God bless the Beverly Hillbillies. Doubtlessly one of the best scenes depicting their countryfied ignorance was when the doorbell would ring and Jethro would say to Jed, “Uncle Jed, there goes that bell again, next thing you know someone’s gonna come a-knockin’ at the door.” Classic.
Well, the way my colleagues, both fellowship trained foot and ankle orthopaedic surgeons and my step brothers, podiatrists, are approaching the spectrum of 2nd MTP synovitis, eventual hammertoe formation, and even more eventual second MTP dislocation is really no different than Jethro and Jed on the doorbell.
Most everyone is waiting for the knock at the door because they don’t know what the doorbell is about. Not a clue!
They are waiting way too long to deal with this problem, but they don’t know it. Pity…for you. In the case of foot and ankle orthopods, they at least are not waiting until the MTP joint dislocates. Currently, most of us have gone on a rampage of doing a Weil osteotomy combined with repair of plantar plate ruptures, the precursor to dislocation and part of a hammertoe. In fact, there are whole systems developed by both Smith & Nephew, and Arthrex for this purpose. All I have to say about these innovations is “If you build it they will come.”
The “pre-dislocation syndrome,” a term used by many, is full of mystery and intrigue.
How would one pose this concept to a patient anyway? The doctor says to the patient: “The pain, swelling, and hammertoe you have is called pre-dislocation syndrome. We don’t know what it is or what caused it (which means we don’t know how to treat it), but we do know what will eventually happen, your toe is going to dislocate.” Speaking of letting the cat out of the bag.
Here is another favorite line I hear way too often from my patients: “They told me the reason for my problem is that my 2nd metatarsal has grown too long, so it has to be shortened.” And this is said with a straight face. Seriously, a 2nd metatarsal that has grown too long? Believe me when I say something has changed to force this situation, but it is definitely not the magical growth of one’s 2nd metatarsal midlife.
By the way, the podiatrists have gotten fully on board and are performing these procedures with reckless abandon. Everybody is joining in on the party.
…letting the cat out of the bag.
Unfortunately, this whole issue is where medicine and technology goes haywire all too often today.
Systems and techniques like this are developed mostly because we can.
They seem like a good idea on paper. But do they really work?
In our profession, these same docs continually yell out the mantra “where’s the evidence?” Well, I’m going to call them on this one and say, “where’s your evidence?” That would be a big Blutarsky, zero-point-zero. If and when the evidence comes forth it will be mostly about semi-straight toes and little about patient satisfaction or problem resolution.
…where’s your evidence
I would estimate that in excess of 1000 of these reconstructive procedures are being done every day in the U.S…based on nothing. I am also going to go out on a limb and say this concept is doomed and in time will not be the answer. That is if we ever get any clinical evidence to tell us how they are doing.
So all the while we will continue to merrily cut away…until we find out it was not a good idea.
“Okay, Mr. AO smarty pants, what is the reason we develop 2nd MTP synovitis and a hammertoe?” Stay tuned while I think about it and I will be back with an answer in a few days.
Stay tuned.
Stay healthy my friends,
AO
I’m a stay at home mother of 3, so I’m continually on my feet. About 2 years ago, I had a painful callus removed from ball of my foot. At the time, was told that 2nd toe was too long and could cause a problem. Started walking on side of foot to avoid too much pressure on ball of foot. About a year later, felt very sharp pain. Looked at foot and realized that 2nd toe had moved up on top of big toe. Saw a podiatrist and was given anti-inflammatories. Today, saw orthopedist who said it’s a hammer toe. Although, it’s not bent at all. It’s just moved laterally, so I don’t get that one. Gave me a horrible little toe splint with no follow up. Very frustrated and so tired of this foot. Is there anything to be done? Recently, 3rd toe started hurting and arch feels like something is trying to burn its way out of my foot from the inside. Thank you for any help.
Excellent question. I will answer with my latest short blog done just to answer your situation.
Stay healthy my friends.
Best regards,
AO
Dear AngryOrthopod,
It was a unique pleasure to find your website, I have never seen a more encouraging site to this topic!
A year ago I noticed that my second toe ( next to the big toe ) of my left foot was somehow lifeless, sort of dragging along. Then about 2 weeks later sharp pain around the 2-3-4 metatarsal area and then I could not walk. The toe got back to life a bit later, maybe within weeks ( no crossover toe, no deviation ) but the pain remained there, „ stepping on a stone „ feeling under the 2 metatarsal head.
What was done since then throught the following months:
– wearing orthotic inserts
– injection on one occasion between the 2-3 meta heads
– X-ray and them MR. X ray showed that the second metatarsal head was ok, it was not long or anything. MR showed just mild synovitis at the first metatarsal head ( not the second but the first, I do not understand that ), no Morton neuroma, no planar plate tear ( at least the report did not mention that ). Everything looked ok.
