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Updated: Jul 7 2023

Synovitis of 2nd MTP

Images MTP dislocation - courtesy Richardson_moved.jpg plate.jpg plantar plate.jpg procedure - courtesy Richardson_moved.jpg
  • summary
    • Synovitis of 2nd MTP is the most frequent monoarticular synovitis of the MTP joint frequently associated with elongated 2nd metatarsal or a hallux valgus deformity.
    • Diagnosis is made clinically with tenderness plantarly over 2nd MTP plantar plate or over dorsal capsule. MRI can be helpful in cases of unclear diagnosis.
    • Treatment is a trial of conservative management with shoe modifications and NSAIDs. Surgical management is indicated for patients with progressive symptoms who fail nonoperative management. 
  • Epidemiology
    • Risk factors
      • elongated second metatarsal relative to the first metatarsal
        • Morton Foot
      • hallux valgus deformity
  • Etiology
    • Pathoanatomy
      • synovitis causes the capsuloligamentous apparatus of the MTP joint to become stretched
        • stretching leads to instability
          • instability leads to deformity
      • attenuation of plantar plate
        • extension of MTP joint
        • sagittal plane deformity
        • associated with cross-over toe deformity
      • MTP instability can lead to dorsal dislocation of MTP joint
        • predisposition to hammer toe deformity
  • Anatomy
    • Cadaveric cross section of plantar plate
    • MRI of plantar plate
  • Presentation
    • Symptoms
      • pain
      • warm joint
      • fullness of joint
    • Physical exam
      • pain and tenderness
        • may have pain in second web space
        • tenderness may be worse plantarly over plantar plate or over dorsal capsule
        • caused by inflammation or extrinsic pressure on interdigital nerve
        • pain with range of motion decreased with traction
      • global swelling of MTP
      • motion
        • decreased plantar flexion
      • deformity & motion
        • deformity is often passively correctable in the predislocation stages
        • instability, if present, can be demonstrated with the dorsal drawer test
        • if able to dorsally sublux then attenuation of plantar plate present
        • as deformity progresses second toe may cross over adjacent toe in a varus or valgus deformity
          • disruption of a collateral ligament and the plantar plate
          • "cross over toe deformity"
  • Imaging
    • Radiographs
      • recommended views
        • weight-bearing AP and lateral views of foot
      • findings
        • widening or medial-lateral joint space imbalance of second MTP joint
        • dorsal subluxation of MTP joint
          • may appear like joint space narrowing or overlapping of the proximal phalanx on distal metatarsal head
        • varus or valgus deformity of toe
    • MRI
      • indications
        • if diagnosis unclear
        • quantify the extent of plantar plate or ligamentous disruption
  • Differential
    • Morton's neuroma
      • may mimic Mortons neuroma
      • important to differentiate MTP synovitis from interdigital neuroma because a steroid injection into the interdigital space may weaken the capsuloligamentous structures at MTP joint leading to progressive deformity
  • Treatment
    • Nonoperative
      • activity/shoe wear modifications, NSAIDs, external support of MTP joint
        • indications
          • first line treatment
        • technique
          • external support with crossover taping or Budin-type toe splint
          • nonoperative treatment should last 10 to 12 weeks
          • subsequently avoid shoes that aggravate symptoms
    • Operative
      • synovectomy
        • indications
          • no deformity
          • failure of nonoperative treatment
      • distal oblique shortening MT osteotomy (Weil procedure)
        • indications
          • fixed deformity with long second metatarsal
        • technique
          • preserves joint
          • rebalances metatarsal cascade
          • relaxes plantar plate and rebalances alignment
      • FDL-to-EDL tendon transfer (Girdlestone-Taylor) or MTP capsular release with extensor tendon lengthening
        • indications
          • fixed deformity and NO long second metatarsal
          • sagittal deformity
  • Complications
    • Vascular compromise
      • if correcting a chronic dislocation the soft tissue, including vasculature, can contract
      • stretching of the vasculature can compromise flow
      • procedure may need to be reversed to save digit
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