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Review article
COMMON CAUSES OF PAIN IN THE FOREFOOT IN ADULTS
Michael J. Coughlin
From Oregon Health Sciences University, Portland, USA
A complaint of pain in the forefoot may be a potential
source of frustration to the orthopaedic surgeon but the
evaluation needed to give a definitive diagnosis is usually
straightforward and the treatment uncomplicated.
The forefoot includes the digits and extends as far
proximal as the middle of the shafts of the metatarsals. The
term metatarsalgia is often used to describe pain in the
distal forefoot, but does not define a specific diagnosis or
indicate a particular mode of treatment. Pain in the forefoot
must be carefully analysed to establish a correct diagnosis.
It is necessary to assist the patient in determining the exact
location of the pain. This may not be easy since the initial
complaint may be of a large area of ill-defined pain. With
time, however, it is usually possible to isolate this to a
small discrete site. Other pertinent information includes the
presence of a deformity, inflammation of the soft tissue,
pain on palpation of a specific region, and/or associated
neuritic symptoms.
Radiological studies are helpful in determining the presence and magnitude of deformities, although physical
examination may be sufficient in the evaluation of many
lesser abnormalities of the toes. Radiographs are most
helpful in assessing the presence of intra-articular problems
such as degenerative arthritis, Freiberg’s infraction, stress
fracture of the metatarsal and inflammatory arthritis, but
there is no substitute for an adequate physical examination.
Radionucleide scanning, MRI and CT may be of value in
establishing a diagnosis in the case of pain not associated
with clinical or radiological deformity. Laboratory evaluation including a full blood count and measurement of the
ESR, the level of uric acid and rheumatoid factor is occasionally helpful in the diagnosis of a patient with recalcitrant pain in the forefoot in whom inflammatory arthritis is
suspected.
Observation of the presence or absence of a callus
associated with well-localised pain in the forefoot is the
M. J. Coughlin, MD, Clinical Professor of Orthopaedic Surgery
Oregon Health Sciences University, Portland, Oregon, USA.
Correspondence should be sent to Professor M. J. Coughlin at Suite 503,
901 N Curtis Road, Boise, Idaho 83706, USA.
©2000 British Editorial Society of Bone and Joint Surgery
0301-620X/00/611422 $2.00
J Bone Joint Surg [Br] 2000;82-B:781-90.
VOL. 82-B, NO. 6, AUGUST 2000
first step in the diagnostic evaluation (Fig. 1). A dorsal
callus overlying a plantar flexed distal interphalangeal joint
(DIP) occurs in a mallet-toe deformity and a similar callus
overlying a plantar flexed proximal interphalangeal joint
(PIP) in a hammer toe. With a claw toe, hyperextension of
the metatarsophalangeal joint (MTP) and flexion of the PIP
joint may be associated with a callosity beneath the
involved head of the metatarsal, overlying the PIP joint,
and even at the tip of the toe (Fig. 2). A callus localised to
the lateral aspect of the fifth toe may indicate a hard corn
while that in the webspace between the lesser toes occurs
with a soft corn. A callus overlying the lateral aspect of the
head of the fifth metatarsal is associated with a bunionette.
With an intractable plantar keratosis (IPK) a callus develops beneath the head of a lesser metatarsal.
The complaint of pain in the forefoot in the absence of a
callus should alert the physician to other abnormalities of
the soft tissue or joint. The presence of neuritic symptoms
in the digits may indicate an interdigital neuroma. In the
absence of such symptoms, capsulitis or instability of a
lesser MTP joint should be considered. Palpation of the
painful areas can differentiate many of these diagnoses. A
positive drawer sign (Fig. 3) in a lesser MTP joint and/or
malalignment of the symptomatic toe (Fig. 4) may help in
the diagnosis of capsulitis, synovitis or instability of the
joint. Often symptoms may be vague and ill-defined, necessitating repeated physical and radiological evaluation to
establish a correct diagnosis.
Problems in the first ray such as hallux valgus, hallux
rigidus, and sesamoiditis are beyond the scope of this
discussion, but have been thoroughly discussed in other
1-3
articles.
