during the final phase of the step. If treatment is not followed by quick recovery, fracture54,55 or there is a muscular imbalance between the adductor hallucis post-traumatic osteochondritis56 should be suspected. Immo- and abductor hallucis, the big toe will deviate laterally (B) and bilization in a plaster cast or surgical intervention is then undergoes a pronation movement (C).67 This is accentuated by required. Surgical treatment may include partial or complete the contractions of the flexors and long extensor of the toe, resection of the sesamoid, shaving of a prominent tibial sesa- which act like a bowstring and shift the tip of the big toe moid or autogenous bone grafting for non-union.49 further into adduction (D). When this predisposed splayed Alternatively, the pain can be caused by overuse, which forefoot is now forced into a high-heeled pointed shoe, exces- sets up a traumatic arthritis at the sesamoid–first metatarsal sive weight is added and the first toe deviates increasingly and joint.57,58 This condition is similar to metatarsalgia of the big rapidly in a lateral direction. The pointed shoe increases the toe. Treatment is an infiltration with 10 mg of triamcinolone pressure at the medial aspect of the metatarsophalangeal joint, between the sesamoid and the first metatarsal, together with which results in an inflamed and painful bursa (tailor’s prevention by use of a raised horizontal heel. bunion).68, 69 Technique: infiltration and injection The diagnosis is made on the typical appearance: The patient lies supine on a high couch. The tender point is • The forefoot is broadened and the transverse arch identified. Because the skin is usually thick and difficult to flattened. sterilize, the medial side of the metatarsophalangeal region must be scraped until the epidermis is clean. A 1 ml syringe is fitted to a thin needle and filled with 10 mg of triamcinolone. The insertion is made from the medial aspect. The thumb of the free hand is kept on the tender spot and the needle is C advanced in the direction of the palpating thumb (Fig. 7), whether at the sesamoid bone or at the joint between sesamoid and metatarsal. Depending on the lesion, an infiltration or an injection is then made. D B

A {

Fig 7 • .Infiltration .of .sesamoid .lesions . Fig 8 • .Aetiologies .of .hallux .valgus .(see .text .for .details) .

• The big toe is angled towards the second toe and Gout is less frequent at the outer toe joints than at the big frequently overlies it. The medial portion of the first toe. The acute redness and tenderness should always be dif- metatarsal head is enlarged. ferentiated from a march fracture. • The skin and the bursa over the medial aspect of the first metatarsophalangeal joint are inflamed and thickened. Freiberg’s osteochondritis Treatment depends on the degree of disability. It is as well to remember that many patients with extreme deformities have This is an ischaemic epiphyseal necrosis of the head of the no pain at all. Because most of the pain stems from the com- second metatarsal bone, first described by Freiburg in 1914,76 pression of the enlarged forefoot in too narrow shoes, the and later by Kohler,77,78 who showed that the third instead of primary conservative treatment is appropriate shoes: a wide the second metatarsal is involved in about 20% of cases. The shoe with a horizontal heel should be advised; sometimes a disease occurs in adolescence, before the epiphyseal closure of ‘pouch’ can be pressed out at the side of the metatarsal head. the metatarsal head has been completed.79 Local tenderness at the skin or at the inflamed bursa can often The precise aetiology is unknown but it is assumed that the be treated successfully with ichthammol ointment. Surgery is development is precipitated by an abnormally long second indicated when there is continuous pain or for cosmetic metatarsal bone, indirect trauma and changes in bone marrow reasons.70–73 There is a choice of several procedures depending pressure.80,81 Sometimes the disease is asymptomatic until on the severity of the lesion and the age and mobility of the adulthood, when deformity of the involved metatarsal head patient.74,75 and osteoarthrosis supervene and cause symptoms. If the condition itself causes symptoms, examination will show localized arthritis of the second (or third) metatar- The outer four sophalangeal joint, with local swelling and warmth and limita- metatarsophalangeal joints tion of flexion and extension. It takes a month from the onset of pain before the characteristic radiographic changes become visible. Therefore, in its early stages the lesion is difficult to The capsular pattern diagnose and a scintigraph or MRI image may be needed to distinguish it from a march fracture of the metatarsal shaft.82,83 The capsular pattern at the outer metatarsophalangeal joints is Spontaneous recovery from this subacute stage takes up to more limitation of flexion than extension (Fig. 9). a year. By that time the metatarsal head is permanently enlarged and palpation reveals a prominent ridge at the dorsal aspect of the metatarsal shaft. There is also some painless limitation of Rheumatoid arthritis and gout flexion and extension. Sometimes, and if no proper prophylactic measures are taken, metatarsalgia caused by the bony Rheumatoid arthritis affects the metatarsophalangeal joints enlargement may supervene. symmetrically. In advanced cases, the toes become fixed in the Later on, when the patient is 40–50 years old, osteoarthrosis clawed position of extension at the metatarsophalangeal joint may complicate the picture and the joint becomes fixed in a and flexion at the proximal interphalangeal joint. manner analogous to hallux rigidus. Treatment consists of using orthotic metatarsal platforms to release pressure on the second metatarsal head. If there is limitation of extension, a ‘rocker’, as in hallux rigidus, can be prescribed. In advanced cases, surgery may be necessary.84

