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Saw a patient a few days ago complaining of pain in her 2nd toe.
Pain was elicited by extension of the proximal phalanx and direct pressure to the dorsal aspect of the mtpj.She has reduced dorsiflexion stiffness of the 1st ray,met formula is fairly normal,no digital deformity.No history of direct trauma.Symptoms occur immediately on weight bearing,intense pain.
I applied a 2-4 s.c.f toe prop which gave much relief,but only for 1 day,pain returned.
I have sent her for x-ray to rule out a stress fracture but feel perhaps it is related to extensor hood,or extensor digitorum brevis tendinitis.
Could this be,as you said an extensor hood problem?Maybe (since there is a problemwt bearing) lumbrical or interosseus tendonitis?Try an MRI if no relief.
Saw a patient a few days ago complaining of pain in her 2nd toe.
Pain was elicited by extension of the proximal phalanx and direct pressure to the dorsal aspect of the mtpj.She has reduced dorsiflexion stiffness of the 1st ray,met formula is fairly normal,no digital deformity.No history of direct trauma.Symptoms occur immediately on weight bearing,intense pain.
I applied a 2-4 s.c.f toe prop which gave much relief,but only for 1 day,pain returned.
I have sent her for x-ray to rule out a stress fracture but feel perhaps it is related to extensor hood,or extensor digitorum brevis tendinitis.
Scott:
In these cases of atypical presentations of pain, it is always best to try and isolate the specific anatomical structure that may be the cause of the patient's pain.
With dorsal 2nd metatarsophalangeal joint (MPJ) pain, do the following tests:
1. Have the patient dorsiflex the toe against manual resistance, does this produce pain?
2. While the patient is dorsiflexing the toe against resistance, palpate the long and short extensor tendons to see if they are tender.
3. Does active dorsiflexion and plantarflexion cause pain?
4. Does passive dorsiflexion and plantarflexion cause pain?
5. Manually distract the digit, does this cause pain?
6. With the patient relaxed palpated dorsal to the MPJ area, centrally, medially and then laterally to see where the tenderness exactly is.
7. Next, palpate proximally along the 2nd metatarsal shaft to see if the metatarsal head or neck or shaft or tender or irregular in shape and palpate along the proximal phalanx distally to detect any tenderness or morphological abnormalities.
8. Perform a dorsal drawer test at MPJ to test for possible plantar plate tear (more dorsal movement of proximal phalanx base to metatarsal head) and to see if the test was painful.
From the decrease in first ray dorsiflexion stiffness you noted, I would also palpate plantarly to see if the patient has tenderness or swelling at the plantar plate area. A stress fracture of the digit or MPJ area would be rare. The area where a stress fracture will most likely occur is the area where the greatest bending strains occur in the forefoot: at the metatarsal neck. Bending strains are greatest at the metatarsal neck due to the reduced cross-sectional area (i.e. area moment of inertia) at this area of the metatarsal combined with the bending moments in the metatarsal.
Why not try an accommodative insole for the 2nd MPJ using a metatarsal pad and 2nd MPJ cutout to see how this works. It very may well be that the dorsal pain is due to increased plantar pressure.
If you can provide answers to the above tests for us, then I think we will be able to help you further.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I have seen the patient again this evening and have answers to your questions.
1)Manual p/f & d/f does not produce symptoms.
2)Pain is elicited when I actively plantarflex the proximal phalanx
3)No pain on active dorsiflexion of proximal phalanx
4)Direct palpation centrally over the dorsal aspect of the mpj gave neuralgic stabs.
5)No pain on intermet or on dorsal met shaft.
6)No pain on direct palpation of plantar met head but pain when flexed on weightbearing.(on tiptoes)
7)No pain when distracting digit.
8)No sub 1st plantar pain.
9)Pressure mat scan showed high 2nd met pressure.
10)No pain when palpating along the course of the extensor digitiorum tendon.
In summary.
Direct palpation on dorsal mpj and active plantarflexion very sore,tender/neuralgic sensation in 2nd plantar met region.
I have seen the patient again this evening and have answers to your questions.
1)Manual p/f & d/f does not produce symptoms.
2)Pain is elicited when I actively plantarflex the proximal phalanx
3)No pain on active dorsiflexion of proximal phalanx
4)Direct palpation centrally over the dorsal aspect of the mpj gave neuralgic stabs.
5)No pain on intermet or on dorsal met shaft.
6)No pain on direct palpation of plantar met head but pain when flexed on weightbearing.(on tiptoes)
7)No pain when distracting digit.
8)No sub 1st plantar pain.
9)Pressure mat scan showed high 2nd met pressure.
10)No pain when palpating along the course of the extensor digitiorum tendon.
In summary.
Direct palpation on dorsal mpj and active plantarflexion very sore,tender/neuralgic sensation in 2nd plantar met region.
Extensor hood,predislocation syndrome?
Thanks for your help
Scott Shand
Scott:
I have seen some patients with "predislocation syndrome" with neuritic symptoms in the 2nd digit, however the tenderness and neuritic symptoms are plantar, not dorsal. However, these patients usually have pain with plantarflexion of the metatarsaphalangeal joint (MPJ). I am not sure exactly what your patient has but I would reduce the plantar loading forces on the 2nd MPJ with a modified insole or orthosis, have the patient ice 20 min twice daily both dorsal and plantar at the 2nd MPJ and see how she responds in 2 weeks. Also, no barefoot walking, no heeled dress shoes.....running/walking shoes only for 2 weeks.
She will likely be 50-75% improved in 2 weeks.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
What is your definition of predislocation syndrome?
Is it much the same as plantar plate disruption?
Scott
The term "2nd metatarsophalangeal joint predislocation syndrome" is one that was, to my knowledge, first proposed by the late Gerard Yu, DPM, in a paper he cowrote and published in 2002. This is an excellent paper on the pathology and probably the best paper I have ever seen on the subject (Yu GV, Judge MS, Hudson JR, Seidelmann FE: Predislocation syndrome: Progressive subluxation/dislocation of the lesser metatarsophalangeal joint. JAPMA, 92: 182-199, 2002).
However, I don't really like the term "2nd metatarsophalangeal joint predislocation syndrome" since it implies that all patients with plantar plate pathology (i.e. inflammation, partial tears, complete tears) will eventually end up with metatarsophalangeal joint (MPJ) dislocation, which is simply not the case.
I have been calling this pathology "2nd metatarsophalangeal joint capsulitis" for many years now since this is what the pathology was called when I was a student and resident. However, I don't think that the term "2nd metatarsophalangeal joint capsulitis" is precise enough at isolating the involvement of the plantar plate as the primary pathology.
The term "2nd metatarsophalangeal joint stress syndrome" is also very inclusive, but does not precisely describe the anatomical structure that is primarily injured which makes me think that this is also not a good term. We could call it "2nd metatarsophalangeal joint plantar plate stress syndrome" but this doesn't seem to include plantar plate tears which are very common.
I propose that the preferred name for this disease be called 2nd metatarsophalangeal joint plantar plate dysfunction since this is inclusive of all possible plantar plate pathologies (i.e. inflammation, partial tear, complete tear), precisely describes the anatomical structure where the primary injury has occured, and is consistent with our currently accepted terminology for inflammation, partial tears and complete tears of the posterior tibial tendon (i.e. "posterior tibial dysfunction" or "posterior tibial tendon dysfunction").
This would be an excellent topic for an article or newsletter which I will seriously consider writing in the coming months.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Help needed-2nd mtpj pain
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