Interdigital neuroma
This frequent cause of ill-defined pain in the forefoot
commonly occurs in the second or third intermetatarsal
4,5
space, but rarely in the first or fourth. It is unusual for
6
two neuromas to occur in the same foot. Symptoms often
increase with activity and diminish with the removal of
shoes. Numbness or neuritic symptoms may be noted in the
distribution of either the second or third common digital
nerve (Fig. 5). It is important to assess the state of the
circulation of the foot since vascular insufficiency is an
781
782
M. J. COUGHLIN
Fig. 1
Algorithm for diagnosis of pain in the forefoot.
Fig. 3
With the involved toe grasped between the
examiner’s thumb and index finger, a dorsalplantar stress will often elicit exquisite pain
in the involved MTP joint. This finding is
absent in patients with a symptomatic interdigital neuroma.
Fig. 2
A hyperextended MTP joint and a flexion deformity of
the PIP joint occur with a claw toe. A callus may
develop beneath the involved metatarsal head, on the
dorsal aspect of the DIP joint, and at the tip of the
involved toe.
occasional cause of pain in the forefoot. The presence or
absence of instability of a lesser metatarsophalangeal joint,
a plantar callosity, and deformity of a lesser toe should be
noted. The intermetatarsal spaces are palpated since pain
may be experienced on compression. With simultaneous
compression of both the transverse arch and the involved
7
interspace, a click (Mulder’s sign) may be demonstrated as
the neuroma is subluxed beneath the transverse metatarsal
ligament.
The clinician aims to educate and assist the patient in
defining the location of pain. Over time, it is often possible
to pinpoint the exact area. When this proves difficult, an
8
injection with a local anaesthetic agent may be helpful.
Multiple injections may be necessary to differentiate pain
originating from either the second and third intermetatarsal
spaces or the adjacent MTP joints. Temporary relief after
infiltration of anaesthetic around a specific nerve and
increased pain when the anaesthesia subsides is diagnostic
of an interdigital neuroma.
Treatment. Non-surgical management of a symptomatic
THE JOURNAL OF BONE AND JOINT SURGERY
COMMON CAUSES OF PAIN IN THE FOREFOOT IN ADULTS
Fig. 4a
Fig. 4b
783
Fig. 4c
Fig. 4d
Figure 4a – Photograph showing the clinical appearance of mild cross-over second toe. Figure 4b – Radiological appearance
demonstrating medial deviation of the second toe. Figure 4c – Photograph showing end-on view of cross-over second toe.
Figure 4d – Photograph showing severe cross-over second toe.
Fig. 5
Diagram showing an interdigital neuroma with entrapment of the common
digital nerve beneath the transverse metatarsal ligament. Hyperaesthesia
and/or radiating pain may be observed. The shaded area in the inset shows
the neuritic area in a neuroma of the third intermetatarsal space.
neuroma requires diminished activity, the wearing of roomy
footwear or modification of the shoe with a less constricting toe box, the administration of non-steroidal anti-inflammatory drugs and the redistribution of weight-bearing with
a metatarsal pad placed just proximal to the area of the
symptomatic neuroma (Fig. 6a). Occasionally, an injection
of corticosteroid in the involved interspace will relieve
9,10
symptoms.
Conservative measures are successful in
5,11,12
over 50% of cases,
but when these fail operation may
be considered.
5,13
A dorsal approach is preferred
since this avoids the
possibility of a painful plantar scar which may be the
source of intractable postoperative pain. The incision can
also be extended should other pathology be identified in the
webspace. Transection of the transverse metatarsal ligament exposes the common digital nerve and the neuroma in
the depths of the intermetatarsal space. The nerve is sectioned distally at the level of division into the digital nerves
14
and any capsular branches to the MTP joint are severed.
The nerve is transected in the interosseous region and the
proximal segment allowed to retract. In general, the results
of operation are satisfactory with relief of symptoms in
VOL. 82-B, NO. 6, AUGUST 2000
Fig. 6a
Fig. 6b
Figure 6a – Photograph showing a soft wool pad placed on the insole just
proximal to the symptomatic area which may relieve symptoms. Figure 6b
– A Harris Mat study shows increased pressure beneath the involved
metatarsal head.
4,5,12
about 80% of patients.
Postoperative complications
may include recurrence of or failure to relieve the pain,
limitation in shoe wear, a painful scar or a painful sensory
deficit.
