Evaluation and Management of Metatarsal and

Forefoot InjuriesCharlesJ.Gatt,Jr.,MD

Chair,DepartmentofOrthopaedicSurgeryRutgersRobertWoodJohnsonMedicalSchool

NewBrunswick,NJ

• NoDisclosures

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Questions

• Whatarethecommoninjuriesoftheforefoot?• Whatarethecausesofinjury?• Whatisthetreatment?

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The Problemn300,000lbs ofstresspermileofrunningiscenteredonheelandthendissipatedtotherestofthefoot

Foot and Ankle Sports Injuries History

n Sportn Surfacen Shoesn Custom/Prefab Orthosisn Onset

n Position at injuryn Noisen Pain locationn Swellingn Time out of Sports

Foot and Ankle Sports InjuriesPhysical Exam

n Gaitn Callus Distributionn Shoe Wearn Orthosis wearn Palpation

n Auscultationn Range of Motionn Percussionn Pulsesn Sensory Exam

Imaging

• Xray–Weightbearingxray mayaddclarity

• MRI• MSKUS

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Metatarsalgia

n Commonoveruseinjurydescribedaspainintheforefootthatisassociatedwithincreasedstressoverthemetatarsalheadregion

n Oftenreferredtoasasymptom,ratherthanasaspecificdisease.

Metatarsalgian CommoncausesofMetatarsalgia

n Sesamoiditis

n Interdigitalneuroma(alsoknownasMortonneuroma)

n Avascularnecrosis(Frieberg’sInfarction)

nMetatarsophalangealSynovitisnInflammatoryarthritisnSynovitis/InflammationfromRepetitiveTrauma

SesamoiditisSIGNS

n Local Tenderness

n Pain with Hyperextenion

n Rare Swelling

Sesamoid FractureMechanism

nAcute fall from height (Ballet)nHyperextension of MTP (football) nStress fracture (Runners)nOsteochondritis

Kilman, F+A,3:220 1983

SesamoiditisIncidence

n Stress FracturenAny age nTibial or Fibular Sesamoid

n OsteochondritisnFemale, 20’snlateral Sesamoid

Sesamoid FractureX-RAY

n AP/Lat/Obliquen Tangential Views

Acute sesamoid fracture

nPresentationnMay mimic Turf Toe

nTreatmentnDepends on amount of Diastasis

Acute sesamoid fracture

n Diastasis >2mmn Bony Fixationn Soft tissue repair

n Diastasis < 2mmn SLC 3-6 weeksn Steel shank insolen Prevent Hyperextension

Richardson, F + A 7:29, 1987

Sesamoid FractureSurgical Treatment

n DisplacedFracture

n Non-Disp Fx NotResp tocastImmob.orshoeinsertsx12wks

n UnrelievedSesamoiditis/Bursitis

n Osteomyelitis

Mann AOFAS 1985

Sesamoid FractureExcision of Fragment-Complications

nMigrationofHallux10%

n PersistentPain41-50%

n Stiffness33%

nWeakness60%

Sesamoid FractureLate Repair

•Seventeen Patients

•Treated with Curretage and Bone Grafting

•Post-op SLC for Six Weeks

•Mean Follow-up 33 months

•15/17 Asymtomatic return to all Pre Injury Activities

•14/15 Healed by Tomography at 12 weeks

Anderson/McBryde AOFAS March 1991

Turf ToeMechanism

n Acuten Hyperextension of first

MTPn Direct blow to heel with toe

planted in dorsiflexion

n Chronicn Repetitive valgus stressn Runner’s (Especially

Cross-country)

Turf Toe in FootballCollegeFootball• Incidence.062/1,000AE

• 14xmorelikelyingamesvspractice

• Contactw/otherplayer

GeorgeE,“Incidenceandriskofturftoeinintercollegiatefootball;datafromNCAAInjurysurveillancesystem”FAI2014;35(2):108-115

ProfessionalFB• 80playerssurveyed• TimelossequaltoAnklesprains• 83%firsttimeonartificialturf• Hyperextensionmechanism• 60%Offense

– OL– >Age27(5+yearsexp)

• Progressiontochronicinjury– Careerending

RodeoSA,“TurfToe:“Analysisofmetatarsalphalangeal injuriesinprofessoinalfootball”AJSM1990;18(3):280-5

Turf ToeAnatomy

n MTP Capsulen Articular Cartilagen Great Toe Flexorsn Sesamoidsn Abductor Hallicusn Plantar Nervesn Bones

