Metatarsalgia

Question 1

What’s the Lachman’s test?

Answer 1

• Also called drawer test/vertical stress test

- Tests for plantar plate tear or rupture (> 2 mm dorsal translation of the proximal phalanx)

Question 2

Who was Lisfranc?

Answer 2

A surgeon in Napoleon’s army

Question 3

What’s the management plan for suspected grade 0 capsulitis?

Answer 3

1. Arrange X-ray and US

2. Issue Darco toe splint to plantar flex and prevent further plantar tension/attenuation

Question 4

Outline the staging system for 2nd MTP joint instability (i.e. capsulitis)

Answer 4

Grade 0 - MTP joint alignment normal with no deformity

Grade 1 - Mild malalignment at MTP joint with mild deviation, widening of web space, mild positive drawer test (< 50 % subluxable)

Grade 2 - Moderate malalignment with medial/lateral/dorsal/dorsomedial deformity and hyperextension of toe

Grade 3 - Severe malalignment with dorsal/dorsomedial deformity, second toe can overlap the hallux, very positive drawer test

Grade 4 - Severe deformity with dorsomedial/dorsal dislocation, fixed hammertoe, no toe purchase

Question 5

What is the goal of taping as a conservative treatment for an unstable 2nd MTP joint?

Answer 5

To secure the toe in a neutral position with the hope that stabilisation will lead to capsular scar tissue formation, although this can require several months of taping

Question 6

What is Freiberg’s disease?

Answer 6

Is a form of osteochondrosis (osteonecrosis/avascular necrosis) or focal disturbance of endochondral ossification affecting the MTP joint in rapidly growing children

Question 7

Describe the classification system used for Freiberg’s disease

Answer 7

Smillie’s classification

Stage I - a fissure develops in the epiphysis which can cause synovitis and lead to joint space widening on radiographs

Stage II - the metatarsal head flattens due to central bone resorption

Stage III - further collapse of articular surface with peripheral irregularities

Stage IV - irregular peripheral areas and the remaining plantar cartilage can #, leading to loose body formation

Stage V - marked flattening and widening of the metatarsal head with loss of joint space and end-stage arthritic changes

Question 8

What is an adventitious bursa?

Answer 8

In contradistinction to the other types of bursae that we are born with (synovial and subcutaneous bursae), adventitial, or accidental, bursae are acquired: they arise in soft tissue as a result of repeated subjections to unusual shearing stresses, particularly over bony prominences

Question 9

Outline the postoperative follow-up protocol for sesamoidectomy, cheilectomy, joint implant and exostectomy

Answer 9

Week #1 - Rest w leg elevated for the first 24 h.
Dressing change within a week.
Week #2 - Dressing and stitches removed.
ROM exercises started.
Can return to comfortable footwear.

Question 10

Outline the postoperative follow-up protocol for decompressive metatarsal osteotomy

Answer 10

Week #1 - Aircast boot placed in theatre should be removed at rest and foot and ankle mobilised.
Rest with leg elevated for the first 48 h.
Dressing change within a week and foot X-rayed.
Walking to tolerance around the house.
Week #2 - Dressing and stitches removed and ROM exercises started.
Remain in Aircast boot for a further 4 weeks fully weightbearing.
Gradual increase of low impact activity.

Question 11

Outline the postoperative follow-up protocol for joint fusion

Answer 11

Week #1 - Aircast boot placed in theatre should be removed at rest and foot and ankle mobilised.
Rest with leg elevated for the first 48 h.
Dressing change within a week and foot X-rayed.
Walking to tolerance around the house.
Week #2 - Dressing and stitches removed and ROM exercises started.
Remain in Aircast boot for a further 4 weeks fully weightbearing.
Gradual increase of low impact activity.