Intractable plantar keratosis
When a callus develops beneath one or more of the lateral
metatarsals, it is termed an intractable plantar keratosis
(IPK). It may be a well-localised discrete keratosis or a
15
large diffuse callus (Fig. 7). The latter often develops as a
result of repetitive abrasion associated with athletic activities, but is also associated with a long second and third
metatarsal. Pain often increases with build-up of a thick
784
M. J. COUGHLIN
Fig. 7a
Fig. 7b
Fig. 7c
Fig. 7d
Photographs showing various plantar keratoses: a) a small discrete keratosis; b) a large keratotic lesion; c) a diffuse abrasion-type
callosity; and d) a verruca.
Fig. 8
Fig. 9a
Through a dorsal approach, a plantar condylectomy resects 30% of the
plantar metatarsal head. A prominent fibular condyle is resected. An
intramedullary Kirschner wire may be used to stabilise the toe.
callus. A discrete callus develops most often beneath a
single metatarsal head and is associated with an enlarged
16
lateral condyle. It is important to determine the magnitude of symptoms and the duration of pain as well as which
activities influence discomfort. Minimal symptoms rarely
demand treatment. Evaluation using the Harris Mat (Fig.
6b) or a similar pressure plate, together with weightbearing radiographs using a marker placed beneath the
keratosis, will help to determine the location of the IPK and
any osseous abnormalities. On examination, it is important
to differentiate a callosity from a verruca or wart (Fig. 7). A
wart is infrequently located beneath the head of a lesser
metatarsal. Shaving of a callosity helps to differentiate it
from an IPK since there are minute punctate arterioles in
the centre of a wart while an IPK has an avascular
centre.
Treatment. This involves trimming the callus to relieve
pressure. Initially, the physician may debulk the callus and
then on a weekly basis the patient may use a rasp or pumice
stone to reduce the keratosis further. A wool pad placed on
the insole just proximal to the symptomatic metatarsal head
(Fig. 6a) helps to redistribute pressure to the metatarsal
diaphysis. A prefabricated or custom orthosis can then be
Fig. 9b
Diagram showing a capital oblique osteotomy. Figure 9a – A sagittal saw
is used to create an oblique osteotomy as parallel as possible to the plantar
aspect of the foot. The amount of proximal displacement is determined
before operation. If elevation is desired, two or three saw blades may be
stacked together in the saw to create a larger area of bone resection which
elevates the capital fragment. Figure 9b – As the osteotomy is completed,
the capital fragment is displaced proximally and is fixed by one or two
mini-fragment compression screws. The remaining metaphyseal flare is
excised.
used to maintain this redistribution of pressure.
With unremitting pain, operation may be warranted. A
plantar condylectomy is indicated for a well-localised discrete IPK (Fig. 8). Through a dorsal approach the MTP
joint is plantar flexed and the plantar aspect of the metatarsal head is shaved. For a large diffuse callus, a capital
oblique osteotomy is performed on the second and/or third
metatarsals (Fig. 9).
THE JOURNAL OF BONE AND JOINT SURGERY
COMMON CAUSES OF PAIN IN THE FOREFOOT IN ADULTS
Fig. 10a
Fig. 10b
Figure 10a – The Chevron osteotomy is proximally based
and orientated in a medial/lateral direction. The capital
fragment is shifted medially and stabilised with a 0.045
Kirschner wire. Figure 10b – The midshaft oblique osteotomy is directed in a dorsal/proximal to plantar/distal direction and the distal fragment is rotated in a medial direction
to reduce the wide intermetatarsal angle. It is stabilised by
two mini-fragment compression screws.
16
Mann and DuVries described the results of MTP
arthroplasty and condylectomy in 142 feet, noting that 95%
of the results were satisfactory with elimination of or a
substantial reduction of the callus in these patients. Transfer
lesions occurred in 13% of cases. While several techniques
of distal metatarsal osteotomies have been proposed for the
17-20
(Weil, personal communication), varitreatment of IPK
able results have been reported, with the incidence of
17
20
postoperative pain varying from 12% to 53%, transfer
20
21
20
lesions from 32% to 41%, recurrence in 50% and
17
21
21
malunion or pseudarthrosis in 8% to 53%. Trnka et al
in comparing distal metatarsal osteotomy with and without
internal fixation found significantly better results with a
capital oblique osteotomy noting no transfer lesions but
recurrent metatarsalgia or pseudarthrosis in 15 cases. These
procedures may be associated with delayed or nonunion or
transfer lesions and should be undertaken only after conservative measures have been exhausted. Unsecured and
simultaneous multiple osteotomies have a high rate of
20
complications including malunion and transfer lesions.
