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Some of you may be interested in a panel discussion on 2nd metatarsophalangeal joint injuries in Podiatry Today that I recently participated in along with Drs. Doug Richie, Rich Bouche and Jim Clough.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

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Dr Kirby,
I found this link very interesting, as sub 2nd MTP joint pain is something I come across almost on a weekly basis.
In my limited experience, footwear advice and OTC orthoses +/- steroid injection generally works well (for my patients anyway). From a surgical perspective however, how often do you find that surgical repair of the plantar plate is necessary and is this something you undertake regularly? And if so, how effective/successful have you found this over long term? I have seen this done a few times and results are impressive early post op, but have not seen any long term results.
Many thanks for you time,
Ryan

Related threads:
Threads tagged with 2nd MTPJ

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Kevin

I have had a lot of success with plantarflexion taping, that you recommened some years ago, of the affected digit wher there is plantar plate tear - where the Dx is when the pain is illicited my manual plantarflexion of the toe.

The pain I have most difficulty with is where the paitient complains of pain along the toe-met sulcus 2-5, that feels like cramp or the sock rucked up after walkingn some distance. This pain cannot be ellicited by palpation and has no obvious biomechanical pattern. Orthoses rarely cure the problem, which is often accompanied by some other biomechanical dysfunction that is causing pain elasewhere.


Cheers Dave

Dave

I have good success rates with bespoke silicone toe props made with the patient in a 'corrected/supported' weight bearing position.
May be a placebo but the patients find them easy to wear in their less than ideal footwear.

Might be worth a go if you have a suitable patient.

Cheers

Phil

Ryan:

I also use changes in shoegear, over the counter (OTC) orthoses and cortisone injections (in addition to the treatments mentioned in the Podiatry Today article) to treat 2nd metatarsophalangeal joint (MPJ) capsulitis/plantar plate pathology. Surgical repair of the plantar plate is done infrequently in my community with many surgeons preferring to do a flexor transfer to avoid the plantar incision and its potential problems. However, of the surgeons I know that do plantar plate repairs frequently, they seem to have good success with a minimum of problems.

You must remember, just as you would not surgically repair all partial or complete tears of the anterior talo-fibular ligament from inversion ankle sprains, all plantar plate tears do not need to be surgically repaired since most will heal well with conservative care. In fact, there is some evidence that plantar plate tears are common in asymptomatic individuals so a question that remains is when or when not to repair a plantar plate tear...the jury is still out on this question.

Hope this helps. By the way, welcome to Podiatry Arena

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Dave:

Many patients with plantar plate pathology (i.e. MPJ capsulitis) complain of the feeling of "thickening" or "walking on a wadded up sock" plantar to the metatarsal heads which I suspect is caused by the plantarly located soft tissue edema that frequently accompanies this pathology. First of all, one of the simplest methods to reduce this edema is to put the patient on a strict regimen of 20 minutes of direct plantar icing two times a day along with an avoidance of all barefoot walking/standing. In addition, I have found that if I can make a foot orthosis that can significantly reduce the ground reaction force (GRF) plantar to the affected MPJs, then the symptoms invariably improve.

Here are some orthosis modifications that I have used with great success in treating lesser MPJ pathology over the past 23 years (I see probably 3-4 of these patients a week with this pathology):

1. Increase the length of the orthosis plate.
2. Increase the thickness of the distal orthosis plate by adding padding plantarly and/or having the lab do a "no grind anterior edge" modification.
3. Add accommodative materials to the forefoot extension (e.g. use korex in forefoot extension plantar to 1st, 3rd, 4th and 5th MPJs to reduce GRF plantar to the 2nd MPJ).
4. Add metatarsal pads to dorsal distal orthosis edge just proximal to affected MPJ.
5. Use extra thick topcovers (normal topcover for these patients in my practice is 3 mm neoprene).

Other podiatrists have also told me initially that "orthoses rarely cure this problem" until they start modifying their orthoses as I have suggested above, after which they then will claim that "orthoses commonly cure this problem". Such is the learning curve in gaining expertise in foot orthosis therapy.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Kevin

Thanks for th reply.

Never heard of that one, what is this mod?


Cheers Dave

Kevin

I think that particular curve is actually one of those single sided twisted figure of eight loops. (there's got to be a technical name for that) Just when your furthest away from the start you end up back at the start.


LoL Dave

I believe you may be speaking of a Mobius strip or something similar?

Or are you speaking of the works of Maurits Cornelis Escher (1898-1972), one of my favorite artists, and his interesting and thoughtful graphic art?

Attached Images

Escher Mobius Strip II.jpg (102.6 KB, 142 views)

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

The anterior edge modification is one I first wrote about in my October 1986 Precision Intricast newsletter (Kirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona, 1997, pp. 1-3) and involves having the lab leave an abrupt, full-thickness dropoff of the anterior edge of a 4-6 mm thick polypropylene orthosis (or other suitable material) so that the ground reaction force is transferred to the metatarsal necks, at the anterior orthosis edge, and away from the metatarsal heads. John Weed, DPM, first described this modification to me in about 1984 and he would use 5.0 mm thick Rohadur to accomplish the same mechanical effect from this extra thick Rohadur plate.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

2nd Interspace Neuroma vs Plantar plate tear

". Dr. Kirby adds that plantar digital nerve irritation, or neuritis, will be most tender either medially or laterally, off-center, from the second MPJ.
Furthermore, Dr. Kirby says plantar plate injuries will often be painful with plantarflexion testing of the digit at the MPJ and this finding is uncommon with neuromas. In addition, a neuroma by itself will not likely be associated with plantar MPJ edema, which Dr. Kirby says is the case in plantar plate injuries.
“Therefore, if you see a swollen second MPJ with classic plantar plate ..."