First doc said nothing, the second doc said stretching the calf, Achilles but no Weil operation intended.
I did wall stetching the soleus and gastrocnemius, it did good but as I did not do it regularly, I did not have much result.
Then I found your web site, 2 weeks ago and your words were very encouraging. I started stretching again, now on a step as you recommended 3minutes x 3 times a day. A few days later I could walk barefoot in my house without feeling much pain!
But I have a question that might makes you angrier than ever:
I noticed that when I just sit down putting pressure on the forefoot ( with the calf out of function ) I still have as my second metatarsal head was dropped ( now I can see you real angry ) and with that a „ stepping on a stone „ feeling. Looking down on my feet, everything looks fine but it looks to me that the 4-3-2 metatarsal area dorsally were hollower than that of the other foot. What thought comes back to me very often is this: when damage was done it was done. Surrounding tissues/muscles/ligaments ( I have no idea what else is there, I am just trying to think ) ) got weakened and if they are damaged/weakened then nothing could make the metatarsal head or its surroundings be as it was before.
I really hope that you would get really angry and explain a little biomechanics to me as I would like to really undertand it. Thanks for any help.
Attila, from Hungary
Hi Attila,
I am not angry, I am pissed off. Thanks, I feel better already. BTW, one of my favorite American trauma surgeons is Attila Polka in Ohio.
Thanks for the compliment and I am glad you found me. It is surprising you found a doc who even recommended calf stretching. As usual the message is weak because the source, you’re doc, feels it is “just something to do”, while I know it is DEFINITIVE. “Why is it definitive?”, you ask. As you have read, the source is not the foot, it is equinus, it is your calf. OK, on rare occasion it can be the foot, but keep in mind this is the same foot you had a year ago, 5 years ago and so forth. So, in those cases the foot is more susceptible, but equinus is still the initiator at age 45, 55, etc.
To answer your question, which does make me angry (thanks again) you are thinking too much, really. First, this synovitis “damage” is completely reversible. Once the instigator/cause/equinus is removed, things revise. The 2nd MT head plantar pressure is back to age 20, or normal, the increased synovial pressure is gone, the synovitis quells and BOOM, you are back doing the stuff you want to do. What is not reversible is any toe deviation such as lateral drift towards the third toe, or hammertoe formation. As far as what you are seeing with the 2-3-4 “dripped” (it took all my willpower to even type that), I can’t help you understand that other than it is not cause by this episode. Maybe it was always there and not you are looking for first time or see below.
Also, keep in mind that there is a baseline period of time when the symptoms, while much better like yours are, are still present and can be up and down. Then one day, poof, you realize, “Hey, my foot has not bothered me for weeks. I think it is really gone.”
I would bet a large bundle of Zloty’s that in a month or two, when you are completely done with this you will look down and see your feet to symmetrical, and if they are not, you won’t care.
Thanks for pissing me off!
Stay healthy my friends,
AO
PDS is linked to a long or plantarflexed /plantar prominent 2nd met. But it rarely needs surgery. Orthotics or a prefab support with a 2nd met recess in a rocker sole shoe (like MBT), to prevent the hyper-extension of the toe that forces the metatarsal condyle plantarly into the “plantar plate”.
The scorpion suture repair of the plantar plate is pretty ingenious though. Nice toy!!
My own 2 cents based on anecdotal bias confirming selective recognition of limited follow ups on busy clinic days is this: Weil’s generally “work”, as do plantar condylectomies. Tendons can heal without our help if the deforming/ damaging factors are removed or reduced enough to let the body function as intended. If you feel better placing a $1000 stitch with the scorpion and aren’t up for changing the world of massive overspending on $1000 stitch worth $5 of improvement.
This issue is far broader than PDS. Hernia surgery, many bunion situations, tarsal tunnel releases. They all “work” which is to say sometimes, for a variable period of time and with a possible list of complications as bad or worse than the original condition..
Marc, Marc, Marc,
I will respectfully disagree with you on the cause. This is the dogma passed down over time and no one cares or thinks to challenge it. Well I do challenge I!. Of course a few of the cases of are structural like a long 2nd MT, hyper mobile first ray from a bunion, etc. But here is what you must ask yourself, why does this issue happen at 56 years of age. I don’t think it is somehow the 2nt MT just magically grew. I favor equinus. I like your attitude and skepticism towards surgery in general. These are the words of experience folks. The older I have gotten I have progressively revered the knife. As for the plantar plate repair with or with out a Weil, this procedure can be summed up by your last perfect comment, “They [surgeries] all “work” which is to say sometimes, for a variable period of time and with a possible list of complications as bad or worse than the original condition.”