Bunionettes
A bunionette is characterised by a painful callus overlying
the head of the fifth metatarsal and results from friction
between an underlying bony prominence and constricting
VOL. 82-B, NO. 6, AUGUST 2000
785
footwear. Neuritic symptoms may develop because of compression of the lateral digital nerves of the fifth toe. With a
progressive deformity, ulceration or infection may occur.
On physical examination a lateral keratosis is seen in
approximately 70% of cases, a plantar keratosis in 10% and
22
combined plantar and lateral keratosis in 20%. Radiographs may demonstrate a large head of the fifth metatarsal
or a widening of the angle between the fourth and fifth
metatarsals and an abduction deformity of the fifth toe at
the MTP joint.
Treatment. Symptoms can often be substantially reduced
with a change in footwear or by stretching the shoe overlying the head of the fifth metatarsal. Shaving of the
hypertrophic callus and placing a soft wool pad just proximal to the head of the fifth metatarsal may also reduce
symptoms. A prefabricated or custom orthotic device may
eliminate pronation and thus reduce symptoms.
Surgery may be considered when symptoms are refractory to conservative care. Lateral condylectomy has been
23
associated with minimal angular correction and is rarely
15,24
While many
performed as an isolated procedure.
operations have been suggested to correct a symptomatic
bunionette deformity, the author currently favours two
procedures. The location of the keratosis (plantar, lateral
or plantar-lateral) helps to determine the appropriate
choice for correction of the deformity. In the presence of a
lateral callosity and a large head of the fifth metatarsal, a
25
Chevron osteotomy is performed (Fig. 10a). When there
is a wide angle between the fourth and fifth metatarsals, an
22
oblique diaphyseal osteotomy is carried out (Fig. 10b).
For a combined plantar and lateral keratosis, a modification of the oblique osteotomy is performed in which the
saw blade is angled in a more dorsal direction allowing the
22
distal fragment to elevate as it is rotated medially.
Extensive stripping of soft tissue, multiple metatarsal
osteotomies, and unsecured osteotomies in general should
be avoided.
22
Coughlin reported a satisfaction rate of 93% after a
diaphyseal osteotomy. No cases of nonunion developed.
25
Kitaoka et al reported experience with the distal Chevron
metatarsal osteotomy for correction of a bunionette in 19
feet with good results in 17. One case of transfer metatarsalgia was noted.
Metatarsophalangeal joint instability
The diagnosis of instability of a lesser MTP joint can be
difficult to make as ill-defined pain in the forefoot can also
be associated with both extra-articular abnormalities such
as an interdigital neuroma and formation of a synovial cyst,
and intra-articular disorders, including inflammatory arthritis, degenerative arthritis and Freiberg’s infraction. The
second MTP joint is most often involved. In older women,
it has been suggested that the long-term use of high-heeled
shoes places the lesser MTP joints in a position of chronic
hyperextension, which eventually leads to attenuation and
786
M. J. COUGHLIN
Fig. 11a
Fig. 11b
Fig. 11c
Figure 11a – Photograph showing methods of padding the lesser toes which include a pad over the hard corn on the
fifth toe, a pad placed in the webspace to alleviate pain from a soft corn, and tube gauze placed over either a soft corn
or hammer-toe deformity. Figures 11b and 11c – Photographs showing the taping technique. Adjacent toes may be
taped to stabilise an involved toe. This technique is used both before and after operation. A sling-type method of taping
may be used to pull the toe in a plantar/lateral direction. It is also secured by circumferential tape around the
forefoot.
Fig. 13a
Fig. 12
Diagram showing MTP arthroplasty. Reefing of the
lateral capsuloligamentous complex combined with
a medial release may achieve soft-tissue
realignment.
later rupture of the plantar capsule with resultant instab26
ility. Instability has also been reported in younger athletes
27,28
associated with an overuse syndrome.
The initial complaint of pain in the forefoot must be differentiated by
repeated examination to pinpoint an exact area of tenderness. Palpation often isolates the pain to the joint capsule
beneath the involved metatarsal head. Typically, neuritic
symptoms are not noted nor is pain observed in the second
or third intermetatarsal spaces. The use of a drawer test
(Fig. 2) is a reliable means of differentiating capsulitis and
instability of the MTP joint from an interdigital neuroma.
Early on, without obvious clinical or radiological deformity, the diagnosis of instability of the MTP joint is more
difficult to make. With time, obvious deformity of the
lesser toe is characterised by dorsal/medial or dorsal deviation at the MTP joint (Fig. 4). This may occur acutely
although it usually progresses insidiously over several
months. Serial injections of an anaesthetic agent performed
during sequential office visits may be helpful in determining the location of maximal symptoms. Radiological examination may demonstrate widening of the MTP joint
because of synovitis or an effusion, narrowing of the space
secondary to degenerative joint disease or hyperextension
of the MTP joint, or medial or lateral malalignment due to
Fig. 13b
Fig. 13c
Figures 13a and 13b – The tendon of flexor digitorum
longus is released through a distal puncture wound at
the level of the DIP joint and brought out through the
more proximal plantar incision. The tendon is split
longitudinally and a limb of the tendon is passed
through the tunnels on either side of the proximal
phalanx. Figure 13c – The limb may be tightened to
create more medial or lateral deviation depending upon
the alignment desired. The tendon limbs are then tensioned appropriately to control dorsiflexion/plantar flexion and rotation of the digit, and sutured to the extensor
tendon with the toe in proper alignment.
THE JOURNAL OF BONE AND JOINT SURGERY
COMMON CAUSES OF PAIN IN THE FOREFOOT IN ADULTS
787
Photographs showing a) mallet-toe and b) hammer-toe
deformities.
Fig. 14a
Fig. 14b
capsular rupture consistent with instability of the MTP
joint.
Treatment. Conservative treatment may be successful
when capsulitis or instability is diagnosed early. Before the
onset of deformity, the use of a metatarsal pad placed just
proximal to the involved metatarsal head helps to redistribute weight-bearing (Fig. 6a). Taping adjacent toes or
taping the toes using a sling technique to minimise dorsiflexion also helps (Fig. 11). The judicious use of an intraarticular injection of steroid has been shown to be effective
29
in decreasing synovitis and pain. With continued discomfort or progression of the deformity, surgical intervention may be necessary.
Operative correction of instability of the lesser MTP
joints is performed in a sequential fashion depending upon
the magnitude of the deformity. If hyperextension is present
a capsulotomy of the MTP joint, lengthening of the extensor tendon and fixation with a Kirschner wire may stabilise
and realign the involved toe. With medial deviation, lateral
26
deviation is uncommon, an additional reefing of the
ruptured or attenuated lateral capsuloligamentous complex
may be necessary to realign the MTP joint (Fig. 12). A
flexor tendon transfer is often added to give dorsoplantar
stability to the toe (Fig. 13). For severe subluxation and
dislocation of the MTP joint, a more extensive soft-tissue
release and reconstruction may be necessary. Bony decompression with a distal metatarsal osteotomy (Fig. 9) has
been used successfully in combination with soft-tissue
21
realignment in cases of more severe deformity. Reconstruction of the unstable deviated lesser MTP joint is a
technically demanding procedure which requires a meticulous surgical technique and careful postoperative followup. Decreased range of movement, recurrent deformity, and
transfer metatarsalgia are complications which may be
associated with attempts at surgical reconstruction.
30
Coughlin reported good or excellent long-term results
in 93% of cases in which the sequential technique described above had been used. In a later report on a younger
group of more athletic patients, 73% were noted to have
21
good or excellent results. Trnka et al described 15 lesser
toes treated by a capital oblique osteotomy for subluxation
VOL. 82-B, NO. 6, AUGUST 2000
of the lesser MTP joint and noted no symptomatic transfer
lesions. All subluxated or dislocated MTP joints were
successfully reduced.
Hammer toes, mallet toes, claw toes
IPKs may develop in association with contractures of the
lesser toes because of the buckling effect on the toe (Fig.
2). Realignment of the MTP and interphalangeal joints may
decrease plantar pressure and relieve symptomatic callosities. A mallet toe is characterised by a flexion contracture
of the DIP joint (Fig. 14a), a hammer toe by a flexion
contracture of the PIP joint (Fig. 14b) and a claw toe by
hyperextension of the MTP joint and flexion of the PIP
joint (Fig. 2). These deformities may be flexible and easily
correctable, but eventually a rigid contracture may develop.
The presence and location of callosities, the position of the
involved toe and the magnitude and rigidity of the deformity determine the method of treatment.
