Porter & Schon: Baxter's The Foot and Ankle in Sport, 2nd ed.

Section 3 - Anatomic Disorders in Sports

Chapter 17 - Lesser-toe disorders

Michael J. Coughlin,Jerry Speight Grimes,
Robert C. Schenck Jr


CHAPTER CONTENTS

  

 

Bunionettes

  

 

Intractable plantar keratoses

  

 

Interdigital neuromas

  

 

Hard corns and soft corns

  

 

Hammertoes, mallet toes, and claw toes

  

 

Claw toe

  

 

Metatarsophalangeal joint instability

  

 

Conclusion

  

 

References

  

 

Further reading

Metatarsalgia in the athlete can be a debilitating disorder leading to loss of competitiveness or even loss of the ability to participate in a recreational fashion. Forefoot disorders encompass lesser-toe abnormalities such as claw toes, hammertoes, mallet toes, and hard and soft corns. More proximally, problems can include intractable plantar keratosis (IPK), bunionettes, neuromas, and metatarsophalangeal (MTP) joint capsulitis and instability.

For the athlete, repetitive activities can lead to repeated stress reactions in soft tissues, as well as bones and joint. Abrasions and repeated trauma over bony prominences can lead to callus formation and bursitis.

Ideally, the goal should be to avoid the development of problems through the use of good footwear, proper training practices, and education. Many foot problems may develop despite prophylactic care and thus require the intervention of the orthopaedic surgeon either conservatively or surgically. When possible, nonsurgical treatment is preferred, usually leading to a rapid resumption of athletic activity.

The complaint of pain in the forefoot must be differentiated to make a correct diagnosis. The accompanying algorithm ( Fig. 17-1 ) may prove useful in determining the specific forefoot diagnosis when a patient complains of metatarsalgia. Most important is the exact location of pain. In addition, the physician should ask the following questions: Which specific activities increase symptoms? Which activities alleviate discomfort? Is the pain dorsal or plantar, medial or lateral? Is there an associated neuritic symptom with the pain? Are enlarged exostoses or prominences associated with pain, swelling, or inflammation?

   Pearl

Location of Foot Pain

When a patient complains of metatarsalgia, the initial concern on physical examination is the presence of an associated callosity. This can be seen laterally over the fifth metatarsal head with a bunionette formation. It can be localized to the plantar metatarsal region with an IPK. A callosity may develop over the dorsal distal interphalangeal (DIP) joint (a mallet toe) or the dorsal proximal interphalangeal (PIP) joint (hammertoe). On occasion a patient may complain of a callosity both overlying the PIP joint and beneath the associated metatarsal head. With a concomitant contracture of this toe, the diagnosis of a claw toe is made based on the basis of clinical findings.

Development of a callus between two toes (a soft corn) or over the lateral aspect of the fifth toe (a hard corn) can be extremely painful.

When a patient complains of metatarsalgia but there is no callosity present, the patient should be examined carefully for neuritic symptoms. When such a scenario is present (along with other specific symptoms), the diagnosis of an interdigital neuroma can be made. When neuritic symptoms are not present but symptomatic pain still is localized to the forefoot, suspicion of MTP joint capsulitis and/or instability should be considered. The presence of a positive drawer sign (dorsal plantar instability) or actual malalignment of the involved toe at the MTP joint aids in confirming the diagnosis of second toe instability or “cross-over toe.” Although this algorithm is not all-inclusive and much more enters into the specific diagnostic process than this flowsheet allows, it does offer a method of approaching the athlete with metatarsalgia. Sometimes symptoms overlap; frequently symptoms are vague, and repeated evaluation and physical and radiographic examinations are necessary to confirm a diagnosis. The cooperation of patients in defining their symptomatic complaints and in defining their problem through varying their athletic activity is highly important. Likewise, patient cooperation in modifying activities when conservative management is attempted is a critical factor in any successful treatment. When surgery is performed, patient cooperation in allowing adequate healing to occur before resuming athletic activity is instrumental not only in the recovery process but also in the avoidance of other associated problems or complications.

   Pearl

Location of Foot Pain

When evaluating forefoot pain, it often can be difficult to localize the exact location of a patient's pain to make a correct diagnosis. Often, the physical examination is inconclusive, especially when the patient presents to clinic when asymptomatic. This is especially common in athletes, whose complaints often are activity related. To identify the location of pain, instruct the patient to repeat the offending activity, recreating the patient's symptoms. The patient then is instructed to mark the spot with a felt tip marker pen. This “spot” will stay with the patient for the next clinical examination.

 

 
 

Figure 17-1  Algorithm.  From Coughlin MJ: J Bone Joint Surg 82B:781, 2000.

 



Bunionettes

The development of inflammation, an enlarged bursa, or a callus over a prominent fifth metatarsal head may lead a physician to diagnose a bunionette ( Fig. 17-2 ). Just as bunions can present with differing magnitude and different characteristics, so too can a bunionette.[1] A bunionette may appear radiographically as an enlarged fifth metatarsal head (type I). A flare in the metaphysis may cause outbowing of the fifth metatarsal (type II), leading to symptoms, or a widened 4-5 intermetatarsal angle (type III) characteristic of a splayfoot may lead to pain and callus formation ( Fig. 17-3 ).

 
 

Figure 17-2  Bunionette with enlarged bursa.  From Mann RA, Coughlin MJ: In Surgery of the foot and ankle, St Louis, 1993, CV Mosby, p. 443.

 



 
 

Figure 17-3  (A) Bunionette with enlarged fifth metatarsal head. (B) Bunionette with bowing of metaphysic. (C) Bunionette with enlarged 4-5 intermetatarsal angle.

 

 

Initially an athlete may complain of pain directly lateral over the fifth metatarsal head, but the examiner should be aware of plantar symptoms as well. Neuritic symptoms involving the fifth toe may occur because of pressure over the lateral digital nerve to the fifth toe. The athlete may note complaints of inflammation, blistering, ulceration, or infection.

On physical examination, the aforementioned complaints usually are obvious. Significant callus formation may be observed on the lateral, plantar, or in a lateral plantar position overlying the fifth metatarsal head. Any pronation of the longitudinal arch should be noted, as well as any restriction in hindfoot motion.

Radiographic evaluation may demonstrate an enlarged metatarsal head, outflaring of the fifth metatarsal metaphysis, or widening of the 4-5 intermetatarsal angle. Widening of the 4-5 angle is the most common. Abduction of the fifth toe in relation to the fifth metatarsal head also may be demonstrated.

Conservative treatment

Early treatment involves attempting to relieve pressure on the underlying bony prominence. Stretching of shoes or obtaining shoes with a soft upper that is more forgiving will relieve overlying pressure. Seams or stitching directly over the bunionette should be avoided. Moleskin applied to a blister may promote healing and protect the area while athletes continue their activities. Altering running and/or training activity also may diminish symptoms. Nonimpact activities such as stationary cycles or swimming can be integrated into the training program. A reduction in total miles per day and per week may be required. Trimming the callus may significantly relieve symptoms. Physicians may teach their patients how to pare the callus appropriately. The callus is shaved in thin layers with the scalpel parallel to the toe. A pumice stone also may be used to pare down the callus. A pumice stone is safer and often more acceptable to patients for home use than a scalpel.

When athletic activity is significantly impaired after conservative efforts, surgical intervention may be contemplated (see Case Study 1 ). The type of osteotomy selected is dependent on the location of the callosity because specific osteotomies of the fifth metatarsal are oriented to redirect the metatarsal in different directions. Surgical intervention in treating forefoot callosities should be tailored to the patient. Extensive soft-tissue stripping, unsecured osteotomies, and multiple metatarsal osteotomies all should be avoided in athletes. Although a surgical procedure may relieve the painful callosity, athletic performance of the patient may be diminished and thus surgery may be considered unsuccessful. The two surgical procedures presented here fulfill the requirements of exposing the patient to less extensive surgery, use internal fixation, and appear better suited to athletes. Again, when possible, conservative treatment should be advocated by the treating physician until it obviously is incompatible with continued athletic function.