Coker, J Ark.Med Soc. 74:309 1978

Turf ToeTreatment

n No role for injectionsn RICE, Shoe Mod. And Tapingn If can’t jog w/in 3 wks. Consider

n open treatmentn Late repair works

Hallux RigidusnLiterally“StiffBigToe”nSentinalFinding–

nDecreasedDorsiflexion(Pain)nCanbepredisposed

nTypeoffootnTypeofactivity

nAcuteinjurysquellaenChronicrepetitiveinjury

Hallux Rigidus17yo

Hallux Rigidus

nTreatmentnNonoperative

nSymptomaticnMechanical–DecreaseDorsiflexion

nOperativenCheilectomynArthroplasty

nBiologic

Hallux Rididus

Morton's Neuroman Symptoms

n Classicallydescribedasaburningpainintheforefootncanalsobefeltasanachingorshootingpainintheforefoot

n Painmayoccurinthemiddleofarunorattheendofalongrun

n Ifshoesaretightortheneuromaisverylarge,thepainmaybepresentevenwhenwalking

nOccasionallyasensationofnumbnessisfeltinadditiontothepainorevenbeforethepainappears.

Morton’s Neuroman “Click"whichisknownasMulder'ssignn Theremaybetendernessintheinterspacen Ruleoutsimilarorconcurrentproblems

n Tendernessatoneofthemetatarsalbonescansuggestastressreaction(pre-stressfractureorstressfracture)inthebone.

n Anultrasoundscancanconfirmthediagnosisandisalessexpensiveandatthistime,atleastassensitiveatestasanMRI

n Anx-raydoesnotshowneuromas,butcanbeusefulto"ruleout"othercausesofthepain.

Morton’s Neuroman Cause

n AnenlargementofthesheathofanintermetatarsalnerveinthefootnMostCommon–Thethirdintermetatarsalspace

nThesecondinterspacebeingthenextmostcommonlocation.

Morton’s Neuroman ContributingFactors

n Pronation ofthefootcancausethemetatarsalheadstorotateslightlyandpinchthenerverunningbetweenthemetatarsalheadsnChronicpinchingcanmakethenervesheathenlarge.Asitenlargesitthanbecomesmoresqueezedandincreasinglytroublesome.

n Tightshoes,shoeswithlittleroomfortheforefoot,pointytoeboxescanallmakethisproblemmorepainful.

nWalkingbarefoot mayalsobepainful,sincethefootmaybefunctioninginanover-pronatedposition.

Morton’s Neuroma

n Self-TreatmentnWearwidetoeboxshoesnDon'tlacetheforefootpartofyourshoetootightnMakesureyourfeetareinsupportiveshoesthatdonotsqueezeyourforefoot

Morton’s Neuroman Orthotics– esp.forthePronatorn InjectionofSteroidandLocalAnestheticn Occasionallyinjectionofothersubstancesto"ablate"the

neuroma.n SurgicalRemovalofNeuroman Tips

nWearshoesdesignedwitharoomytoebox.nWearshoesthathavegoodforefootcushioning.nUsesportspecificshoes.n Fityourshoeswiththesocksthatyouplantowearduringaerobicsactivity.

Freiberg's Infractionn AKAAvascularNecrosis,Osteonecrosis,Osteochondrosisn Generalconsiderations

nNamed“infraction”becauseitwasoriginallythoughtsecondarytotrauma

n Exactcauseremainsuncertainbutthoughttobeoneoftheosteochondroses inadolescentsnOsteochondroses arediseasesthatusuallyaffecttheepiphysesofgrowingbonesresultinginnecrosismostlikelyonavascularbasis,althoughtheexactmechanismisnotknown

n Inothers,Freiberg'smaybeduetoacombinationoftrauma,andvascularinsults

Metatarsal Stress Fractures• .7-21%IncidenceLiterature• 90Reported(63F,27Male)– F– basketball,Lax– M– Football,indoortrack

• 2nd MTMostcommon– Middle1/3– MajorityOccurredongrass

NationalStressFx Registry

Base of 5th metatarsal fracture

n TuberosityAvulsionFracturenMechanism- InversionnHeals Clinically-3wks

Radiograghically-6wks

Dancer’s Fracture

nSpiralFractureoftheFifthMetatarsalnTreatWBATinpostopshoenLongertimetohealing

Stress fractures of the 5th metatarsalJones fracture

nGradualincreaseinlateralfootpainnPointtendermetaphysisof5th MTnHighindexofsuspicionnMRIifxrays negativeandhighsuspicion

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Stress fractures of the 5th metatarsalJones fracture

Jones FractureTreatment

nAsymptomaticandpositiveMRIn?Orthotic/shoemodification

nSymptomaticandpositiveMRInOrthoticnActivitymodificationnClosemonitoringofsymptoms!!

nSymptomaticwithvisiblefractureline,hypertrophynStronglyconsidersurgery

Acute on chronic stress fracture

Jones Fracture

n IMFixationnWBATincamwalkerwhencallusvisiblenHealedRadiographicallyby13weeks

Summary

• Manycausesofforefootpain• Detailedhistoryimportant• Clinicalexamimportant;Promptrecognition• Conservativeandaggressivetreatment• Highlevelofsuspicionwithadolescentbonypain

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Thank you

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