Stay healthy my friends,
AO
Thank you for your insights. I would love your opinion. I am a 42 year old active physical therapist. I have seen 2 Orthopaedics and 2 podiatrists for opinions. I have not had an MRI but I think I have a plantar plate tear. My second toe is medially deviated, has a hammer toe and is trying to crossover my great toe. I have pain with any walking over metatarsal head. Even at rest, it throbs. I cannot walk with a normal gait. I have tried conservative treatment. I wear Hokas, tried taping, custom orthotics, metatarsal pad. I am to the point that I am ready for surgery due to pain and impact on my life. I have been dealing with this for almost a year. Every doctor I see tells me outcomes of surgery are not optimal. Due to my profession, I have seen the good and bad with surgeries. I have appointments to see more doctors as I have not found the one yet I am confident with. In your opinion, what is the difference between podiatrist and Orthopaedics when looking at this procedure. Benefits to one over the other? One orthopedic I saw said that he would not repair the plantar plate even if it’s torn. Do you have any thoughts on that? I am trying to make an educated decision on the next step I need to take but I’m getting conflicting information from professionals. Would love some insight if you have any. Thanks for your time.
Hey Sheri,
I don’t know whether to feel worse for you about the synovitis or the finding a doc issue. I always felt terrible for patients coming in who were in this position regarding their care. It is a real problem for too many people for sure. It is not that the docs are not trying their best, but it is vital that we have trust in them regarding their experience, their knowledge, and their commitment to our orthopaedic care. As far as surgeon choice, ask other professionals as you are in the biz, but you’ve done this I am sure. There is no doubt there are both good and bad podiatrists and MD orthopaedic surgeons. As little as 10 years ago I would have said MD all the way, but the podiatrists have seriously upped their game especially the ones graduated more recently.
Plantar Plate rupture repairs are hit and miss and do not provide consistent enough results, in my opinion. But some do provide reasonable, but inconsistent results.
No doubt most if not all of your pain/problem is the synovitis, which caused the plantar plate rupture (that I agree with) in the first place. You must separate the hammertoe/plantar plate rupture from the second MTP synovitis. Which one is your real problem? I say the second MTP synovitis, which can be solved in time with the stretching. In the meantime, the symptoms can be controlled temporarily with intraarticular cortisone injections. Besides making you feel fantastic, these injections also take down the joint swelling and as a result, slow if not stop the damage to the plantar plate. Below is the story of my own wife, and this story has played out for my patient is at least several hundred cases. Then there is me! Poor me as this seriously cuts down on my trips to the OR. Oh well.
My wife had second MTP synovitis on both sides no less. One foot started, and the other followed maybe a month or so later, and of course, we caught hers early because her husband is a talented surgeon. As expected, my lovely bride faithfully stretched. However, the stretching takes time, and her pain and swelling was in the now and in time was going to exact damage to her plantar plate. To mitigate this, I had to inject one side 3 times and the other four times over about 4 months, each about 4-6 weeks apart. As soon as she said it was ”coming back” I injected her quickly before it got too flared up. I was protecting those plantar plates as aggressively as I could knowing the force/pressure under the 2nd metatarsal head would come back to normal once the stretching started to work. Sorry, but the stretching does take some time.
It took about 3-4 months for each side to “resolve.” She said the relief at that point was definite but somewhat iffy. She had a sense it might flare again if she got too active like running, or walking too much barefoot on a hard floor. During this time, while her activity level was near normal, she would wisely back off before it got going again. However, it didn’t flare and about 2-3 months later (6-7 months in) she came in the room one day and said, “It’s gone,” and that was that. She continues to stretch today. Of the swelling/synovitis
Finally, the formation of the hammertoe deformity is a function of how long and how much swelling one has had and how early these issues are addressed. Here is the thing, you can be injected ”forever”, but it won’t stop until the cause, equinus, is corrected.
Stay healthy my friends,
AO
I really like your insight on the issue of metatarsal pain. I believe I am one of those typical 56ish year old women who walk in your door. I have the 2nd MTP synovitis as described so clearly by you. I have been to my podiatrist a dozen times and my pain is only getting worse increasing from one foot to the other. Like many of us, I have high arches, a small bunion, the beginning of arthritis, but also a plantar fibroma. That was the original reason for my visit to the 2nd young podiatrist I chose. He successfully reduced its size with Vitrase enzyme shots.
Now back to my real pain—the metatarsalgia. I have followed through with all of the conservative treatments including rest, ice, orthotics, shoe change and advil for more than 6 months to no avail. I am religiously doing your calf stretches on a step, but it does cause me pain in my arches, scaring me into thinking I’ll get another fibroma if I’m not careful. My question for you is, can I adequately do these stretches on the floor by putting one foot back at a time to stretch each calf, 3 minutes each? Those do not hurt.