Case Study 1

A 30-year-old skier developed pain and swelling over the plantar lateral aspect of the fifth metatarsal head. An increased callosity was observed over the plantar lateral aspect of the bunionette. A painful, inflamed bursa developed during the middle of ski season that was partially relieved by grinding down the inner aspect of the ski boot overlying the bunionette. Likewise, the area overlying the fifth metatarsal head was relieved in the athlete's everyday footwear by stretching the leather surface.

On physical examination, a normal neurologic and vascular examination was noted. Prominence of the fifth metatarsal head was characterized by a callosity on both the plantar and lateral aspect. Radiographic evaluation demonstrated an enlarged fifth metatarsal lateral condyle ( Fig. 17-4, A ).

Conservative care, stretching of shoes, and padding all were recommended.

At the end of ski season, the patient requested surgical treatment because of continued symptoms. An oblique osteotomy was performed and fixed with screws. At 8 weeks following surgery, the osteotomy was healed and the patient began progressive walking that evolved over the ensuing 2 months to jogging and sports activities. Figure 17-4, B shows the correction obtained. The patient skied the following season without symptoms.

Surgical Treatment

  

1   

The foot is cleansed and draped in the routine fashion. An Esmarch bandage is used to exsanguinate the foot. The ankle is padded carefully and the Esmarch is used as a tourniquet.

  

2   

A longitudinal lateral incision is centered directly over the bunionette, extending from the midproximal phalanx to 1cm above the metatarsal head. Care is taken to protect the neurovascular bundles.

  

3   

The MTP capsule is detached on the dorsal and proximal aspect and turned downward, exposing the prominent lateral condyle ( Fig. 17-5 ).

  

4   

A sagittal saw is used to resect the lateral condyle in line with the diaphyseal shaft of the fifth metatarsal. (At this point, a decision must be made regarding the type of osteotomy to be performed. For a pure lateral callus, a chevron osteotomy is performed. For a combined plantar lateral callus, a distal oblique osteotomy is performed.)

  

5A   

Chevron osteotomy [0020] [0030]—A lateral to medial drill hole is placed in the center of the fifth metatarsal head, marking the apex of the chevron osteotomy. A 60-degree angled osteotomy based proximally is directed in a lateral to medial plane. The metatarsal head is translated medially and fixed with a percutaneous 0.045 K-wire ( Fig. 17-6 ).

  

5B   

Distal oblique osteotomy [0040] [0050]—After exposing the metatarsal head and metaphysis, an oblique osteotomy is performed from a distal lateral to proximal medial direction. The metatarsal head is displaced medially and slightly proximally and is allowed to “raise up” approximately 3mm to decrease plantar pressure beneath the fifth metatarsal head. The osteotomy is fixed with one or two percutaneous 0.045 K-wires ( Fig. 17-7 ).

  

6   

Any remaining prominent metaphysis is shaved with the sagittal saw. A drill hole is placed in the dorsal proximal metaphysis, and the capsule is anchored with an interrupted suture. Remaining interrupted sutures are placed to reinforce the capsular repair ( Fig. 17-8 ).

  

7   

The skin is closed in a routine fashion. A gauze and tape dressing is applied and changed on a weekly basis. The patient is allowed to ambulate in a wooden-soled shoe.

 

 
 

Figure 17-5  An L-shaped capsular incision is used to approach the bunionette.

 

 

 
 

Figure 17-6  (A) A drill hole is placed in the center of the metatarsal head and drilled in a lateral to medial direction. (B) A chevron-shaped osteotomy is based proximally with the apex at the drill hole. (C) Medial translation of the metatarsal head with K-wire fixation and shaving of the metaphyseal flare (shaded area denotes shaved bone in metaphysic).

 

 

 
 

Figure 17-7  Distal oblique osteotomy with K-wire fixation (shaded area denotes shaved bone in metaphysic).

 

 

 
 

Figure 17-8  L-shaped capsular closure. The dorsal proximal corner may be fixed with a drill hole in the metaphysic to anchor the repair.

 

 

Athletic activity is increased as swelling and pain diminish. Radiographic confirmation of healing should be present before aggressive activity such as jogging, running, or jumping is commenced. In general, a patient can return to nonimpact activities at 2 months. Limited-impact activities such as jogging are permitted at 3 months. Full-contact/impact activities can be resumed at 4 months, depending on radiographic evidence of healing.

In general, resolution of the symptomatic bunionette can be achieved with one of the above procedures for type I or type II bunionettes. With a splayfoot and a significantly wide 4-5 metatarsal angle, a diaphyseal midshaft osteotomy may be necessary to achieve more correction.[6] More extensive procedures such as this should be reserved for athletes with significant limitations, because the extensive nature of this surgery may limit postoperative athletic expectations.

 

Intractable Plantar Keratoses

The development of a keratosis beneath one or more of the metatarsal heads is referred to as an intractable plantar keratosis or IPK. A callosity beneath the fifth metatarsal when associated with a bunionette already has been discussed. A callus may be a localized discrete lesion or a diffuse keratotic buildup ( Fig. 17-9 ). Callus formation in athletes is not uncommon, and if asymptomatic rarely requires medical intervention. With significant buildup, painful symptoms may occur, requiring evaluation and treatment.

 
 

Figure 17-9  (A) Discrete callus in a tennis player with an enlarged fibular condyle. (B) Diffuse callus in a runner.  Courtesy Roger A. Mann, MD, and Michael J. Coughlin, MD.

 



A diffuse callus may be due to repetitive abrasion associated with athletic activity. It also may be associated with a long second metatarsal or a long second and third metatarsal. A discrete callus may occur beneath a single metatarsal head.[7] It typically is associated with an enlarged fibular metatarsal condyle. It is important to distinguish this from a wart ( Fig. 17-10 ). Although warts (plantar verrucae) typically are not found beneath a metatarsal head, on occasion they can occur in this region and thus must be differentiated from an IPK. Trimming of a wart will uncover end arterioles in the lesion characterized by punctuate hemorrhages. Evaluation of the athlete with an IPK involves determining the significance of the symptoms, length of duration, and association, if any, with specific athletic activity. A patient with minimal symptoms requires no treatment.

 
 

Figure 17-10  A wart is characterized by punctate hemorrhages that are obvious when the callus is trimmed.  Courtesy Roger A. Mann, MD, and Michael J. Coughlin, MD.

 



Radiographic evaluation entails weight-bearing films with markers to determine the exact location of the IPK (a long metatarsal may be associated with an IPK; likewise a marker may be located directly beneath the fibular condyle of a metatarsal head).

   Pearl

Pressure Points

A Harris mat imprint is invaluable in identifying abnormal pressure points on the plantar surface of a patient's foot. The patient is instructed to walk in a normal manner, stepping on the Harris mat. The test is repeated with the contralateral foot. Abnormal pressures are illustrated as unusually dark regions and will aid in making the correct diagnosis and appropriate treatment.

Conservative treatment

Conservative treatment revolves around paring the IPK and padding it to relieve the pressure ( Fig. 17-11 ). A patient can be instructed to trim the lesion every 7 to 10 days, and this will significantly relieve discomfort. Placement of a metatarsal pad just proximal to the IPK can transfer pressure to the metatarsal diaphysis and relieve symptoms (see Case Study 2 ). Custom or prefabricated orthotic devices also can aid in relieving symptoms. Athletes may alter their workout, change sporting activities, or change duration or intensity of the workout, all with gratifying results.

