Evaluation and Management of Metatarsal and Forefoot Injuries

Charles J. Gatt, Jr., MD Chair, Department of Orthopaedic Surgery Rutgers Robert Wood Johnson Medical School New Brunswick, NJ • No Disclosures

www.UOANJ.com Questions

• What are the common injuries of the forefoot? • What are the causes of injury? • What is the treatment?

www.UOANJ.com The Problem n300,000 lbs of stress per mile of running is centered on heel and then dissipated to the rest of the foot Foot and Ankle Sports Injuries History n Sport n Position at injury n Surface n Noise n Shoes n Pain location n Custom/Prefab Orthosis n Swelling n Onset n Time out of Sports Foot and Ankle Sports Injuries Physical Exam n Gait n Auscultation n Callus Distribution n Range of Motion n Shoe Wear n Percussion n Orthosis wear n Pulses n Palpation n Sensory Exam Imaging

• Xray – Weight bearing xray may add clarity • MRI • MSK US

www.UOANJ.com Metatarsalgia n Common overuse injury described as pain in the forefoot that is associated with increased stress over the metatarsal head region n Often referred to as a symptom, rather than as a specific disease. Metatarsalgia n Common causes of Metatarsalgia

n Sesamoiditis

n Interdigital neuroma (also known as Morton neuroma)

n Avascular necrosis (Frieberg’s Infarction)

n Metatarsophalangeal Synovitis nInflammatory arthritis nSynovitis/Inflammation from Repetitive Trauma Sesamoiditis SIGNS n Local Tenderness n Pain with Hyperextenion n Rare Swelling Sesamoid Fracture Mechanism nAcute fall from height (Ballet) nHyperextension of MTP (football) nStress fracture (Runners) nOsteochondritis Sesamoiditis Incidence n Stress Fracture nAny age nTibial or Fibular Sesamoid n Osteochondritis nFemale, 20’s nlateral Sesamoid

Kilman, F+A,3:220 1983 Sesamoid Fracture X-RAY n AP/Lat/Oblique n Tangential Views Acute sesamoid fracture nPresentation nMay mimic Turf Toe nTreatment nDepends on amount of Diastasis Acute sesamoid fracture n Diastasis >2mm n Bony Fixation n Soft tissue repair n Diastasis < 2mm n SLC 3-6 weeks n Steel shank insole n Prevent Hyperextension Sesamoid Fracture Surgical Treatment n Displaced Fracture n Non-Disp Fx Not Resp to cast Immob. or shoe inserts x 12 wks n Unrelieved Sesamoiditis/Bursitis n Osteomyelitis

Richardson, F + A 7:29, 1987 Sesamoid Fracture Excision of Fragment-Complications n Migration of Hallux 10% n Persistent Pain 41-50% n Stiffness 33% n Weakness 60%

Mann AOFAS 1985 Sesamoid Fracture Late Repair •Seventeen Patients •Treated with Curretage and Bone Grafting •Post-op SLC for Six Weeks •Mean Follow-up 33 months •15/17 Asymtomatic return to all Pre Injury Activities •14/15 Healed by Tomography at 12 weeks

Anderson/McBryde AOFAS March 1991 Turf Toe Mechanism n Acute n Hyperextension of first MTP n Direct blow to heel with toe planted in dorsiflexion n Chronic n Repetitive valgus stress n Runner’s (Especially Cross-country) Turf Toe in Football

College Football Professional FB • 80 players surveyed • Incidence .062/1,000 • Time loss equal to Ankle sprains AE • 83% first time on artificial turf • Hyper extension mechanism • 14 x more likely in • 60% Offense games vs practice – OL – >Age 27 (5+ years exp) • Contact w/ other • Progression to chronic injury player – Career ending

George E, “Incidence and risk of turf toe in Rodeo SA, “Turf Toe: “Analysis of metatarsalphalangeal injuries in professoinal intercollegiate football; data from NCAA Injury football” surveillance system” FAI 2014;35(2):108-115 AJSM 1990;18(3):280-5 Turf Toe Anatomy n MTP Capsule n Articular Cartilage n Great Toe Flexors n Sesamoids n Abductor Hallicus n Plantar Nerves n Bones Turf Toe Treatment

n No role for injections n RICE, Shoe Mod. And Taping n If can’t jog w/in 3 wks. Consider n open treatment n Late repair works