Secondly, I have not given in to the steroid injection because I am afraid of reducing the already meager foot pad I have to protect my metatarsal bones. It’s been more than 6 months. What do you recommend?
Hi Laura,
I am sounding like a broken record, but my apologies for the late response, no excuses. Now I am angry with my self.
No doubt some stretching methods are better than others, but as long as you feel it in your calf and you follow the protocol you should be good. I don’t think you will create permanent damage if you feel pain in the arch, but why cause it? One thing to do to mitigate this make sure you have shoes on and there are not orthotics or arch supports.
Steroid shots are pretty safe as long as they are strategically targeted and not just injected into some random area, like a fat pad. But with a high arch, I agree to not jeopardize your fad pads if possible.
Stay healthy my friends,
AO
Hi AO. I hope you are well. I’m hailing here from Sydney Australia. 41 year old male. I have Morton’s neuroma both feet, and they bother me for the first 2-3 steps each morning and that’s it.
But more to the point, I have mild/moderate bunions which have never given me problems till recently. I wear 4e shoes for the last 3 years (since MN diagnosis), but have started running in the last 6 months. Bunions only just starting to feel sore.
The podiatrist said I had most of my windlass mechanism in place, but had lost some flexibility in the big toe.
Would calf stretching be of any benefit to me?
Much appreciated
Phil
Hi Phil,
The first answer once I calmed down is that calf stretching will likely resolve your Morton’s neuroma as well as provide prevention of several running-related potential issues of which can be found throughout my site.
As an aside, I was in AUS for business last June and it was delightful. I found Perth, Carnes, and Sydney to all be wonderful cities matched with wonderful people. No one came close to making me angry.
This mini-discussion is for every runner out there. If you are a runner, of any skill level, you should be calf stretching proactively, every day. I find it curious and disheartening at the same time that people (runners, researchers, etc.) keep looking for the source(s) of runner’s injuries in shoes, running form, and any number of random factors. I am stating here unequivocally that equinus (calves too tight) is the singular root cause of the majority of runner’s “injuries” and non-traumatic acquired foot and ankle pathologies. BTW, Phil, this does not apply to bunions, however, there is evidence that equinus is related to the advancement of bunions and reduction of great toe mobility or dorsiflexion. So there is a potential benefit there was well. So, my friend, you have any numberer of reasons to stretch your calves:
-General start-up pain and stiffness
-Foot pain especially associated with start-up pain or stiffness
-Plantar fasciitis
-Sever’s disease
-Shin splints
-Posterior Tibialis Tendon Rupture(PTTR)-Acquired flatfoot deformity
-Second MTP synovitis/capsulitis/plantar plate rupture which leads to hammertoe
-Morton’s neuroma
-Insertional Achilles tendinosis/Haglund’s deformity
-Achilles tendinitis
-Musculotendinous Achilles ruptures
-Calf camps at night/Charlie horse
-Midfoot osteoarthritis
-Ankle arthritis/Anterior ankle spurs (prevention)
-Navicular stress fracture
-Calcaneal stress fracture
-Diabetic Charcot arthropathy
-Diabetic malperforans ulcer formation
-Metatarsal stress fractures (prevention)
-Achilles tendon ruptures (prevention)
-Hammertoe formation secondary to MTP synovitis (prevention)
Finally to your real question, painful bunions (hallux valgus or hallux abducto valgus). Unfortunately, calf stretching will not help this problem. I am going to break this down to the simplest denominator. The pain experienced over the side bump or the exostosis is nothing more than a peak pressure point on your skin. Wider shoes can help, but only to a point as the contour of the shoe still does not match your foot. Normal, store-bought shoes are made with a contour (the last) for a “normal” shaped foot. Simply put, your bump is pressing and rubbing against a more flat contoured area of the shoe. Adapting Johnny Cochran’s famous quote, “If the shoe does not fit, you must not quit.” There are two ways to create space to accommodate your unique foot shape beyond wider shoes:
* For leather shoes a Hoke Ball & Ring shoe stretcher really works well. And if it does not there any number of other wacky uses one could dream up for this wicked looking thing. It is reasonably priced and is worth a shot. Unfortunately, running shoes are not leather, at least in the area of concern here. It is worth a try though even with running shoes.
* If the Hoke device does not work on your running shoes there is another option. You can cut through and through the shoe, an “X” centered where the bunion bump is. First and foremost do this without your foot in there. Stranger things have happened. Do this with an older pair of shoes and start small and expand the cuts until it feels right. It takes some patience and trial and error, but it ain’t rocket science. Once you sort of have it down then apply to newer shoes.
* I don’t recommend the Zola Budd method
Stay healthy my friends,
AO