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Lesser metatarsophalangeal (MTP) instability is a common cause of forefoot pain. In this prospective study, we looked at its presentation, management and outcome.
We studied characteristics of patients presenting to a specialist foot and ankle clinic with lesser MTP instability. We used the drawer test to diagnose and stage instability. Patients were followed up in clinic or by telephone interview.
We identified 154 patients with lesser MTP instability; 127 (82%) were female, median age was 56 years. One foot was affected in 107 patients (69%). The second toe only was affected in 99 patients (64%) and multiple toes in 52 (34%) but always involving the second toe if multiple toes involved. 150 toes (52%) had Grade 1 instability, 108 (37%) Grade 2 and 21 (7%) Grade 3 instability. Twelve toes (4%) presented dislocated. Ninety nine patients (64%) were treated nonoperatively, using functional taping, shoe modifications, and injections. Fifty five patients (36%) were treated operatively, including lesser toe straightening, flexor-extensor transfer, Weil and Stainsby procedures. At followup, the mean AOFAS score and standard deviation was 69 ± 16.3 for the nonoperative group compared to 67 ± 17.8 in the operative group. The mean pain score and standard deviation was 31 mm ± 23.7 mm for the nonoperative group and 23 mm ± 24.1 mm in the operative group. Thirty-nine patients (52%) were either satisfied or very satisfied with treatment in the nonoperative group compared to 31 patients (66%) in the operative group. None of these differences were statistically significant.
Painful MTP instability is a common cause of forefoot pain. Most patients can be treated nonoperatively. Operatively treated patients had no significant improvement in outcomes with regards to pain or function.
The findings of this article correlate well to the rigid/stable rearfoot/flexible forefoot FFT's that has been previously published ( http://www.zimbio.com/The+stock+mark...haracteristics ) as the most common foot types presenting with single 2nd ray pathology and the flexible rearfoot/flexible forefoot FFT as the most common foot type presenting FFT presenting multiple ray pathology but always including the 2nd.
This peer reviewed article reinforces foot centering theory.
The advantage of utilizing functional foot typing to make diagnostic predictions that allow for preventive care is reinforced by this article.
Dorsal instability of the metatarsophalangeal joint (MTPJ) of the lesser toes is an important cause of forefoot pain. Both conservative and surgical treatment options have been proposed. However, the role of each static stabilizing structure has not been elucidated. We hypothesized that isolated sectioning of the plantar plate (PP) would result in greater dorsal translation compared to isolated sectioning of the medial collateral ligaments (MCL) or lateral (LCL) collateral ligaments, or the extensor hood (EH), and that combined injury to two or more structures would result in greater dorsal translation compared to isolated PP injury. Fifty-four cadaveric lesser toe specimens were randomized into groups for individual and combined sectioning of the PP, EH, and LCL and MCL. A 30 N axial load was applied to each specimen in the plantar-dorsal direction and dorsal translation of the phalanx was measured for each condition. ANOVA was used to compare groups. A 19% change in MTP translation was found from intact after sectioning the PP. No significant difference in translation was seen after individual sectioning of the EH, MCL, or LCL. A significant increase in translation occurred from intact with the following sectioning combinations: MCL + LCL, 37%; EH + MCL + LCL, 45%; and PP + MCL + LCL, 63%. Thus, the PP is the main restraint for dorsal MTPJ translation. MCL and LCL have important partial contribution to MTPJ stability. Injury to the PP, individually, or combined injuries to the PP, EH, MCL, or LCL, appear to cause significant instability that may warrant more aggressive treatment.
What if the plantar plate was simply stretched or lengthened but not injured?
Wouldn't this elongated and distorted lever arm cause instability and the same clinical impact as a transection?
I suggest that is the more common problem in lesser toe dysfunction than an actual "injury" or transection.
If my suspicions are correct, then wouldn't a positional change in the architecture of the lesser MP Joints in the direction of reducing M-P Joint prominence cause Davis's Law to stabilize the plantar plate over time?