Hope you don't mind my taking this quote from the Pod Today article.

I'm so happy to see this. WHY is this so commonly misdiagnosed as a neuroma? And the worse part about the misdiagnoses is not that the patient may not be treated properly, but that the patient's condition may worsened by the treatment. How commonly do we see a patient with OBVIOUS sub second prox base pain giving a history of being injected over and over again with cortisone because of a neuroma diagnosis?

And what's the consequence? A fully subluxed 2nd MTPJ.

What ever happened to "first, do no harm" ?


Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

I've been having some positive results with tension taping across the plantar surface of the transverse arch whereby I apply hyperfix followed by 3 strips across. Each strip has tension to create the transverse arch.
This I re tape after a week but have the patient remove the tape and monitor using pain scale and how long it takes to come back?
This is handly on female patients who are hesitant to change their footwear (heels)

Met raises on OTS or custom depending depending on biomechanical needs.

G'day all,

I see many of these 2nd metatarsal plantar plate injuries, as we all do, in practice. Taping the second digit in a neurtal position and limiting dorsiflexion I've found really effective for cases where it is an isolated pathology. For those unfamiliar with the taping, I use 1cm (2/5 inch) wide sports tape, strip approx 10 cm long (4 inches) starting on the plantar surface of the foot just lateral and proximal to the 2nd metatarsal head, wrap the tape up the medial side of the 2nd , across the top, down the lateral side, and stick the other side just medial and proximal to the plantar surface of the 2nd metatarsal head, crossing the tape over. Repeat 3-4 times. This is nice and easy and can be taught to patients to do every second day.

Quite often though, I find that the 2nd metatarsal pathology is secondary to 1st ray pathomechanics (as the link describes). Hallux limitus/rigidus, metatarsus primus elevatus, Hallux abducto-valgus (HAV), congenital short 1st metatarsal, etc will all overload the 2nd metatarsal, and in cases of HAV, will apply a transverse force on fibres of the transverse intermetatarsal ligamnent, which is consistent with the plantar plate of the 2nd MTPJ. This can assist in longitudinal tear of the plantar plate, allowing the metatarsal head to herniate plantarly, and giving rise to the 2nd digit claw toe consistent with HAV. In these patients, the taping fails quite quickly unless the 1st ray/MTPJ pathomechanics are addressed. This is achieved as Kevin suggests with an appropriate orthotic device. When the foot does get to this stage, issues such as trauma to the plantar fat pad, bursitis and osseus contusion of the 2nd metatarsal head should be considered, as the plantar plante is no longer plantar to the metatarsal head.

The other really fundamental idea that needs to be addressed is footwear. Unfortunately this is more than often the most difficult aspect of the treatment plan. ANY shoe with a heel will increase ground reaction forces (GRF) under the metatarsal heads, and where an insufficiency at the 1st MTPJ is present, will further increase GRF at the lessor metatarsal heads, and specifically the 2nd metatarsal heads. Try to get your female patienst into runners instead of heels, give them notes for work if necessary, but get them out of heels if you want to heal the 2nd met pathology! Runners are great because there's no heel, and increased padding at the MTPJ area, reducing GRF to the 2nd metatarsal heads. Of course, when it's all better, and they get back into heels, there's every chance it'll happen again, so footwear education is so imporant here.

Thanks Kevin for a great thread!

__________________
Adrian Misseri
B.Pod.,M.Hlth.Sci.(Pod.)

You know.. we could just cut it off.....?

Steve:

Thanks for that. Maybe you can comment on plantar plate repair vs. flexor transfer for these pathologies for Ryan. What are your experience with the results from these procedures?

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Hi Kevin:
Hi Kevin, et. al. / I'll try to make this short.

"plantar plate repair vs. flexor transfer"

Over the past "decades" my approach has certainly evolved.

Re; Flexor transfer. I do not perform these anymore. I found that the patient's that failed to respond to conservative treatment rarely had an underlying pathology that was so specific that a flexor tranfer would give them long term relief.

I began doing the transfer with the primary repair of the plate. These also, unless there was an acute injury, on an otherwise normal foot, that I could identify (which was rare) gave por long term results.

In addition, these do not heal very quickly and patients, especially those that have had ongoing conservative treatment for months are not too happy with the prolonged post operative period.

MOST of these fall into one of several categories causing repeated microtrauma;
1. Isolated long second metatarsal with progressive subluxation in otherwise "normal" foot.
2. Long second metarsal with functional equinus and progressive subluxation.
3. Functional Hallux limitus with relative long second metarsal and progressive subluxation
4. Metarsaus primus elevatus
5. Hallux limitus or rigidus with increased load on second and progressive subluxation
6. Pes Cavus/equinus with progressive subluxation of all MTPJs

AND in addition sometimes;

7. Acute isolated trauma to the 2nd MTPJ

the underlying commonality of these is the long second metatarsal.

I began performing a shortening osteotomy of the second metarsals with very good results. In addition, frequently I found synovitis, Osteochondral defects, transverse plane subluxation, contracted soft tissue; all of which can be dealt with at the same time.
I do not repair the plantr plate anymore. THe shortening osteotomy seems to correct enough of the pathomechanics that it either fibrosis in or the decreased demands eliminated the pain.

Achilles stretches are always given pre-operatively and continued ad nauseum as long as I can get the patient to do them.

There's more but I have to see some patients!!!!!

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA