If you have been reading my crap information on second MTP synovitis you already have a good idea where I am going with this.
I have one correction, actually an omission, regarding Part 1. In Part 1 I talked about the notion that the 2nd metatarsal has grown “too long.” Here is another knee slapper, actually even more ridiculous; being told your 2nd metatarsal has “dropped.” Seriously, DROPPED? These two long held reasons, actually myths, for problems related to the 2nd metatarsal, plantar callosities and second MTP synovitis, are short sighted and demonstrate a total lack of biomechanical understanding. To quote my favorite online quip from the Musings of a Dinosaur, Rule number 10, “A bad idea held by many people for a long time is still an bad idea.”
Law 10: A bad idea held by many people for a long time is still an bad idea
So let’s just get this straight for the sake of a crystal clear understanding, the 2nd metatarsal does not change in time. It does not grow longer and it does not drop, period.
The isolated gastrocnemius contracture is the underlying problem, and the only underlying problem, causing second MTP synovitis, which eventually leads to 2nd hammertoe and more eventually to a 2nd MTP joint dislocation. BOOM! Another scoop, I called it! I know what you are thinking and before you get going, hear me out.
So, let’s take this on step by step. As we age, the majority of us experience a gradual tightening of our calves: the isolated gastrocnemius contracture. It is almost always unnoticeable, so you are unaware it is there or that it is causing a problem. Over time the isolated gastrocnemius contracture will do cumulative harm to your foot and ankle in many areas and ways. Because of this calf tightness, the amount of pressure born on the front of your foot, the metatarsal heads or ball of your foot, increases.
All the while our forefoot anatomy has not changed, such as the magical growing or dropped 2nd metatarsal. The statement “Your 2nd metatarsal has dropped” has always cracked me up and at the same time gotten a lot of patients in trouble. The 2nd metatarsal has not changed one bit. It is well known to be the longest and the stiffest metatarsal (due to the “Keystone effect”) of the five in the great majority of humans. We were born this way and this anatomy does not change. The only thing that has changed is the isolated gastrocnemius contracture creeping up on us.
So, if there is going to be more pressure born to the metatarsal region because of the isolated gastrocnemius contracture it will be focused on the 2nd metatarsal head because of our natural anatomy. Step after step the pressure focused on this one poor innocent bystander, the 2nd metatarsal head, creates damage to the second MTP joint. You could say the 2nd MT is a victim of circumstances.
Then comes the pain and usually swelling along with the painful ball or lump feeling on the bottom of the foot. BTW, one will never experience actual swelling with a Morton’s neuroma. A kissing cousin, a metatarsal stress fracture, far and away most commonly of the 2nd metatarsal (any guesses why the 2nd is most common? Hint: it is not a “dropped” 2nd metatarsal) is characteristically pain and swelling is exclusively on the top of the foot.
But I digress. The 2nd MTP joint capsule and synovium (joint lining whose purpose is to make joint fluid providing nutrients for the cartilage) becomes angry and inflamed trying to solve the problem of the repetitive trauma and there is excessive joint fluid produced. This is exactly what our bodies are supposed to do when stressed in this manner. This is the inflammatory response and is a good thing unless the underlying mechanical problem is not corrected, then it becomes a chronic inflammation.
The joint becomes distended much like blowing up a balloon and as a result the structural support system becomes stretched out. This includes the collateral ligaments and the plantar plate. Left unattended, voilà, you have a hammer toe. Wait longer and you will get to experience that mysterious dislocation syndrome.
Just in case you need additional help with this concept watch my animation of how you get an acquired second hammer toe:
This is not trauma, or some random mysterious inflammation, or a only plantar plate rupture, and it is definitely not a dropped second metatarsal. You can’t avoid getting older, but you can treat this problem in development and better yet you can prevent the second crucial step by stretching your calves. It’s your choice, symptomatically treat your foot or fix the problem and stretch your calves.
Stay healthy my friends,
AO
I was recently diagnosed with MN. I had an MRI that showed inflammation and thickening of the soft tissue. I had 3 rounds of cortisone injections with no relief.
I have a burning, pins and needles type nerve pain and swelling in the ball of the foot and the toes. The swelling has been consistent since prior to the diagnosis. The burning pain is on the ball of the foot by the 3rd, 4th and 5th toes.
I have had a nagging feeling that I have been misdiagnosed. I have been researching MN on the internet for months. I spoke to the doctor about the MPJ Capsulitis/Synovitis and he said all the symptoms point to MN.
You mentioned in several posts that MN “NEVER” has swelling. That concerned me because my foot has been swollen since day one. I started doing the calf stretching that you recommended. It’s only been a few days, but I am feeling confident that this will help.
I would greatly appreciate your feedback.
