Metatarsalgia

Dislocated toes

This is an abnormally positioned toe that has lost alignment at the joint where the toe meets the foot.  The poor position means that the toe can rub on the upper of the shoe, or cross over adjacent digits with its ability to purchase the ground lost. This initially tends to be due to a soft tissue injury, often a torn ligament.  Initially this is reducible, but with time the joint adapts to this poor position and this can lead to arthritic changes.  Symptoms include soreness from shoe pressure on the toes or joint pain as a result of the soft tissue injury.

The picture shows that the second toe is elevated, non-weight bearing and bent. The scan on the right shows the anatomy with M3 (3rd metatarsal head), ET (extensor tendon), FT (flexor tendon) and the black arrows marking out the attachments of the plantar plate that provides significant stability to the metatarsal phalangeal joint.

Treatment

Conservative care

• The right footwear for the right occasion. When active, a firmly laced, rigid soled shoe with a cushioned inlay should be worn e.g. hiking shoes
• Insoles
• Strapping or toe props
• stretching the calf muscles
• Routine podiatry to reduce hard skin
• Immobilisation with an Aircast Walker
• Steroid injection into a painful joint or around soft tissue structures

Strapping the mal-aligned toe into a straight position using athletic tape.

Surgical Management

 Metatarsalgia

 Weil’s osteotomy (Proximal displacement osteotomy)

This approach is used when an abnormality in the metatarsal lengths has been diagnosed as causing the metatarsalgia. The Weil osteotomy has been used to shorten and when necessary elevate one or all three of the central metatarsals to provide an even distribution of weight across the forefoot. Post-surgery patients have to use a post-operative sandal for ten-days.

The pre-operative x-ray shows an acute metatarsal parabola measuring 136 degrees.  The norm is considered to be 142-144 degrees.  An acute parabola increases the loading beneath the 2^nd and 3^rd metatarsal phalangeal joints.  Post-surgery the central three metatarsals have been shortened to provide an even distribution of weight across the forefoot.

Post-operative stretching is advocated across the metatarsal phalangeal joints to reduce the risk of complications, notably floating toes.

Neuroma management – See the separate information sheet on the management of neuromas.

Dislocated toe

The surgery will vary depending on a number of factors including:

• Whether the toe can be moved into the corrected position manually without pain.  If this is the case then minimal joint changes have occurred
• Other deformities that may be affecting the toe e.g. hallux valgus (bunion)
• The effect that this complaint has on your lifestyle, as well as your expectations

Surgical options:

If the joint is manually reducible with minimal pain on mobilisation then reconstructive procedures are advocated otherwise a more aggressive approach is indicated.  Ideally the aim is to reposition the toe without compromising the joint allowing full function.  However, this is not always achievable. 

Reconstructive procedures

• Arthrodesis and plantar plate repair:

This involves straightening the toe by an arthrodesis and repairing the torn plantar plate (ligament), that has allowed the toe to move out of alignment. 

The MRI shows an elevated, non-weight bearing and bent toe with a torn plantar plate. The diagram shows the intact ligaments around the metatarsal phalangeal joint along with the associated plantar tendons and the plantar fascia.

One or two K-wires may be used to hold the small bones in a straight position while the bones fuse together. The wires maybe internal and cut close to the bone remaining in place indefinitely or placed percutaneously and removed after six weeks.

Tendon Transfer:

This procedure is selected when the toe sits in a subluxed position, but it can still be straightened manually. The flexor digitorum longus tendon from the bottom of the toe is cut and transferred onto the top of the toe, pulling it down into a straight position. This procedure will require being in an Aircast for 4-6 weeks.

Closing Wedge Osteotomy

This procedure is selected when the toe deviates towards the next toe. A section of bone is removed from the digit in such a way that the toe can be straightened.  A small wire or a screw is used to hold the 2 bones together whilst they unite.  These normally remain in place unless they move or cause irritation.

Joint Destructive Procedures

These operations are employed when the joint cannot be realigned manually due to severe joint adaptation, arthritis or reconstructive surgery is not appropriate for the patient.

Syndactylisation

This procedure is selected when the toe is dislocated/crosses over the next toe or the joint is arthritic. Here half of the joint is removed allowing the toe to be realigned, resolving any arthritic pain.  However, the toe is now unstable and is unlikely to stay in this corrected position without further support.  Consequently, the toe is joined to its neighbour by removing the skin between the two and sewing them together.  This provides stability with the two toes moving in unison.

The picture on the left shows an arthritic 2^nd MTP joint, the middle and lateral pictures shows the joint having been removed and the 2^nd and 3^rd toes joined together

Amputation of the toe:

This procedure is most commonly selected when the patient has a severe bunion with the second toe overlying it. Here reconstructive surgery would require the bunion to be corrected in order for there to be room for the second toe to sit down.  In patients who do not want to undergo bunion surgery and a major reconstructive procedure for the 2nd digit, or are too frail; this procedure offers a quick return to normal shoes and function.  The risk is that the big toe could drift over further.

Discharge

Before you leave the hospital, you will be given a post-operative sandal or Aircast Walker boot with or without crutches, and the physiotherapists will show you how to use them. Post-operative painkillers will be dispensed along with your next appointment.   You should arrange to go home by car or taxi with an escort.  You should have someone with you for the first 24 hours in case you feel unwell.

Recovery

You must rest with the leg elevated for the first 48 hours (essential walking only). It is important that you do not interfere with the dressings and keep them dry.  You can buy a purpose made waterproof cover to keep the leg dry, from your chemist (Limbo M100 above the knee).

Full recovery takes six months

Possible complications

Most patients have an uneventful recovery. Outlined below are the common problems or those rare complications with serious outcomes. In cases where we don’t have accurate audit, we have used published results from the podiatric literature.  These are accompanied by an asterisk *

• Prolonged swelling taking more than 6 months to resolve occurs 1 in every 500 operations*
• Haematoma – a painful accumulation of blood within the operation
• Thick and or sensitive scar
• Adverse reaction to the post-operative pain 1 in every 50 patients report that the codeine preparations can make them feel sick*
• Infection of soft The incidence is 1 in every 83 operations*
• Delayed healing of soft tissue  
• Circulatory impairment with tissue loss occurred in 3 out of 9000 patients over a 10-year period
• Deep vein thrombosis which can result in a clot in the lung is potentially a life-threatening Deep vein thrombosis requiring treatment, within the published literature, is 0.3% *
• Chronic pain syndrome: this is where the nervous system dealing with pain over reacts in a prolonged manner often to a minor This normally requires management by specialists in this condition and does not always resolve.  This is a rare complication with no audit data available

The risk of having a complication can be minimised when the patient and all those concerned with the operation and aftercare work together. This starts with the pre- operative screening and continues through to rehabilitation.

Pre-operative screening of your health allows us to determine whether you are fit for surgery. Further investigations and the advice of other surgical and medical specialities will be sought as required. We will ensure that the operation is performed effectively and with the minimum of trauma.

You can improve the healing process and reduce the risks of complications by:

• Adhering to the post-operative instructions which include resting and elevating the operated
• Keeping the wound clean and dry until advised otherwise is essential; please ask the team if you are not sure what to
• Having a healthy diet is important; this provides the nutrition required for
• Smoking is associated with 20% increased risk of delayed or non-union of
• Alcohol can interact with the drugs that we will prescribe and in excess can impair wound
• Post-operative mobilisation when advised helps to improve the surgical outcome