 
 

Figure 17-11  Padding an intractable plantar keratosis often is successful treatment.

 

 

Case Study 2

A 50-year-old tennis player developed a painful callus beneath the second and third metatarsals. It was a diffusely thickened callus that began to limit his sports activities. On initial evaluation, the diffuse callus was trimmed and the patient instructed in how to care conservatively for the IPK. A pumice stone was used to pare the callus. The patient also obtained disposable scalpels to shave his thickened callosity. When he returned for further follow-up, radiographs demonstrated a long second and third metatarsal in relation to the adjacent metatarsals. A soft pad was placed in his shoe just proximal to the callosity. With the combination of shaving the callosity and padding it, symptoms were completely relieved and the patient returned to full sports activities. Later, a soft orthotic device was fabricated to relieve pressure beneath the second and third metatarsals. This convenient orthotic device can be moved from shoe to shoe and replaced the temporary soft pads that were used to alleviate his initial symptoms.

When all methods of conservative treatment have been exhausted, surgical intervention may be considered. Caution is advised in considering any metatarsal osteotomy in a high-level athlete. The possibility of delayed union, nonunion, or malunion can significantly impair later athletic activity. The development of a transfer lesion beneath another metatarsal head is not uncommon. Multiple metatarsal osteotomies are to be discouraged. Likewise, floating metatarsal osteotomies without internal fixation have a high rate of malunion with resultant transfer lesions.

Surgical Treatment: Partial Condylectomy[8]

  

1   

The foot is cleansed and draped in a routine fashion. As Esmarch bandage is used to exsanguinate the foot. It is padded carefully at the ankle and used as a tourniquet.

  

2   

A longitudinal incision is centered over the metatarsal head with a “hockey stick” extension distal into the adjacent interspace. (The extensor tendon may be released temporarily to aid exposure and is repaired at the conclusion of the procedure.)

  

3   

The MTP joint capsule is released and the toe is flexed to 90 degrees at the MTP joint.

  

4   

An osteotome is used to osteotomize 25% of the plantar condyle. Care is taken to avoid fracture to the metatarsal head ( Fig. 17-12 ). The condyle is removed.

  

5   

A 0.045 K-wire introduced at the MTP joint is driven distally out the tip of the toe. With the MTP joint reduced, the pin is driven in a retrograde fashion, stabilizing the joint.

  

6   

The extensor tendon (if released) is repaired. The skin is closed in a routine fashion.

  

7   

A gauze and tape dressing is applied and changed on a weekly basis. The patient is allowed to ambulate in a wooden-soled shoe.

  

8   

At 3 weeks, the sutures and K-wire are removed.

 

 

 

Figure 17-12  (A) Plantar condylectomy for a discrete intractable plantar keratosis. (B) Interoperative view of plantar condylectomy (one fourth to one third of the plantar metatarsal head is excised).

 

 

Athletic activity is permitted as swelling and pain decrease. The toe is protected for 6 weeks following surgery with taping immobilization. In general, a patient can return to nonimpact activities at 1 month. Limited-impact activities such as jogging are permitted at 6 weeks. Full-contact/impact activities can be resumed at 3 months.

Surgical Treatment: Metatarsal Osteotomy

  

1   

The foot is cleansed and draped in a routine fashion. An Esmarch bandage is used to exsanguinate the foot. It is carefully padded at the ankle and used as a tourniquet.

  

2   

A dorsal longitudinal incision is centered over the involved metatarsal.

  

3A   

If a distal oblique osteotomy[9] is performed ( Fig. 17-13 ), the cut is directed in a vertical direction. The metatarsal head is displaced upward 3mm[10] and fixed with a 0.045 K-wire.

  

3B   

If a vertical chevron osteotomy[2] is performed ( Fig. 17-14 ), the V-shaped osteotomy is directed in a vertical direction. (This is more stable side to side than a transverse osteotomy.) The metatarsal head is displaced upward 3mm and fixed with a 0.045 K-wire.

  

3C   

If a proximal transverse osteotomy[11] is performed ( Fig. 17-15 ), a dorsal based wedge is excised. The farther proximal the osteotomy is located, the more elevation is achieved with wedge removal. (Care must be taken not to overcorrect at the osteotomy site.) The wedge may be removed with a sagittal saw or with a small rongeur. Internal fixation is recommended. A screw, pin, or wire loop fixation is used.

  

4   

The wound is closed in a routine fashion. A gauze and tape dressing is applied and changed on a weekly basis. The patient is allowed to ambulate in a wooden-soled shoe bearing weight on his or her heel.

  

5   

Sutures are removed 3 weeks following surgery. Percutaneous K-wires are removed 3 to 4 weeks following surgery. The forefoot then is strapped with tape and gauze until symptoms remit.

  

6   

Radiographic confirmation of union is important before aggressive athletic activity can be commenced.

 

 
 

Figure 17-13  (A) Distal oblique osteotomy (dotted line shows proposed osteotomy site). (B) Following displacement and internal fixation with K-wire.

 

 

 
 

Figure 17-14  Distal chevron osteotomy with internal fixation.  Courtesy Roger A. Mann, MD, and Michael J. Coughlin, MD.

 



 
 

Figure 17-15  Proximal closing wedge osteotomy with screw fixation.  Courtesy Roger A. Mann, MD, and Michael J. Coughlin, MD.

 



Athletic activity is permitted as swelling and pain diminish. In general, a patient can return to nonimpact activities at 2 months. Limited-impact activities such as jogging are permitted at 3 months. Full-contact/impact activities can be resumed at 4 months based on radiographic healing.

In general, with a partial plantar condylectomy, satisfactory results are attained for relieving the symptoms of a discrete, well-localized IPK.[8] Likewise, a distal osteotomy [0090] [0110] may be efficacious for a similar lesion. A diffuse callus in the athlete probably is best treated with padding and shaving because a more extensive procedure involving a diaphyseal osteotomy[12] may require prolonged healing time and place the athlete at greater risk for delayed healing, malunion, and transfer metatarsalgia. A proximal closing wedge osteotomy[9] may be used to elevate a symptomatic long second or third metatarsal. Meticulous attention to the osteotomy and fastidious postoperative care are necessary to avoid complications.

 

Interdigital Neuromas

An interdigital neuroma may be a source of ill-defined forefoot pain. Located in the second or third intermetatarsal space (IMS), a neuroma is rarely isolated to the first or fourth interspace. Rarely, in less than 3% of cases, do two neuromas occur in the same foot simultaneously.[13]

Typically an athlete initially describes ill-defined forefoot pain, often exacerbated with running or sports activities, which is relieved by rest or removal of a pair of shoes. Sometimes pain increases with intensity and/or duration of sports activities.

The physical examination includes educating patients regarding which symptoms to watch for. Although ill-defined forefoot discomfort is common, the treating physician must help patients define the exact area of pain. With time and education, athletes may be able actually to pinpoint the exact area of pain from the dorsal and plantar aspect, usually in either the second or third interspace. Neuritic symptoms or numbness in either the second or third common digital nerve distribution may be observed.

On physical examination, care is taken to observe for evidence of peripheral neuropathy or vascular insufficiency. Peripheral neuropathy is characterized by a loss of cutaneous, positional, and vibratory sensation. The Semmes-Weinstein 5.07 monofilament is the classic test for protective sensation. Vascular insufficiency is characterized by loss of distal hair, lack of pulses, dependent rubor, varicose veins, atrophic skin, and delayed capillary refill. The toes are examined for fixed deformity. Any callus or IPK is noted, and the adjacent MTP joints are evaluated for pain or instability (see section on MTP Instability). MTP capsular instability symptoms closely mimic those of an interdigital neuroma.[14] Palpation of the involved interspace usually elicits pain. Grasping and compressing the transverse arch at the level of the metatarsal heads may elicit a click (Mulder's sign),[15] which occurs when the neuroma subluxates below the metatarsal head and transverse metatarsal ligament (TML).

