evaluation and management of metatarsal and forefoot injuries · 2017-06-01 · morton’s neuroma...
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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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