Coker, J Ark.Med Soc. 74:309 1978 Hallux Rigidus nLiterally “Stiff Big Toe” nSentinal Finding – nDecreased Dorsiflexion ( Pain) nCan be predisposed nType of foot nType of activity nAcute injury squellae nChronic repetitive injury Hallux Rigidus 17yo Hallux Rigidus nTreatment nNonoperative nSymptomatic nMechanical –Decrease Dorsiflexion nOperative nCheilectomy nArthroplasty nBiologic Hallux Rididus Morton's Neuroma n Symptoms n Classically described as a burning pain in the forefoot ncan also be felt as an aching or shooting pain in the forefoot n Pain may occur in the middle of a run or at the end of a long run n If shoes are tight or the neuroma is very large, the pain may be present even when walking n Occasionally a sensation of numbness is felt in addition to the pain or even before the pain appears. Morton’s Neuroma n “Click" which is known as Mulder's sign n There may be tenderness in the interspace n Rule out similar or concurrent problems n Tenderness at one of the metatarsal bones can suggest a stress reaction (pre-stress fracture or stress fracture) in the bone. n An ultrasound scan can confirm the diagnosis and is a less expensive and at this time, at least as sensitive a test as an MRI n An x-ray does not show neuromas, but can be useful to "rule out" other causes of the pain. Morton’s Neuroma n Cause n An enlargement of the sheath of an intermetatarsal nerve in the foot nMost Common –The third intermetatarsal space nThe second interspace being the next most common location. Morton’s Neuroma n Contributing Factors n Pronation of the foot can cause the metatarsal heads to rotate slightly and pinch the nerve running between the metatarsal heads nChronic pinching can make the nerve sheath enlarge. As it enlarges it than becomes more squeezed and increasingly troublesome. n Tight shoes, shoes with little room for the forefoot, pointy toeboxes can all make this problem more painful. n Walking barefoot may also be painful, since the foot may be functioning in an over-pronated position. Morton’s Neuroma n Self-Treatment nWear wide toe box shoes nDon't lace the forefoot part of your shoe too tight nMake sure your feet are in supportive shoes that do not squeeze your forefoot Morton’s Neuroma n Orthotics – esp. for the Pronator n Injection of Steroid and Local Anesthetic n Occasionally injection of other substances to "ablate" the neuroma. n Surgical Removal of Neuroma n Tips n Wear shoes designed with a roomy toebox. n Wear shoes that have good forefoot cushioning. n Use sport specific shoes. n Fit your shoes with the socks that you plan to wear during aerobics activity. Freiberg's Infraction n AKA Avascular Necrosis, Osteonecrosis, Osteochondrosis n General considerations n Named “infraction” because it was originally thought secondary to trauma n Exact cause remains uncertain but thought to be one of the osteochondroses in adolescents nOsteochondroses are diseases that usually affect the epiphyses of growing bones resulting in necrosis most likely on a vascular basis, although the exact mechanism is not known n In others, Freiberg's may be due to a combination of trauma, and vascular insults Metatarsal Stress Fractures • .7-21% Incidence Literature • 90 Reported (63 F, 27 Male) – F – basketball, Lax – M – Football, indoor track • 2nd MT Most common – Middle 1/3 – Majority Occurred on grass

National Stress Fx Registry Base of 5th metatarsal fracture n Tuberosity Avulsion Fracture nMechanism - Inversion nHeals Clinically-3 wks Radiograghically-6 wks Dancer’s Fracture nSpiral Fracture of the Fifth Metatarsal nTreat WBAT in post op shoe nLonger time to healing Stress fractures of the 5th metatarsal Jones fracture nGradual increase in lateral foot pain nPoint tender metaphysis of 5th MT nHigh index of suspicion nMRI if xrays negative and high suspicion Stress fractures of the 5th metatarsal Jones fracture

www.UOANJ.com Jones Fracture Treatment nAsymptomatic and positive MRI n? Orthotic/shoe modification nSymptomatic and positive MRI nOrthotic nActivity modification nClose monitoring of symptoms!! nSymptomatic with visible fracture line, hypertrophy nStrongly consider surgery Acute on chronic stress fracture Jones Fracture nIM Fixation nWBAT in cam walker when callus visible nHealed Radiographically by 13 weeks Summary

• Many causes of forefoot pain • Detailed history important • Clinical exam important; Prompt recognition • Conservative and aggressive treatment • High level of suspicion with adolescent bony pain

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