   Pearl

Diagnosis of MTP Instability versus Interdigital Neuroma

When a patient has difficulty isolating the location of pain, a 1% lidocaine injection may be used to determine the site of pain.[16] During serial office visits 1 week apart, the physician may inject local anesthetic into the second IMS, then the third IMS, then the second MTP joint, and then the third MTP joint. Fluoroscopy and injectable contrast may be used to verify an intra-articular injection. It is important to use small volumes (1-3ml) to prevent extravasation of anesthetic agent to adjacent structures. While anesthetized, the patient is asked to repeat the activity that causes the most discomfort, Within 1 or 2 hours the anesthetic wears off. When temporary relief is achieved with the injection, followed by recurrent symptoms, an anatomic diagnosis is confirmed.[14]

Conservative treatment

Early conservative treatment may alleviate symptoms in the athlete. With intermittent symptoms exacerbated by intense athletic activity or sports of significant duration, a change in the type of activity or its duration may completely relieve symptoms (i.e., a person who jogs 4 miles at a time and develops pain at 2.5 miles may jog for 2 miles and bicycle for 2 to 3 miles and be symptom free).

Placing a small metatarsal pad just proximal to the symptomatic interspace may relieve symptoms. Change in athletic shoes also may alleviate pain.

When conservative methods including the modification of sports activities have not relieved symptoms, surgical intervention may be considered. [0170] [0180] [0190]

Surgical treatment: Excision of interdigital neuroma

  

1   

The foot is cleansed and draped in the usual fashion. An Esmarch bandage is used to exsanguinate the foot. The ankle is padded carefully and the Esmarch is used as a tourniquet.

  

2   

A 3-cm dorsal incision is centered in the involved interspace.

  

3   

The dissection is carried down to the transverse metatarsal ligament (TML) ( Fig. 17-16 ).

  

4   

A two- to three-prong Weitlaner retractor is used to distract the adjacent metatarsals and place the TML under tension.

  

5   

The TML is sectioned only when necessary to expose the neuroma and common digital nerve.

  

6   

The digital nerves distal to the bifurcation are severed at the level of distal webspace. The proximal stumps are tensioned. A nerve freer is used to dissect longitudinally to isolate the common digital nerve. Special attention is directed at freeing the plantar branches. With tension on the proximal nerve, a scalpel is used to transect the nerve as proximal as possible in the interspace.

  

7   

The interspace is inspected for any other nerve tissue that may be a cause of pain. It is important to sever any adjacent capsular nerve branches that prevent proximal migration of the nerve stump. The retractor is removed, and the surgical wound is irrigated and closed in a routine fashion.

  

8   

A gauze and tape dressing is applied and changed on a weekly basis, and the patient is allowed to ambulate in a postoperative shoe.

  

9   

Suture removal is carried out 3 weeks following surgery, and a circumferential gauze and tape strapping is continued for 3 more weeks to allow adequate healing of the TML if it was sectioned (Fig. 17-17 ).

 

 
 

Figure 17-16  Dorsal incision demonstrates a large interdigital neuroma. The transverse metatarsal ligament has been sectioned.  From Coughlin MJ: In Chapman M, editor: Operative orthopaedics, Philadelphia, 1993, JB Lippincott, p. 2289.

 



 
 

Figure 17-17  Strapping of the foot is continued for 6 weeks postoperatively to promote healing of the transverse metatarsal ligament.

 

 

Aggressive walking can be commenced 4 weeks following surgery, with increased activity as pain and swelling permit. Limited-impact activities such as jogging are permitted at 2 months. Full-contact/impact activities can be resumed at 3 months.

Patients can present with concurrent interdigital neuroma and MTP joint capsular instability. Isolated treatment of one of these conditions is unlikely to resolve the patient's symptoms. Simultaneous interdigital neuroma resection and stabilization of the MTP joint results in better outcomes than isolated procedures.[14] Techniques to address capsular instability are addressed later in this chapter.

 

Hard Corns and Soft Corns

A hard corn ( Fig. 17-18 ) develops over the lateral aspect of the fifth toe usually because of pressure of the shoe against an underlying exostosis or condyle on the fifth toe. Patients may complain of pain associated with a hypertrophic callus on the lateral aspect of the fifth toe. A soft corn ( Fig. 17-19 ) develops between the toes because of pressure between two adjacent bony prominences. Patient may complain of exquisite pain; maceration sometimes occurs that resembles a mycotic infection. Desiccation of the lesion then may help to distinguish it from an infection.[20]

 
 

Figure 17-18  Hard corn with keratotic buildup.  Courtesy Roger A. Mann, MD, and Michael J. Coughlin, MD.

 



 
 

Figure 17-19  A soft corn is demonstrated in the fourth webspace, mimicking a mycotic infection.  Courtesy Roger A. Mann, MD, and Michael J. Coughlin, MD.

 



On physical examination, the obvious callosity occurs overlying a bony prominence. Radiographic evaluation may help to define the location of the lesion ( Fig. 17-20 ).

 
 

Figure 17-20  Radiograph demonstrating the location of a soft corn.  Courtesy Roger A. Mann, MD, and Michael J. Coughlin, MD.

 



Conservative treatment

Padding of the hard corn ( Fig. 17-21 ) may alleviate discomfort. Stretching of shoes overlying the lesion may decrease symptoms. Shaving of the callosity on a frequent basis may diminish the painful symptoms.

 
 

Figure 17-21  (A) An underlying exostosis combined with restrictive footwear leads to a hard corn. (B) A pad may be used to relieve pressure.

 

 

With a soft corn, padding of one or both toes with either a foam spacer ( Fig. 17-22 ) or tubular foam gauze often eliminates compression between the two toes. Shaving of the callosity also may be indicated (see Case Study 3 ). When conservative measures have failed, surgical resection of the involved condyle may eliminate the prominence and alleviate the symptoms.

 
 

Figure 17-22  A pad is used to relieve pressure in the webspace.  Courtesy Roger A. Mann, MD, and Michael J. Coughlin, MD.

 



Case Study 3

A 40-year-old jogger developed exquisite pain beneath the fourth and fifth toes. He recognized maceration in the fourth webspace. It was unclear whether this was a fungus infection or a soft corn.

On his initial orthopaedic evaluation, radiographs demonstrated impingement between the PIP joint of the fourth toe and DIP joint of the fifth toe.

Initial treatment used rubbing alcohol applied with a cotton-tipped applicator three times a day to desiccate the area. Then lamb's wool was placed between the toes to pad and alleviate pressure between the two prominent condyles. Later, a foam spacer was placed between the toes and the patient was allowed to resume all jogging activity. No surgery was performed.

Surgical Treatment for Hard Corns[21],33

  

1   

The foot is cleansed and draped in the usual fashion. Often a digital anesthetic block is used, although a foot block also may be considered.

  

2   

A dorsolateral longitudinal incision is centered over the prominent lateral condyle.

  

3   

With sharp dissection, the capsular fibers are peeled off the condyle.

  

4   

A rongeur is used to remove the prominent condyle, with care taken to leave enough articular surface to retain joint stability ( Fig. 17-23 ).

  

5   

The sharp, bony edges are beveled with a rongeur.

  

6   

The capsule is closed with two or three interrupted absorbable sutures.

  

7   

A percutaneous flexor tenotomy is performed at the MTP joint.

  

8   

The skin is closed with a running skin closure. A gauze and tape dressing is applied and changed on a weekly basis. The patient is allowed to ambulate in a postoperative shoe.

  

9   

Sutures are removed 3 weeks after surgery. The toe then is taped to the adjacent toe for 3 more weeks to promote stability and avoid injury.