Treatment. The use of roomy shoes which avoid pressure
on the deformed toe will often relieve discomfort. Padding
of a toe (Fig. 11a), shaving of a prominent callus and the
use of a soft wool pad placed just proximal to the plantar
callosity (Fig. 6a) may reduce symptoms and allow
increased activity. When these measures do not alleviate
symptoms, surgery may be considered.
The distal condyles of the middle phalanx and the proximal articular surface of the distal phalanx are resected to
31,32
(Fig. 15).
correct a fixed mallet-toe deformity
With a fixed hammer toe, the condyles of the proximal
phalanx and the articular surface of the middle phalanx are
resected and a 0.05 Kirschner wire is used to stabilise the
33-35
repair (Fig. 16).
For correction of a flexible hammer toe or a claw toe
which is correctable passively, a flexor tendon transfer is
32,36,37
undertaken (Fig. 13).
This allows flexor digitorum
longus to assume the function of the intrinsic muscles,
namely plantar flexion of the MTP joint and extension of
the interphalangeal joint, while removing a deforming
32
force.
31
Coughlin described the results of mallet toes treated by
788
M. J. COUGHLIN
resection arthroplasty. Relief of pain was achieved in 97%
of patients and satisfactory results were noted in 86%.
35
Coughlin et al also reported the results of the treatment of
118 hammer toes by resection arthroplasty. Relief of pain
was noted in 92% and subjective patient satisfaction was
36
achieved in 84%. Barbari and Brevig noted a high level
of satisfaction in patients after flexor tendon transfer for a
8
flexible hammer-toe deformity, but Thompson and Deland
found that in only seven of 13 cases was complete correction of a subluxated MTP joint achieved.
Hard and soft corns
Fig. 15
Diagram showing correction of a mallet-toe deformity. The condyles of the middle phalanx are excised.
The articular surface of the distal phalanx is resected and a flexor tenotomy is performed in the depths
of the wound. The repair is stabilised with a 0.045
Kirschner wire.
Fig. 16a
Fig. 16b
Diagram of correction of a hammer-toe deformity
showing a) the proposed resection and b) after
repair with excisional arthroplasty and fixation with
a Kirschner wire (X, MTP release and extensor
tenotomy performed for fixed claw-toe deformity).
A hard corn is a hyperkeratotic lesion which develops on
the lateral border of the fifth toe usually because of extrinsic pressure from constricting shoe wear (Fig. 17). A
painful callus develops over a prominent lateral distal
condyle of the proximal phalanx. A soft corn is a hyperkeratotic lesion which occurs either in the webspace or
between two adjacent toes (Fig. 18). It is often exquisitely
painful and may be misdiagnosed as a mycotic infection
because of maceration of the skin. With radiological examination, a marker placed over the cutaneous lesion may help
to localise the underlying osseous exostosis.
Treatment. Treatment of a hard corn is directed at reducing
pressure over it by the wearing of roomy shoes or by
modifying existing footwear. Careful shaving of the callus,
dessication of any macerated areas and placement of a pad
between adjacent toes or over the border of the toe (Fig.
11a) often eliminates compression and relieves symptoms.
When these measures are unsuccessful, surgical resection
of the prominent exostosis may be indicated.
The preoperative planning of surgical repair of a soft
corn involves the decision as to whether to excise one or
both lesions. If there is a large callosity and a small
corresponding lesion, resection of the large exostosis will
usually suffice. With two relatively similar sized lesions, a
dual resection is recommended (Fig. 18c). For a hard corn,
a lateral condylectomy of the distal aspect of the proximal
phalanx is undertaken (Figs 17 and 17b).
No results have been reported on the value of lateral
exostectomy for the treatment of a hard corn. Zeringue and
38
Harkless evaluated 16 patients who had a PIP arthro-
Photographs showing a) a hard corn, b) a
longitudinal incision centred over the
distal condyle and the exostosis resected
with a rongeur, and c) repair of the
capsule to prevent subluxation.
Fig. 17a
Fig. 17b
Fig. 17c
THE JOURNAL OF BONE AND JOINT SURGERY
COMMON CAUSES OF PAIN IN THE FOREFOOT IN ADULTS
Fig. 18a
Fig. 18b
789
Fig. 18c
Photographs (a,b) of a hard corn and diagram (c) showing the resection area of a hard and soft corn.
plasty of the fifth toe and a lateral condylectomy of the
proximal phalanx of the fourth toe for a soft corn between
the fourth and fifth toes. No recurrence of the lesion was
noted at a mean follow-up of 33 months.
