Metatarsalgia Flashcards
what is metatarsalgia?
forefoot pain under metatarsal heads
what are some bony causes of metatarsalgia?
- long metatarsal
- plantarflexed met
- hammertoe
- enlarged met head
- arthritis
- Freiberg’s infarction
- stress fx
what are some soft tissue causes of metatarsalgia?
- calluses
- neuroma
- capsulitis
- plantar plate pathology
- hypermobile 1st ray
- equinus
what are indications for metatarsal osteotomies?
- long metatarsal
- plantarflexed metatarsal
- contracted digit that cannot be reduced w/o dec metatarsal length
- angular deformity
what are contraindications for metatarsal osteotomies?
- pain of unknown etiology
- parabola correction w/o underlying pain or sx
- severe osteopenia
what are contraindications for metatarsal osteotomies?
- pain of unknown etiology
- parabola correction w/o underlying pain or sx
- severe osteopenia
what is the weil osteotomy?
a shortening osteotomy where you make a cut parallel to WB surface at cartilage surface, causing the soft tissue to shrink back
when is the plantar condylectomy procedure used?
- used in older patients w/ prominent metatarsal head due to fat pad atrophy
- used in diabetic patients with chronic callus/ulcer
when is the V metatarsal osteotomy indicated?
for a purely plantarflexed metatarsal and you just want to raise it up
what are two procedures that correct a plantarflexed metatarsal?
- V metatarsal osteotomy
2. dorsiflexory wedge osteotomy
what are the indications for a weil osteotomy?
long metatarsal
for distal procedures, what is the post-op directions?
WB in post-op shoe for 6 weeks if fixated
if not fixated, may consider NWB
for proximal procedures, what is the post-op directions?
NWB for 6-8 weeks
what are complications of metatarsal osteotomy?
- floating toe
- transfer lesions onto adjacent met heads
- delayed or nonunions w/o fixation
what is freiberg’s ifnarction?
avascular necrosis of the 2nd metatarsal head leading to collapses of articuarl sruface
what do late changes of freiberg’s infarction look like on radiographs?
flattening of met head, spurring, sclerosis
conservative treatment for freiberg’s infarction?
- initially: immobilization
- chronic tx: steroid injection, rocker bottom shoes, carbon plate for shoes
surgical treatment for freiberg’s infarction?
- metatarsal head resection
- graft
- implant
how do you diagnose stress fracture?
- pain with palpation dorsally
- pain with tuning fork application over the site itself
- may have edema
- initial x-rays negative
- bone scan will have uptake in 3rd phase
conservative treatment for stress fx?
-immobilize in boot or post-op shoe for 4-6 weeks
surgical treatment for stress fx?
only done if it goes to full fracture or there is excessive callus formation
s/s of neuroma?
- burning pain
- tingling/numbness
- wrinkled sock sensation
- sharp or radiating pain to toes
- symptoms worse with tight shoes
which interspace is commonly affected (aka Morton’s neuroma) and why?
3rd interspace
bc of communicating branch btwn medial and lateral plantar nerves
what physical exam findings do you expect with morton’s neuroma?
- pain on direct palpation to intersapce
- Mulder’s sign: a palpable click is heard when you squeeze forefoot while applying plantar and dorsal pressure
- gauthier test: pain with just squeezing foot
- usually no edema noted
what diagnostic testing do you need for a neuroma?
(usually not necessary)
- x-rays to rule out stress fx; Sullivan’s sign
- ultrasound: ovoid mass with hypoechoic signal
- MRI- T1 image is best
what is sullivan’s sign?
splaying of toes in the involved interspace when WB
conservative treatment options on neuroma?
- wider shoes
- metatarsal pad
- steroid injection
- sclerosing injection
what are the advatnages of a dorsal incision for a surgical tx for neuroma?
- immediate WB
- no plantar scar or wound dehiscence
what are teh disadvantages of a dorsal incision for a surgical treatment for neuroma?
need meticulous dissection (can lead to hematoma or hammertoe formation)
what is the advantages of plantar incision for surgical tx of neuroma?
- better visualization
- less incidence of hematoma and hamemrtoe formation
what are the disadvantages of plantar incision?
NWB for 3 weeks
-potential plantar scar
plantar plate pathology commonly affects which metatarsal?
2nd met (bc it is the longest)
s/s of plantar plate pathology?
- pain worse w/ walking
- feels like walking on a stone bruise
- change in position of toes (medial deviation is common)
etiologies of plantar plate?
- long 2nd met/ short 1st met
- 1st ray hypermobility
- overloading due to equinus or high heels
what are the physical exam findings of plantar plate pathology?
- pain w/ palpation directily plantar at joint line
- focal edema over joint
- possible loss of purchase of toe
- vertical stress test
what is vertical stress test?
(for plantar plate pathology)
is (+) with 2mm or more displacement of the toe
what is stage 1 of predislocation syndrome (aka plantar plate pathology)?
- mild edema dorsal and plantar
- very painful
- joint is still aligned
what occurs in stage 2 of predislocation syndrome?
- moderate edema
- deviaition of digit both clinically and radiographically
- loss of toe purchase, noticeable in WB
what occurs in stage 3 predislcoation syndrome?
-moderate edema
-subluxation/ dislocation is pronounced
-
how does the bone scan compare between plantar plate tear and stress fx?
will be (-) in phase 3 of plantar plate tear but (+) for stress fx bc it of bone involvement
conservative tx for plantar plate tears?
- metatarsal pads
- budin splint
- crossover taping
- NSAIDs
- ice, stiff shoes, CAM boot
surgical treatment for plantar plate tear?
-direct repair
-indirect stabilization
(in addition, may fuse PIPJ or do metatarsal osteotomy; may even do 2nd MPJ fusion)
describe the direct repair for a plantar plate tear.
can be a dorsal or plantar incision, although most people approach it from plantar side. The tear is usually on the phalanx side; can suture end-to-end or use anchor in proximal phalanx base. stabilize with K-wire.
*post-op: NWB for 3 wks
describe the indirect repair of plantar plate tear.
- isolate flexor tendon and split in half, bring up over toe and suture to itself and periosteum dorsally
- isolate tendon and insert into bone and secure to itself, periosteum, or use anchor