 

 
 

Figure 17-23  A dorsal incision is used for the condylectomy as the treatment for a hard corn.

 

 

After suture removal, an increase in sports activity can be commenced. Walking and bicycling may be started when sutures are removed. Running may commence after swelling has diminished sufficiently to allow shoe-wear to fit adequately, typically 6 weeks.

Surgical Treatment for soft corns33

  

1   

The foot is cleansed and draped in the usual fashion. Often a digital anesthetic block is used, although a foot block also may be considered.

  

2   

A decision is made whether to treat both lesions on adjacent toes or to treat only one. (With a significant lesion on one toe and a minor lesion on the corresponding toe, a surgical repair of the larger lesion usually will successfully eliminate the entire problem.) Whether one or both lesions are surgically treated remains the decision of the operating surgeon.

  

3   

A dorsolateral longitudinal incision is centered over the prominent lateral condyle. This avoids an incision in the affected webspace.

  

4   

With sharp dissection, the capsular fibers are peeled off the condyle.

  

5   

A rongeur is used to remove the prominent condyle, with care taken to leave enough articular surface to retain joint stability ( Fig. 17-24 ).

  

6   

The sharp edges are beveled with a rongeur.

  

7   

If a fixed contracture of the toes exists, a percutaneous tenotomy of the flexor tendon is performed.

  

8   

The capsule is closed with an interrupted absorbable suture.

  

9   

The skin is closed with a running skin closure. A gauze and tape dressing is applied and changed on a weekly basis. The patient is allowed to ambulate in a wooden-soled postoperative shoe.

  

10   

Sutures are removed 3 weeks after surgery.

  

11   

A small gauze spacer is used between the toes for another 3 weeks until the surgical incisions have softened. After suture removal, walking and bicycling may be started. Running may commence after swelling has diminished successfully to allow shoewear to fit adequately, typically 6 weeks.

 

 
 

Figure 17-24  (A) A soft corn may develop over the base of the proximal phalanx. (B) Resection of the bony prominence.

 

 

 

Hammertoes, Mallet Toes, and Claw Toes

Deformities of the lesser toes include both flexible and fixed deformities. Typically callus formation occurs over bony prominences, and at times during athletic activity these areas may become inflamed and painful. A hammertoe ( Fig. 17-25 ) is characterized by a flexion contracture at the PIP joint. Early on, it may present as a flexible deformity that in time may become fixed. With a mallet toe ( Fig. 17-26 ), there is a flexion contracture at the DIP joint. Early on, it may present as a flexible deformity because of tightness of the flexor digitorum longus (FDL) tendon. With time it may become a fixed deformity. A callus may develop dorsally over the DIP joint because of pressure or abrasion from impacting against the toe box. A callus may also develop at the tip of the toe because of pressure against the insole of the shoe.

 
 

Figure 17-25  Hammertoe deformity.  From Coughlin MJ: Foot Ankle Int 21:94, 2000.

 



 
 

Figure 17-26  Mallet toe deformity.

 

 

With a claw toe deformity, typically a flexion contracture develops at the PIP joint with hyperextension at the MTP joint. A callosity may develop over the PIP joint; with a long-standing contracture an IPK may develop beneath the metatarsal head. Early on, a flexible contracture may be passively correctable, although with time a fixed contracture may develop.

Subjectively a patient typically complains of pain over a prominent callus on the involved toe; occasionally a painful callus will develop at the tip of the toe.

On physical examination, the treating physician not only observes a keratotic buildup over the deformity but also examines the attitude of the toe. The flexibility or rigidity of the deformity may determine the particular surgical repair, should it be necessary. The presence of multiple toe deformities, contractures at adjacent joints, and neurologic deficits must be appreciated during the evaluation. With all of these lesser-toe deformities, an athlete may complain of blistering, callus formation, swelling, or pain because of a dynamic or static deformity. Occasionally an infection may develop in the overlying tissue.

Conservative treatment

Conservative care includes relieving pressure over the painful area.[22] The use of roomy shoewear often will relieve discomfort in the athlete. Padding often allows return to sports activity. Shaving of painful callosities may temporarily relieve keratotic buildup. Often conservative care will allow an athlete to continue activity, although decreasing the duration or intensity of the workout or changing to a different sporting activity may be necessary on a temporary or permanent basis. When conservative measures do not allow acceptable athletic activity, surgical intervention may be necessary.

Surgical treatment: hammertoe repair[23,28]

  

1   

The foot is cleansed and draped in the usual fashion. Usually a digital nerve block is used as an anesthetic.

  

2   

A small Penrose drain may be used as a tourniquet (optional).

  

3   

A dorsal elliptical or longitudinal skin incision is centered over the PIP joint. The incision is carried down to bone with excision of an ellipse of skin, extensor tendon, and capsule, exposing the condyles of the proximal phalanx.

  

4   

The collateral ligaments of the PIP joints are severed, enabling the condyles to be delivered.

  

5   

A bone-cutting forceps is used to osteotomize the proximal phalanx in the supracondylar region ( Fig. 17-27 ). The sharp edges are beveled with a rongeur.

  

6   

The articular surface of the middle phalanx is exposed, and a rongeur is used to remove the articular surface.

  

7   

A 0.045 K-wire is introduced at the PIP joint and driven distally, exiting the tip of the toe. Then, with the toe reduced to the desired position, the K-wire is driven in a retrograde fashion, stabilizing the hammertoe repair. The pin is bent at the tip of the toe to prevent proximal migration.

  

8   

A gauze and tape dressing is applied and changed on a weekly basis. The patient is permitted to ambulate in a bunion shoe. Sutures and K-wire are removed 3 weeks after surgery.

  

9   

The patient then is instructed to tape the toe to an adjacent toe for an additional 4 weeks to protect it from injury.

 






 

Figure 17-27  Hammertoe repair.  From Coughlin MJ: Foot Ankle Int 21:94, 2000.

 



After the K-wire is removed, increased walking activity is permitted. Cycling may be allowed. Running or jogging usually is avoided until swelling has diminished (6 to 8 weeks). Often there will be 10 to 15 degrees of motion at the involved joint following adequate healing. Whether an arthrodesis occurs is not of significant concern. Fibrous ankylosis with a small amount of motion is equally acceptable.

For a hammertoe that can be passively corrected and has no element of fixed contracture, a flexor tendon transfer may be used. The procedure is technically more difficult than a condylectomy but leaves the toe more flexible. The FDL tendon is transferred to the dorsum of the proximal phalanx. This procedure removes a deforming force and at the same time makes the FDL a plantarflexor of the proximal phalanx. Whether it is a dynamic transfer or a tenodesis is unclear, but it is a useful procedure for repair of the flexible hammertoe. This procedure also is used for a flexible claw toe and for the unstable MTP joint (both discussed later).

Surgical treatment: early flexible mallet toe repair[37]

  

1   

The foot is cleansed and draped in the usual fashion. A digital block is used for anesthesia. (With an early mallet toe deformity, the toe can be corrected passively to neutral with pressure.)

  

2   

A no. 11 scalpel blade is introduced on the plantar aspect of the DIP joint and the FDL tendon is released, and a K-wire is used to stabilize the DIP joint repair.

  

3   

The incision is closed with an interrupted skin suture.

  

4   

A gauze and tape dressing is applied, and the patient is allowed to ambulate in a postoperative shoe.

  

5   

The sutures are removed 10 days after surgery.

Athletic activity can be resumed rapidly following this procedure with little downtime. In general, a patient can begin to advance activities at 2 weeks. Full activities typically can be resumed by 4 weeks.

When a fixed mallet toe is corrected, a procedure similar to that for hammertoe deformity is performed as is carried out for a hammertoe deformity. In this case the procedure is carried out at the DIP joint (Fig. 17-28 ).[24]

 
 

Figure 17-28  Mallet toe repair. (A) Proposed resection. (B) K-wire fixation following condylectomy.