Proximal forefoot pain
Although most abnormalities of the lateral forefoot occur
either in the digits or at the level of the lesser MTP joints,
on occasion a patient will complain of pain in the midmetatarsal region. The onset may be variable, but when
pain is felt in the diaphysis of the metatarsal a stress
fracture should be considered. Pain on direct palpation and
moderate diffuse swelling localised to a specific metatarsal
are characteristic of this condition. Although routine radiography may not show the lesion, a positive bone scan may
be obtained. With pain in the proximal forefoot, consideration should also be given to entrapment neuropathy of the
39-41
which may be susdeeper superficial peroneal nerves
tained after injury to the dorsum of the foot or the anterior
aspect of the lower leg. A positive nerve-percussion test
and associated neuritic symptoms with decreased sensation
in the distribution of the involved nerve may give clues to
this diagnosis.
Conclusions
Pain in the forefoot or metatarsalgia is frustrating for the
patient and a challenging diagnostic problem. A meticulous
history will elicit information regarding exacerbation of
symptoms such as athletic activity and specific shoe wear.
Careful observation will delineate the presence or absence
of callosities and anatomical deformity, and palpation will
further define the exact location of pain. Radiological
examination, imaging studies and laboratory tests will
assist in further differentiating the vague symptoms of
metatarsalgia into a specific diagnosis for which appropriate treatment can be initiated.
No benefits in any form have been received or will be received from a
commercial party related dirctly or indirectly to the subject of this
article.
VOL. 82-B, NO. 6, AUGUST 2000
References
1. Coughlin MJ. Hallux valgus: an instructional course lecture. J Bone
Joint Surg [Am] 1996;78-A:932-66.
2. Shereff MJ, Baumhauer JF. Hallux rigidus and osteoarthritis of the
first metatarsophalangeal joint: an instructional course lecture. J Bone
Joint Surg [Am] 1998;80-A:898-908.
3. Coughlin MJ. Sesamoid pain: causes and treatment. AAOS Instructional Course Lectures 1990;39:23-35.
4. Friscia DA, Strom DE, Parr JW, Saltzman CL, Johnson KA.
Surgical treatment for primary interdigital neuroma. Orthopedics
1991;14:669-72.
5. Mann RA, Reynolds JC. Interdigital neuroma: a critical clinical
analysis. Foot Ankle 1983;3:238-43.
6. Thompson FM, Deland JT. Occurrence of two interdigital neuromas
in one foot. Foot Ankle 1993;14:15-7.
7. Mulder JD. The causative mechanism in Morton’s metatarsalgia. J
Bone Joint Surg [Br] 1951;33-B:94-5.
8. Thompson FM, Deland JT. Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot Ankle 1993;14:385-8.
9. Greenfield J, Rea J, Ilfeld FW. Morton’s interdigital neuroma:
indications for treatment by local injections versus surgery. Clin
Orthop 1984;185:142-4.
10. Rasmussen MR, Kitaoka HB, Patzer GL. Nonoperative treatment of
plantar interdigital neuroma with a single corticosteroid injection. Clin
Orthop 1996;326:188-93.
11. Bennett GL, Graham CE, Mauldin DM. Morton’s interdigital
neuroma: a comprehensive treatment protocol. Foot Ankle Int
1995;16:760-3.
12. Dereymaeker G, Schroven I, Steenwreckx A, Stuer P. Results of
excision of the interdigital nerve in the treatment of Morton’s metatarsalgia. Acta Orthop Belg 1996;62:22-5.
13. Coughlin MJ. Soft tissue afflictions of the foot. In: Chapman MW, ed.
Operative orthopaedics. 2nd edition. Vol. 3. Philadelphia: J. B. Lippincott, 1993:2287-98.
14. Amis JA, Siverhus SW, Liwnicz BH. An anatomic basis for recurrence after Morton’s neuroma excision. Foot Ankle 1992;13:153-6.
15. Mann RA, Coughlin MJ. Intractable plantar keratoses and bunionettes. In: Coughlin MJ and Mann RA, eds. Video textbook of foot &
ankle surgery. St Louis: Medical Video Productions, 1991:85-103.
