Evaluation and Management of Metatarsal and Forefoot Injuries Charles J. Gatt, Jr., MD Chair, Department of Orthopaedic Surgery Rutgers Robert Wood Johnson Medical School New Brunswick, NJ
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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