 

 

Surgical treatment: flexor tendon transfer[25]

  

1   

The foot is cleansed and draped in the usual fashion. A foot block may be used for anesthesia.

  

2   

The foot is exsanguinated with an Esmarch bandage. The ankle is padded carefully and the Esmarch is used as a tourniquet.

  

3   

A 1-cm longitudinal incision is centered in the midline over the dorsum of the proximal phalanx. The dissection exposes the extensor digitorum longus tendon. Then with blunt dissection, with a mosquito clamp on either side of the proximal phalanx, a tunnel is created for transfer of each limb of the FDL tendon. The tunnel is created deep to the neurovascular bundles and superficial to the extensor expansion.

  

4   

On the plantar aspect of the toe, a transverse incision is made at the proximal plantarflexion crease of the toe. With blunt dissection, the long flexor tendon sheath is identified.

  

5   

A longitudinal incision is made in the tendon sheath and the flexor tendons are observed. The FDL tendon is the larger of the two tendons and is characterized by a midline raphe (Figs. 17-29 and 17-33 [0290] [0330]). Tension is placed on the FDL and a small plantar tenotomy puncture wound is made at the level of the DIP joint, releasing the FDL ( Fig. 17-30 ).

  

6   

The FDL tendon then is withdrawn through the more proximal plantar wound and is split longitudinally along its median raphe ( Fig. 17-31 ).

  

7   

Each limb of the FDL is passed on either side of the proximal phalanx.

  

8   

With the ankle held in neutral position, and the involved toe held in 10 degrees of plantarflexion, the tendon limbs are sutured to themselves with interrupted nonabsorbable suture ( Fig. 17-32 ). Reinforcement sutures may be placed between the tendon and the extensor expansion.

  

9   

The toe then is inspected to ensure that proper alignment has been achieved. The tourniquet is released to ensure that it has not affected the tension of the repair. On occasion it is necessary to retension the repair, with tightening or loosening of one or both of the tendon limbs.

  

10   

The skin then is approximated in a routine fashion. A gauze and tape dressing is applied and changed on a weekly basis. The patient is allowed to ambulate in a postoperative shoe.

  

11   

Sutures are removed 3 weeks after surgery.

  

12   

At 3 weeks, increased walking activity is permitted. Careful cycling also is an acceptable activity. Running, jogging, and aggressive sports should be avoided until swelling has subsided (6 to 8 weeks). The patient should be instructed to start passive manipulation of the toe 4 weeks after surgery. The toe may become stiff because of immobilization, and frequent manipulation during this period increases the passive motion of the toe. Considerable active motion is sacrificed with the flexor tendon transfer.

 

 
 

Figure 17-29  The flexor digitorum longus is the largest of the tendons and is characterized by a midline raphe.

 

 

 
 

Figure 17-33  Cross section of lesser toe at level of metatarsal head demonstrating flexor digitorum brevis and longus.

 

 

 

 

Figure 17-30  (A) Lateral view of toe demonstrating long flexor tendon and other important tendons. (B) Long flexor tendon is demonstrated on the plantar aspect of the foot.  From Coughlin MJ: Orthopedics 10:63, 1987.

 



 

 

Figure 17-31  Flexor digitorum longus is released distally.  From Coughlin MJ: Orthopedics 10:63, 1987.

 



 

 

Figure 17-32  Flexor digitorum longus is transferred dorsally.  From Coughlin MJ: Orthopedics 10:63, 1987.

 



 

Claw Toe

A claw toe deformity may be flexible, semirigid, or fixed. Frequently it involves all of the toes on a foot. Although the etiology frequently is idiopathic, the treating physician should inspect the patient for other causes, such as spasticity, muscular dystrophy, spinal abnormality, and previous trauma (old fractured tibia, old compartment syndrome, and so forth).

Many cases may be treated effectively with roomy footwear, padding, and pedicures; however, on occasion an athlete is so symptomatic that surgery is contemplated. Although claw toes frequently involve multiple toes, they have similarities with different stages in the development and treatment of hammertoe deformity.

Early on, flexible claw toes (although multiple in nature) resemble flexible hammertoes. A flexor tendon transfer of the second, third, and fourth toes may achieve adequate realignment by releasing the contracted FDL tendon and depressing the proximal phalanx through the tendon transfer (see the section on Flexible Hammertoe Repair). Rarely is a flexor tendon transfer performed on the fifth toe. A flexor tenotomy occasionally is performed, although often the fifth toe is asymptomatic.

As a claw toe becomes fixed, a patient may develop symptoms of a hammertoe, with callus formation overlying the PIP joint. Because of the fixed dorsiflexion contracture at the MTP joint, the toe buckles, depressing the metatarsal head. A plantar callus (IPK) may develop because of increased pressure beneath the metatarsal head. The treating physician must remember that the IPK usually is due to the contracted toe rather than to a prominent metatarsal condyle. Correction of the toe deformity often is associated with diminution or resolution of the plantar callosity.

The fixed claw toe resembles a fixed hammertoe, although the claw toe also has a contracture at the MTP joint. A PIP joint contracture is repaired surgically ( Fig. 17-34 ) with a condylectomy of the proximal phalanx (see the section on Fixed Hammertoe Repair). Obviously, once the PIP joint contracture has been corrected, attention must be directed to the MTP joint contracture.

 
 

Figure 17-34  (A) Claw toe deformity. (B) Following metatarsophalangeal joint release and extensor tenotomy and proximal interphalangeal joint arthroplasty.

 

 

Surgical treatment: MTP soft-tissue arthroplasty [0240] [0250]

  

1   

The foot is cleansed in the usual fashion. An Esmarch bandage is used to exsanguinate the foot. The ankle is padded carefully and the Esmarch is used as a tourniquet.

  

2   

An oblique or longitudinal incision is centered over the MTP joint.

  

3   

The long extensor tendon is split longitudinally and Z-lengthened.

  

4   

The medial, dorsal, and lateral capsule is completely released to allow reduction of the MTP joint. (This requires a significant release in a plantar direction of both collateral ligaments.) When a toe still does not reduce completely following an MTP release, there may be adhesions between the plantar capsule and the plantar metatarsal head. These usually can be released with a McGlanery elevator. The toe then should be easily reducible in a dorsal plantar plane.

  

5   

A 0.062 K-wire is used to stabilize the repair. The pin is introduced at the MTP joint and driven in a distal direction exiting the tip of the toe. (When combined with hammertoe repair, it is introduced at the PIP joint and driven distally, exiting the tip of the toe. It then is driven proximally through the proximal phalanx.)

  

6   

The pin then is driven in a retrograde fashion, stabilizing the MTP joint. The pin is bent at the tip of the toe to prevent proximal migration.

  

7   

The extensor tendon is repaired in a lengthened fashion, and the skin is closed in a routine fashion. A gauze and tape dressing is applied and changed on a weekly basis. The patient is allowed to ambulate in a postoperative shoe.

  

8   

Three weeks following surgery, the K-wire and sutures are removed.

The toe is taped in a corrected position for 4 to 6 weeks. After removal of the K-wire, increased activity is permitted. Walking, cycling, and swimming are allowed. It is wise to progress slowly, with the introduction of jogging and running, until adequate healing has occurred and swelling has subsided (6 to 8 weeks).