16. Mann RA, DuVries HL. Intractable plantar keratosis. Orthop Clin
North Am 1973;4:67-73.
17. Helal B. Metatarsal osteotomy for metatarsalgia. J Bone Joint Surg
[Br] 1975;57-B:187-92.
18. Helal B, Greiss M. Telescoping osteotomy for pressure metatarsalgia.
J Bone Joint Surg [Br] 1984;66-B:213-7.
19. Pedowitz WJ. Distal oblique osteotomy for intractable plantar keratosis of the middle three metatarsals. Foot Ankle 1988;9:7-9.
20. Winson IG, Rawlinson J, Broughton NS. Treatment of metatarsalgia
by sliding distal metatarsal osteotomy. Foot Ankle 1988;9:2-6.
21. Trnka HJ, Muhlbauer
¨
M, Zettl R, Myerson MS, Ritschl P.
Comparison of the results of the Weil and Helal osteotomies for the
treatment of metatarsalgia secondary to dislocation of the lesser
metatarsophalangeal joints. Foot Ankle Int 1999;10:72-9.
790
M. J. COUGHLIN
22. Coughlin MJ. Treatment of bunionette deformity with longitudinal
diaphyseal osteotomy with distal soft tissue repair. Foot Ankle
1991;11:195-203.
23. Kitaoka HB, Holiday AD. Lateral condylar resection for bunionette.
Clin Orthop 1992;278:183-92.
24. Mann RA, Coughlin MJ. Keratotic disorders of the plantar skin. In:
Coughlin MJ and Mann RA, eds. Surgery of the foot & ankle. 7th
edition. St Louis: Mosby Yearbook, 1999:392-436.
25. Kitaoka HB, Holiday AD, Campbell DC. Distal chevron metatarsal
osteotomy for bunionette. Foot Ankle 1991;12:80-5.
26. Coughlin MJ. Subluxation and dislocation of the second metatarsophalangeal joint. Orthop Clin North Am 1989;20:535-51.
27. Coughlin MJ. Forefoot disorders. In: Baxter D, ed. The foot and ankle
in sport. St Louis: Mosby Yearbook, 1995:221-44.
28. Coughlin MJ. Second metatarsophalangeal joint instability in the
athlete. Foot Ankle 1993;14:309-19.
29. Mizel MS, Michelson JD. Nonsurgical treatment of monarticular
nontraumatic synovitis of the second metatarsophalangeal joint. Foot
Ankle Int 1997;18:424-6.
30. Coughlin MJ. Crossover second toe deformity. Foot Ankle 1987;
8:29-39.
31. Coughlin MJ. Operative repair of the mallet toe deformity. Foot Ankle
Int 1995;16:109-16.
32. Coughlin M, Mann R, Vol. 1. Lesser toe deformities. In: Coughlin
MJ and Mann RA, eds. Surgery of the foot & ankle. 7th edition, St
Louis: Mosby Yearbook, 1999:320-91.
33. Coughlin MJ. Lesser toe deformities. Orthopedics 1987;10:63-75.
34. Coughlin MJ. Mallet toes, hammer toes, claw toes and corns: causes
and treatment of lesser-toe deformities. Postgrad Med
1984;75:191-8.
35. Coughlin MJ, Dorris J, Polk E. Operative repair of the fixed
hammertoe deformity. Foot Ankle Int 2000;21:94-104.
36. Barbari SG, Brevig K. Correction of clawtoes by Girdlestone-Taylor
flexor-extensor transfer procedure. Foot Ankle 1984;5:67-73.
37. Coughlin MJ. Lesser toe abnormalities. In: Chapman M, ed. Operative orthopaedics. 2nd edition, Vol 3. Philadelphia: J. B. Lippincott,
1993:2213-24.
38. Zeringue GN, Harkless LB. Evaluation and management of the web
corn involving the fourth interdigital space. J Am Podiatr Med Assoc
1986;76:210-3.
39. Deese JM, Baxter DE. Compressive neuropathies of the lower
extremity. J Musculoskeletal Med 1988;5:68-91.
40. Gessini L, Jandolo B, Peitrangel A. The anterior tarsal tunnel
syndrome: report of four cases. J Bone Joint Surg [Am]
1984;66-A:786-7.
41. Kernohan J, Levack B, Wilson JN. Entrapment of the superficial
peroneal nerve: three case reports. J Bone Joint Surg [Br]
1985;67-B:60-1.
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