Thank you,
Lori
Hey Lori,
Thanks for contacting me and inflame me. I will stand behind the fact that Morton’s neuroma NEVER causes actual, visible swelling, but it can make one “feel” swollen. Whereas, second MTP synovitis usually causes swelling. Here is the cool thing, calf stretching will fix both in the great majority of cases, so what do you have to lose. It has been a while, so how are you doing?
Stay healthy my friends,
AO
Angry runner with 2nd MTP synovitis here. Although the (current) state of my condition might be better than many others, I am still angry that I am not able to engage in an activity that I love and hold dear and instead must, at least for now, find my cardio work-out from the utmost boring exercise bike. The anger really boiled over when 50,000+ marathon runners ran through my NYC streets last weekend and I could not be one of them.
Anyway – here is a quick background and few questions to which I hope you could shed some light on.
I was, until my injury, an active runner. Mid September the dreaded ball of foot pain started and I was diagnosed with 2nd MTP synovitis. Wore a boot for about 5 weeks and comfy wide-toe box hokas (with meta pad insole) since then. Engage in daily calf stretching (thanks!!), icing and take over the counter anti-inflammatories. Fast forward to today and I would say I am about 65-75% better. Walking is no longer a problem and the dreaded ball of foot pain is mostly gone – although I do have flare-ups (especially if I walked much that day) and the foot still does not feel “right”. That being said, I do have other pain / strange sensations at random times (but not always) – general stiffness of the forefoot, a shooting pain up my toe and sometimes my big toe feels sensitive.
So, here are my questions:
i) Are the above described pains / sensations natural and part of the healing process even though they are not the traditional ball of foot pain? Is it referred pain or something that is caused by the 2nd MTP synovitis or might the cause be something totally different?
ii) I hope to start running again in December – to start, lightly on the treadmill. I am really concerned that this condition will come back. Besides calf stretching and good shoes, anything you can in particular recommend to prevent this? Should I even start running if my foot doesn’t fill 100% or just wait until it does feel 100%?
iii) My doc said there is always a chance that 2nd MTP synovitis does not go fully away. A little scary. Not a condition, regardless of severity, that I want to have the rest of my life. Is that your experience as well?
iv) Related to iii), from online resources, it appears healing time is all across the board. Some indicate 12 weeks, others I see suffering from this for 7 months or more….assuming proper healing procedures are followed (e.g., stretching, etc.), what do you think is the average time that this condition resolves itself in your experience?
v) With respect to calves / calf tightness / stretching, it appears that calves “shorten” as part of the natural aging process, especially if one is not active / does not stretch them. However, as I am an active person (who does stretch before runs), I am surprised that calf tightness would inflict me. For active people, could the cause of 2nd MTP synovitis might be more related to other conditions (e.g., bad footwear, the shock and wear and tear that feet absorb from running, etc.) than the calves (although the condition of the calves could be a contributing factor)?
Thank you and much appreciated!
Hi Scott,
My apologies for the wait. If you did the calf stretching you doubt (question v) you are past this now and back running. That is my confidence in stretching brother. I will address runners and calves later.
Your description of your anger and angst being “out of the game” seriously just about brought tears to my eyes. What an accurate and poignant glimpse into the mind of one imprisoned is they’re own body. Not that you would be looking for sympathy, who would listen. After all, you could walk and get on with life, at least that is the perception. Why the hell does second MTP synovitis bother you SOOO much? It can’t be that bad? But it is? At least for quality of life.
One of my favorite “sleight of hand” moves on my misdirected patients involved much of your logic. You see it, you get it, but too many do not including my colleagues. BTW, this sleight of tongue hand applies to the great majority of the foot and ankle issues we see, not just second MTP synovitis. So, a patient, actually many patients, come in with a well-deserved attitude because I was the fifth doc they had seen and no one was helping them. At this point in time, they have become desperate, seriously, thus the attitude. When asked what the problem was they insist the problem is the pain. I would ask them about quality of life and often the response in anger would be an emphatic NO, it is the pain. Then I would ask how is the pain when you are sitting on the sofa or not running (in your case) or out for a simple walk, and they would admit the pain is little if any. Then in my smart ass AO attitude I would ask, “then sit on the couch and don’t do those things that cause you pain.” The response has been 100% the same over 30 years, “I can’t do that! I have things I need to do, I have things I want to do.” I would respond, “You just proved my point.” Scott, you did not go on about the pain, you focused on the quality of life. It seems like an inconsequential difference, but we know it is not.
But I digress. Now for your questions:
i) Are the above-described pains/sensations natural and part of the healing process even though they are not the traditional ball of foot pain? Is it referred pain or something that is caused by the 2nd MTP synovitis or might the cause be something totally different?