Traumatic arthritis

Traumatic arthritis at a metatarsophalangeal joint is rare. It can result from a direct blow or from indirect trauma, for instance during a hyperextension movement.85 Recently, hyperplanti- flexion injuries to the great toe sustained in beach volleyball players have been described. This injury is referred to as ‘sand toe’ and may result in significant functional disability.86 Untreated, the capsulitis can continue for months, whereas one injection with 5 mg of triamcinolone can completely relieve pain within 2 days.

Osteoarthrosis

Local injury or a former Freiberg’s osteochondritis can cause Fig 9 • .The .capsular .pattern .at .the .outer .four .metatarsophalangeal . osteoarthrosis at the metatarsophalangeal joints. Limitation of joints . flexion and extension with a hard end-feel results.

Treatment consists of prescribing shoes with hard and thick • Weak flexor muscles: sometimes the short muscles in the soles, eventually fitted with a ‘rocker’ to render extension sole of the foot are weakened after a long rest in bed asymptomatic. during an illness. If too much weight is borne too soon for too long a time, metatarsalgia can result. • Dancer’s metatarsalgia: a dancer working en pointe may Non-capsular patterns bruise the plantar aspect of the second, third and fourth metatarsophalangeal joints.91 To prevent this, most ballet shoes are fitted with a small semilunar pad, which ensures Chronic metatarsalgia that the joints are protected and the body weight distributed as widely as possible. Pain in the plantar aspect of the forefoot is called metatarsalgia. Chronic metatarsalgia affects the middle three toes and arises when the metatarsal heads have to bear a disproportionate Symptoms and signs amount of the body’s weight. There is pain at the plantar aspect of the forefoot on standing and walking, relieved by rest. Sometimes a callus will form, Aetiology which increases the pressure on the metatarsal head and aggra- vates the irritation. 87 Scranton differentiates secondary and primary metatarsalgia. Clinical examination shows pain at the end of dorsiflexion, In the former, the lesion is the result of structural changes in sometimes at the end of both dorsiflexion and plantiflexion. the joint (e.g. Freiberg’s disease, rheumatoid arthritis or gout). Tenderness is noted under the metatarsal heads. Although the The latter occurs if there is any incongruence between load tenderness is described as being of the metatarsal heads, it is and load-bearing capacity. not the articular cartilage but the plantar aspect of the meta- The aetiology of primary metatarsalgia is as follows. In tarsophalangeal joint that is at fault. The difference is impor- a normal foot, only one-third of the body weight is borne tant, because irreversible changes never take place and relief by the forefoot. The transverse arch and the contraction of of too much weight bearing will always lead to full recovery. the long flexor muscles of the toes distribute the weight between the pads of the toes and the metatarsophalangeal Treatment joints. Because of the tautness of the anterior arch, the big toe and the outer toe take most of the weight. When too much The most important measure is to avoid excessive weight weight falls on the forefoot, flattening of the anterior arch and bearing at the forefoot: the high heel must have a horizontal insufficiency of the flexor muscles of the toes results in abnor- surface. This brings more weight onto the hindfoot than the mal pressure on the plantar aspects of the second, third and forefoot and prevents the foot from sliding forwards. A support fourth metatarsophalangeal joints.88,89 In due course, a local with its thickest part stopping just behind the heads of the capsulitis develops. This happens in the following conditions: metatarsals (metatarsal pad) must be fitted into the shoe. This ensures that the shafts of the metatarsals bear more weight • Splay foot: the broadened forefoot, associated with than the joints themselves. weakness of the intrinsic flexor muscles leads to flattening In a splay foot or after a long stay in bed, vigorous strength- of the anterior arch and some clawing of the toes. ening of the short flexor muscles of the toes by exercises is • the dropped forefoot leads to Plantar deformity: necessary, so that the toes flex properly at each step to take too much pressure at the plantar aspects of the most of the body weight during walking. metatarsophalangeal capsules. In long-standing cases, good results can be obtained by a • High heels: if the shoe has a high heel with an oblique single intra-articular injection of triamcinolone into the joint. upper surface, the patient will stand on an inclined plane, sliding constantly downwards on the forefoot. Too much Technique: injection The patient lies supine. The joint is identified at the plantar and weight is imposed on the forefoot, with chronic dorsal aspect; usually the joint line is more proximal than might metatarsalgia as a result. It is not the high heel itself but be expected. A thin needle is fitted to a syringe filled with the oblique upper surface which is the source of the 0.5 ml of triamcinolone. By pulling at the toe and by moving the trouble. High heels with a horizontal upper surface do not proximal phalanx in slight plantar flexion, the joint line becomes cause problems and are even beneficial to women with a accessible to the needle. The needle is thrust downwards, plantaris deformity of the forefoot. Unfortunately, no such lateral to the long extensor tendon. After 1 cm the tip of the ready-made shoes exist. needle is in the joint space and the steroid is injected. • Pes cavus deformity: a pes cavus deformity is very Some soreness is to be expected for about 24 hours. Good often accompanied by extreme hyperextension at the results follow after 2 days. If preventive measures are also metatarsophalangeal joints, caused by shortening of the taken, the relief is permanent. extensor digitorum muscles together with ineffective intrinsic flexors, holding the toes clawed.90 In such cases, the toes do not bear body weight at all and serious Interdigital ganglion metatarsalgia results, with large callosities under the metatarsal heads, together with corns at the dorsal aspects A ganglion arising from a flexor tendon sheath may arise of the interphalangeal joints. between the toes at the dorsum of the foot. It can cause painful

