Metatarsalphalangeal Joint

Ligaments surrounding the joint at the base of the second toe form a capsule which help keep the digit aligned and functioning properly. Second MTPJ Subluxation/Plantar Plate Tear occurs when these ligaments become inflamed and eventually tear. The second toe starts to move either outward or inward and persistent pain develops underneath the second MTPJ joint (directly behind the digit).

Although this deformity/injury can also occur in the joints of the third or fourth toes, it most commonly affects the second toe. Capsule inflammation (surrounding soft tissue structure of the MTPJ) initially occurs and causes considerable discomfort. The capsule of the joint becomes weak leading to subtle dislocation/subluxation (also referred to as predislocation syndrome). If left untreated the severity of the dislocation/subluxation increases eventually causing the plantar plate (strong band of tissue on bottom of the joint) to tear.

Causes

Abnormal foot mechanics (i.e. Bunion, Hammertoe, Flatfoot, Equinus, Elongated Second Toe, Shortened First Toe) predispose the second MTPJ to taken an excessive amount of weight. This joint is not designed to withstand this much repetitive weight during ambulation and causes a structural unstable joint complex and eventually a tear. 

Symptoms This is a progressive disorder and worsens if untreated.

• Pain on the ball of the foot.
• Swelling at the base of the toe
• Difficulty wearing certain shoes
• Pain when walking barefoot

In advanced/severe stages, the supportive ligaments continue to weaken leading to complete failure of the joint to stabilize the toe and eventually causing the second toe to cross over the big toe. Overuse or injury can cause this to progress even quicker if untreated.

Diagnosis

Subluxation/Plantar Plate Tears can vary from an apparent deformity to a subtle change in the toe alignment. The surgeon will assess the reproducibility of your symptoms by moving/manipulating your forefoot as well as gently press on areas to determine any discomfort. A diagnostic injection with local anesthetic may pinpoint the problem.

X-rays are usually ordered to determine the degree of the deformity and assess changes that have occurred.

An MRI may be ordered to determine the extent of the pathology to the plantar plate tear as well as determine surgical planning should surgery be warranted. An Ultrasound may also be utilized to determine the plantar plate structure.

An accurate diagnosis is imperative as symptoms of the subluxation/plantar plate rupture can be similar to a neuroma which is typically treated differently.

Non Surgical Treatments

Treatment approaches for second MTPJ subluxation/plantar plate ruptures are based on how long the pathology has been present and the severity of the symptoms. The earlier the treatment the better the outcome. Conservative treatment options are aimed at easing the pain of the deformity, stabilizing the joint, and addressing the underlying cause, but again this condition is progressive if intervention does not occur.

• Immobilization/Rest. Immobilization may involve the use of a removable walking boot or shoe to reduce the strain and forces going through second MTPJ.
• Ice. Applying an ice pack to the area of discomfort throughout the day helps reduce inflammation and pain.
• Changes in shoewear. Supportive shoes with stiff soles are help control the motion and lessen the amount of pressure on the ball of the foot.
• Taping/Splinting/Strapping. Some taping or splinting modalities can realign the joint minimize the pain as well as assist with joint motion.
• Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed to reduce pain and inflammation.
• Orthotic devices. Custom or over the counter orthotic devices that fit into your shoe help correct the underlying structure of the foot and stabilize motion. A metatarsal pad added to the insert will distribute weight away from the joint.

Surgery

Due to the progressiveness of the deformity once the second toe starts to drift or crosses over the big toe it will not return to its normal anatomical position unless surgery is performed. If nonsurgical treatments fail to relieve the subluxation/plantar plate rupture pain and when the pain interferes with daily activities, surgery may be necessary. Your surgeon will select the best procedure to remove deformity and relive the pain. Together with your surgeon consideration will be taken in regards to the extent of your deformity, imaging, your age, and your activity level. The recovery period will vary, depending on the procedure or other procedures performed.

Surgery is typically an outpatient procedure (day surgery) and scheduled at your convenience.

A splint or boot will be placed on your surgical foot/ankle after surgery. No weight to the surgical foot/ankle is advised until your surgeon encourages weight bearing.