This is likely interdigital neuritis from the adjacent inflammation of the joint. I have addressed this phenomenon somewhere in all my rambling on here, so I will leave it to you to locate. Simply put, fix the synovitis and the neuritis will fix itself. Stretch your calves. Also read elsewhere about palliative, symptomatic treatments such as injections mixed in all my blogs.
ii) I hope to start running again in December – to start, lightly on the treadmill. I am really concerned that this condition will come back. Besides calf stretching and good shoes, anything you can in particular recommend to prevent this? Should I even start running if my foot doesn’t fill 100% or just wait until it does feel 100%?
I would like to be more reasuring, but I do not know where you are in your recovery or if you have stretched. To see yourself in the mirror I include a close to heart, sort of classic story for second MTP synovitis:
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. Her experience was pretty much the same experience that my patients reported over the years under my guidance.
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.
iii) My doc said there is always a chance that 2nd MTP synovitis does not go fully away. A little scary. Not a condition, regardless of severity, that I want to have the rest of my life. Is that your experience as well?
Of course, your doc said this. Did they emphasis equinus or even mention it? NO, they did not. In a scholarly way, I have spent 25 years to get them to see the true pathology, but that would affect the bottom line. BTW your 65% better is just about what you get when the only solution, calf stretching, is not the primary modality of treatment and why your doc can say this. I have had my share of patients (maybe 10-15%) who came too late and failed and required surgery, but this is not you.
iv) Related to iii), from online resources, it appears healing time is all across the board. Some indicate 12 weeks, others I see suffering from this for 7 months or more….assuming proper healing procedures are followed (e.g., stretching, etc.), what do you think is the average time that this condition resolves itself in your experience?
2-8 months given compliant stretching is started day one and depending on when stretching started in the timeline
v) With respect to calves/calf tightness/stretching, it appears that calves “shorten” as part of the natural aging process, especially if one is not active/does not stretch them. However, as I am an active person (who does stretch before runs), I am surprised that calf tightness would inflict me. For active people, could the cause of 2nd MTP synovitis might be more related to other conditions (e.g., bad footwear, the shock and wear and tear that feet absorb from running, etc.) than the calves (although the condition of the calves could be a contributing factor)?
Aha! This is a good one. Distance runners have the tightest calves of any particular group. Running doesn’t make calves more limber, it makes them slowly and incrementally tighter. Maybe one day I will explain on this site, but time does not allow at this point. I am published on it though. I am going to be blunt, calves are not contributing factor as you allege, they are THE singular root cause and the scientific evidence supports it. This is why no one is talking about calves because they are allegedly part of a multifactorial problem. I humbly disagree and believe it is THE problem. Just because only a few are talking about it does not make it true. Who would have thought that sugar is the bad guy and the goods fats (monounsaturated fats and polyunsaturated fats) are okay for 55 years? Is there any wonder that plantar fasciitis and shin splints are so prevalent in runners? One guess what the root cause is of these issues? Finally, it is a 65% chance you had plantar fasciitis in the past.
I hope you make that run in December.
Stay healthy my friends,
AO
Hey there. After making almost daily Dr. Google check-ins, I’m not sure how I missed your site. Glad I found it.
I am a backcountry photographer and five months ago I got a mysterious pain/tingling in my 2nd toe (which happens to be a Morton’s Toe). I didn’t think it was a big deal and was sure it would resolve. WRONG ANSWER. Five months later and things evolved. After wearing a boot for three weeks, getting a lousy first MRI (that came back normal), doing a course of steroids (oral), and completely stopping running and all outdoor photography, I am still dealing with pain. A follow-up MRI revealed a “high grade partial thickness plantar plate tear.” Two weeks ago, following the advice of some Google source, I started taping the toe. And having read your entries, I am now madly rolling out my calf–low and behold, I have found some very sore spots.
Do you think that by “releasing” a tight calf it is possible I will allow the plantar plate to heal? In other words, is it possible the calf was so tight that it was constantly pulling on the plantar plate and therefore never giving it an opportunity to heal?
Any other thoughts would be greatly appreciated. Thanks for taking the time to consider this query.
Hey Euchrid,
I am sorry you got the standard wrong treatment. I never even got MRIs, maybe two in 500 plus cases of second MTP synovitis, and only then when patients demanded it. The diagnosis is clinically simple and can be made over the phone. Taping the toe is only useful to help arrest a hammer toe in progress, but not helpful for the synovitis per se.
If by rolling out the calf you are referring to using a roller, you are wasting your time. While rolling is the hot thing right now there is no evidence that it is anymore than a feel good thing. I content it could stretch a muscle to some degree, but minimal at best. Static calf stretching is what you need, period.
You do need to read more to better understand your problem and the mechanism of injury. It is not about tugging the plantar plate (PP). Equinus is well shown to increase the forefoot pressure and since the second metatarsal is the longest and the stiffest the load concentrates there. This causes synovitis and then the PP rupture. Again, read more on my blog.
Yes, I am certain that “releasing”/lengthening your gastrocnemius will solve almost all second MTP synovitis cases, but it requires static stretching.
Hope this helps.
Stay healthy my friends,
AO