© Copyright 2013 Elsevier, Ltd. All rights reserved. e309 The Lower Leg, Ankle and Foot pressure, especially if small shoes are worn.92 The diagnosis is obvious when a firm mass appears during standing. An excessive interval is then seen between the two toes and palpation reveals a semisolid tumour. Lying down permits the ganglion to recede. Because the mass is thick and composed of fibro lipomatous material, aspiration often fails. Excision is indicated if problems persist. Fig 10 • .Orthotic .device .for .Morton’s .metatarsalgia .

Morton’s metatarsalgia Pressure on the nerves in the forefoot This condition, first described in 1876,93 results from a neuroma at the interdigital nerve between the fourth and fifth toes Symptoms caused by pressure on nerves at the forefoot are (exceptionally between the third and fourth toes). very often regarded as metatarsalgia. The differential diagnosis The history is characteristic. The patient, usually a middle- relies on the fact that the patient describes sharp, unexpected aged woman, states that during walking she is suddenly seized and sudden twinges instead of continuous pain during walking by a sharp and unexpected pain at the outer side of the fore- or running. During clinical examination, no signs of bruising of foot. She has to stop walking and characteristically take the the plantar capsule of the metatarsophalangeal joints are dis- weight off the foot and remove her shoe to rub and massage cernible. Sometimes the symptoms can be reproduced by local the painful area. After some minutes the pain ceases and she pressure on a nerve. can continue to walk. The frequency of attacks is very difficult to predict, because sometimes there may be several attacks a day or none during a year. Usually recurrences tend to become Bruising of the second digital nerve more frequent. Between the attacks the patient is unaware of the condition and there are no symptoms at all. This is a rare condition, which is rather surprising, because the Clinical examination is negative in most cases. Sometimes nerve passes forwards on the lateral side of the plantar aspect the symptoms can be reproduced by moving the heads of the first metatarsophalangeal joint, close to the surface and of the adjacent metatarsal bones against each other during unprotected from external trauma. It can easily be palpated as compression. Recently, ultrasound examination has been a thick band, before it bifurcates just distal to the joint, to shown to be very sensitive in the detection of web-space supply sensation at the adjacent borders of the first and the abnormalities.94,95 second toes. If there is repetitive injury, bruising will persist. The cause was described by Betts in 1940,96 who stated that Consequently, the patient gets sharp twinges during walking. the painful condition results from a fusiform neuroma, about The twinges will be followed by pins and needles and by a 1 cm long, of the fourth digital nerve proximal to its point of constant ache. division.97 When the fibrous swelling is nipped between the During clinical examination the symptoms can be repro- adjacent metatarsal heads, or pulled against a swollen trans- duced by local pressure on the bruised nerve. verse ligament,98 sudden ‘neuritic’ pain results. Treatment consists of wearing a thick rubber pad under the Treatment consists of relieving the pressure on the neuroma forefoot for 3–6 months. An alternative is the injection of by alternating the alignment of the metatarsal heads. For triamcinolone suspension around the inflamed nerve: a needle instance, the head of the fourth bone can be elevated by a small is introduced at the dorsum of the foot between the first and support (Fig. 10). This will keep the bones slightly out of line second metatarsophalangeal joints and thrust in the direction and prevent pressure on the nerve. Steroid infiltration seldom of the affected area, until it is felt to impinge against the succeeds. When conservative treatment fails, surgical excision plantar skin, where 1 ml of the suspension is infiltrated. of the neuroma may be required.99,100

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