 

Metatarsophalangeal Joint Instability

Instability of the MTP joint can be an extremely difficult diagnosis to make, especially in the early stage, when there is a lack of clinical deformity. The second MTP joint is the most frequent location of instability because of the longer length of the second ray. In a report on athletes with second MTP instability, Coughlin[26] reported 100% of the patients to have an elongated second metatarsal in relation to adjoining metatarsals. Most likely because of the stress of repeated and prolonged athletic activity, pain without deformity develops in the forefoot. The mechanism of instability generally is described as rupture or attenuation of the collateral ligaments and volar plate of the MTP joint.[27]

Typically an athlete initially describes ill-defined forefoot pain, often exacerbated by running and sports activities and relieved by rest. Sometimes pain increases with intensity and/or duration of sports activities.

On physical examination, the treating physician initially must isolate the exact point of tenderness. With palpation, tenderness typically is elicited over the plantar, medial, or lateral MTP capsule. Usually pain is not so pronounced in the third or second intermetatarsal spaces (IMSs). Initially it may be difficult to differentiate second MTP pain from a second IMS neuroma. A critical differentiating finding, however, is that there are no neuritic symptoms in the second or third toes and no numbness associated with capsulitis or instability of the second MTP joint. (An IMS neuroma may occur along with MTP instability.)

Capsulitis or inflammation of an MTP joint can be associated with systemic or localized arthritis. These conditions often involve other MTP joints, whereas without a preexisting inflammatory arthropathy only the second MTP joint usually is involved. A drawer sign[28] ( Fig. 17-35 ) typically is the diagnostic test most helpful in defining capsulitis and/or instability of the MTP joint. Grasping the involved toe between the fingers and stressing the MTP joint in a dorsal plantar direction can elicit exquisite pain, likely because of stress on the attenuated plantar capsule or collateral ligaments. (This finding is absent in an isolated interdigital neuroma.)

 
 

Figure 17-35  A drawer sign is used to detect dorsal plantar instability.

 

 

With time, the diagnosis becomes obvious as the toe deviates [0290] [0300] ( Fig. 17-36 ). Initially, the toe deviates medially and with time dorsally, developing into a cross-over second-toe deformity. This development can be acute, although typically in athletes it occurs insidiously over several months.

 
 

Figure 17-36  (A) Instability of the second metatarsophalangeal joint with a cross-over second toe may occur because of degeneration of the lateral collateral ligament. (B) Malalignment as demonstrated with a cross-over second toe.

 

 

Radiographic evaluation involves routine anterior-posterior (AP) and lateral radiographs to determine whether there is widening of the joint space (effusion), narrowing (arthritis), or malalignment in relationship to the adjoining MTP joints ( Fig. 17-37 ). Occasionally an arthrogram may be obtained, but this is not routinely performed.

 
 

Figure 17-37  Axial malalignment may be demonstrated on radiographic examination.

 

 

Conservative treatment

Early conservative treatment relies on early diagnosis by the treating physician. Before deformity has developed at the second MTP joint, early MTP instability is best treated with taping the involved toe, padding, and a change in athletic activity. Taping requires stabilizing the toe to prevent dorsal plantarflexion excursion. Taping to an adjacent toe may be effective. A sling-type taping technique also may be effective ( Fig. 17-38 ). An athlete may need to tape the involved toe for several months, although some athletes find it necessary to tape the toe only during sports activities. A metatarsal pad placed just proximal to the metatarsal head may alleviate pressure and relieve symptoms on the involved MTP capsule. Restructuring workouts and modifying athletic activity can be helpful in relieving pain. A runner may find that pain occurs only with greater than 2 miles of jogging and that shorter distances can be accomplished pain free.

 
 

Figure 17-38  Technique of taping toe.  From Coughlin MJ: Foot Ankle 8:29, 1087.

 



With unsuccessful resolution of discomfort, or insistence on a higher level of athletic activity, surgical intervention may be contemplated. What is presented is a step-by-step approach to MTP instability (seeCase Study 4 ).

Case Study 4

A 25-year-old, female aerobic instructor developed the onset of insidious but increasing pain in the area of her second MTP joint over 6 months. No specific injury was noted. She denied neuritic-type pain. She became unable to tolerate aerobic activity and then noted slight medial deviation of her second toe.

On physical examination, she was noted to have normal sensation and no evidence of a neuroma. She had a negative Mulder sign. She had pain on palpation over the second MTP joint capsule. She had a positive drawer sign, and exquisite pain was elicited. Radiographic examination showed slight medial inclination of the second MTP joint.

Initially the patient taped her second toe to the third toe for 3 months and was able to walk without pain. However, her pain resumed with aerobic activity. She requested surgical intervention. A medial MTP release, lateral capsular reefing, and flexor tendon transfer were performed. She then taped her toe to stabilize it for 6 weeks postoperatively.

She resumed aggressive walking 6 weeks after surgery, jogging at 3 months, and aerobic instruction at 4 months. She achieved resolution of her pain and is very satisfied with her repair.

Surgical Treatment: MTP instability

For patients who fail conservative treatment, several surgical techniques exist. Selection of the appropriate technique depends on clinical assessment of the deformity. Synovitis and mild deviation the MTP joint is classified as a mild deformity and can be treated with capsular reefing. Dorsomedial deviation at the MTP joint or overlapping of the adjacent toe is considered moderate deformity and can be treated with capsular reefing and an flexor tendon transfer. This is the most likely situation for an athlete who does not respond to conservative treatment. This procedure is described in the following. Finally, complete dislocation at the MTP joint is a severe deformity that necessitates an osteotomy of the MTP joint.[29]

Surgical treatment: capsular reefing and flexor tendon transfer[31]

  

1   

The foot is cleansed and draped in the routine fashion. The foot is exsanguinated with an Esmarch bandage. The ankle is padded carefully, and the Esmarch is used as an ankle tourniquet

  

2   

A 2-cm dorsal midline incision is centered over the MTP joint. If hyperextension of the toe is present, the extensor digitorum longus tendon is lengthened and later repaired at the conclusion of the procedure.

  

3   

The dorsal MTP capsule is released. With medial deviation of the phalanx, the medial capsule is completely released. In this case the lateral capsule then is reefed ( Fig. 17-39 ) with two interrupted, 2-0 nonabsorbable sutures to realign the toe in a medial lateral plane. With lateral deviation, the lateral capsule is released and the medial capsule reefed. (This is quite uncommon.)

  

4   

In the presence of remaining hyperextension of the MTP joint, or with remaining dorsal plantar instability, a flexor tendon transfer then is performed (see section earlier in this chapter).

  

5   

The wound is closed in a routine fashion. A gauze and tape dressing is applied and changed on a weekly basis. The patient is allowed to ambulate in a wooden-soled shoe.

  

6   

Sutures are removed 3 weeks after surgery. If a K-wire has been placed, it is removed at this time ( Fig. 17-40 ). The toe is taped in appropriate position for 6 weeks postoperatively (see Fig. 17-38 ).

 

 
 

Figure 17-39  Technique of capsular reefing for repair of axial malalignment.

 

 

 
 

Figure 17-40  (A) Clinical appearance of a cross-over toe deformity. (B) Radiographic appearance of a cross-over second toe. (C) Three-year follow-up demonstrating excellent alignment. (D) Three-year radiographic follow-up demonstrating excellent alignment.  From Coughlin MJ: Foot Ankle 8:29, 1987.

 



The patient is permitted to do aggressive walking 6 weeks following surgery and may increase sporting activity as swelling diminishes and pain permits. Results with this type of approach are gratifying. Significant pain relief can be achieved, although Coughlin[26] reported that several patients had to modify their athletic routine postoperatively.

When possible, the successful conservative treatment of lesser-toe problems will allow rapid return to athletic activity with limited downtime. Surgical procedures on the lesser toes take time to heal, are prone to swell, and leave an element of stiffness at the involved joint, which may be of some concern to the athlete. Adequate preoperative counseling is important to identify areas of concern, problem areas of recovery, and patient expectations.

Surgical Treatment: Weil osteotomy [0360] [0380]

The Weil osteotomy is a shortening osteotomy that primarily benefits patients with painful instability associated with a long lesser toe. This osteotomy should be avoided in patients with a plantarflexed metatarsal because it does not dorsally displace the distal fragment.[31] The relative stability of this osteotomy with weight bearing and the use of internal fixation make this an ideal osteotomy for the active patient.

  

1   

The foot is cleansed and draped in the routine fashion. The foot is exsanguinated with an Esmarch bandage. The ankle is padded carefully, and the Esmarch is used as an ankle tourniquet.

  

2   

A 3-cm incision is made in the adjacent IMS just proximal to the webspace. This allows access to adjacent metatarsals should more than one require attention.

  

3   

The metatarsal head is exposed through a lateral capsular incision under the extensor tendon. The toe is plantarflexed, exposing the metatarsal head.

  

4   

A narrow oscillating saw is used to make the osteotomy parallel to the weight-bearing surface of the foot. The osteotomy originates in the dorsal one fourth of the MTP joint (Fig. 17-41) .

  

5   

The distal fragment is displaced proximally until the metatarsal head is at the level of a line drawn from the MTP of the first and fourth rays. The fragment is fixed with one or two more fragment screws.

  

6   

The overhanging bone is rongeured smooth.

  

7   

The capsule is reefed if necessary as described previously. The capsule is repaired with absorbable sutures.

  

8   

The patient is placed in a surgical shoe and allowed to weight bear with crutches.

 

 
 

Figure 17-41  The Weil osteotomy.  From Trnka H: Foot Ankle 20:72, 1999.

 



 

Conclusion

When correctly diagnosed and treated, forefoot disorders should not limit athletic endeavors. Although many of these conditions are treated nonoperatively, the orthopaedic surgeon often is the most appropriate practioner to identify the problem and direct treatment. When operative treatment is required, the patient should be able to resume activities at the previous level of competition.

 

References

  1. Coughlin MJ: Etiology and treatment of the bunionette deformity.   In: Greens WB, ed. American Academy of Orthopaedic Surgeons instructional course lectures, 39. Chicago: AAOS; 1990:37.1037-1048
  2. Mann RA, Coughlin MJ: Bunionettes.  Video textbook of foot and ankle surgery,  St Louis: Medical Video Productions; 1991.
  3. Throckmorton JK, Bradlee N: Transverse V sliding osteotomy: a new surgical procedure for the correction of Tailor's bunion deformity.  J Foot Surg1978; 18:117.
  4. Coughlin MJ: Bunionettes.   In: Mann RA, Coughlin MJ, ed. Surgery of the foot and ankle,  ed 6. St Louis: CV Mosby; 1992.
  5. Sponsal KH: Bunionette correction by metatarsal osteotomy.  Orthop Clin North Am1976; 7:808.
  6. Coughlin MJ: Treatment of bunionette deformity with longitudinal diaphyseal osteotomy with distal soft tissue repair.  Foot Ankle1991; 11:195.
  7. Mann RA: Intractable plantar keratosis.  American Academy of Orthopaedic Surgeons instructional course lectures,, Vol 33. St Louis: CV Mosby; 1984.
  8. Mann RA, DuVries H: Intractable plantar keratosis.  Orthop Clin North Am1973; 4:67.
  9. Pedowitz WJ: Distal oblique osteotomy for intractable plantar keratosis of he middle three metatarsals.  Foot Ankle1988; 9:7.
  10. Dreeben SM, et al: Metatarsal osteotomy for primary metatarsalgia: radiographic and pedobarographic study.  Foot Ankle1989; 9:214.
  11. Mann RA, Coughlin MJ: Intractable plantar keratoses.  Video textbook of foot and ankle surgery,  St Louis: Medical Video Productions; 1991.
  12. Giannestras NJ: Shortening of the metatarsal shaft in the treatment of plantar keratosis.  J Bone Joint Surg1958; 49A:61.
  13. Thompson FM, Deland JT: Occurrence of two interdigital neuromas in one foot.  Foot Ankle Int1993; 14:15.
  14. Coughlin MJ, et al: Concurrent interdigital neuroma and MTP joint instability: long-term results of treatment.  Foot Ankle Int2002; 23:1018.
  15. Mulder JD: The causative mechanism in Morton's metatarsalgia.  J Bone Joint Surg1951; 33B:94.
  16. Coughlin MJ: Soft tissue afflictions.   In: Chapman M, ed. Operative orthopaedics,  Philadelphia: JB Lippincott; 1988.
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  18. Mann RA, Reynolds JC: Interdigital neuroma: a critical clinical analysis.  Foot Ankle1983; 3:238.
  19. Morton TG: A peculiar painful infection of the fourth metatarsophalangeal articulation.  Am J Med Sci1876; 71:37.
  20. Mann RA, Coughlin MJ: Deformities of the lateral toes.  American Academy of Orthopaedic Surgeons instructional course lectures,, 36. 1987:137-159.
  21. Mann RA, Coughlin MJ: Lesser-toe deformities.   In: Jahss JM, ed. Disorders of the foot,  ed 2. Philadelphia: WB Saunders; 1991.
  22. Coughlin MJ: Mallet toes, hammer toes, claw toes, and corns—causes and treatment of lesser toe deformities.  Postgrad Med1984; 75:191.
  23. Coughlin MJ: Lesser toe deformities.  Orthopedics1987; 10:63.
  24. Coughlin MJ: Lesser toe abnormalities.   In: Chapman M, ed. Operative orthopaedics,  Philadelphia: JB Lippincott; 1988.
  25. Coughlin MJ, Mann RA: Lesser toe deformities.   In: Mann RA, Coughlin MJ, ed. Surgery of the foot and ankle,  ed 6. St Louis: CV Mosby; 1992.
  26. Coughlin MJ: Metatarsophalangeal joint instability in the athlete.  Foot Ankle1993; 14:309.
  27. Haddad SL, et al: Results of flexor-to-extensor and extensor brevis tendon transfer for correction of the crossover second toe deformity.  Foot Ankle Int1999; 20:781.
  28. Coughlin MJ: Subluxation and dislocation of the second metatarsophalangeal joint.  Orthop Clin North Am1989; 20:535.
  29. Coughlin MJ: Cross-over second toe deformity.  Foot Ankle1987; 8:29.
  30. Coughlin MJ: When to suspect crossover second toe deformity.  Musculo Skel Med1987; 4:39.
  31. O'Kane C, Kilmartin TE: The surgical management of central metatarsalgia.  Foot Ankle Int2002; 23:415.

 

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Porter & Schon: Baxter's The Foot and Ankle in Sport, 2nd ed.

Copyright © 2007 Mosby, Inc.

Further reading

Coughlin MJ: Operative repair of the mallet toe.  Foot Ankle  1995; 16(3):109-116.

Coughlin MJ:: Common causes of pain in the forefoot in adults.  J Bone Joint Surg[Br]  2000; 82-B:781-790.

Coughlin MJ: Lesser-toe abnormalities.  J Bone Joint Surg [Am]  2002; 84-A:1446-1469.

Coughlin MJ, Dorris J, Polk E: Operative repair of the fixed hammertoe deformity.  Foot Ankle Int  2000; 21:94-104.

Coughlin MJ, Grimes JS: Geometric analysis of the Weil osteotomy.  Foot Ankle Int  2006; 27:985-992.

Coughlin MJ, Kennedy MP: Operative repair of fourth and fifth toe corns.  Foot Ankle Int  2003; 24:147-157.

Coughlin MJ, Pinsonneault T: Operative treatment of interdigital neuroma: a long-term follow-up study.  J Bone Joint Surg [Am]  2001; 83-A:1321-1328.

Trnka HJ, Muhlbauer M, Reinhard Z, et al: Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints.