Case Presentation and Conclusion:
55 Year old female with left foot pain
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COURSE OF CARE
In this case the patient presented to the office with a chief complaint of sudden onset pain located to the second metatarso-phalangeal joint. This pain had been present for more than two years. Although there was no specific injury, she recalls the pain began one night after �line dancing�. The patient had been treated by another podiatrist and had received two injections with no relief.
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Figure 1: Pre-Operative X-ray
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The patient’s main complaint was pain directly over the second metatarsal head and a worsening deformity of the second toe. The pain was reported as “aching” and “deep” that was rated by her as “severe” and noted in my record as 8 out of 10. The radiographs demonstrated subluxation at the 2nd MPJ (Figure 1). Plantar flexion of the toe created a “snapping” sensation which was reported as “very painful”.
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Figure 2: Pre-Operative MRI
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MRI (Figure 2) confirms subluxation of the MPJ as well as a significant amount of joint fluid within the joint. A definite plantar plate tear was identified in the report. No other tendon tear was visualized. All of the various risks, benefits, and potential outcomes were discussed with the patient, and she did elect to undergo correction of this deformity at this time.
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Figure 3: Plantar Plate Tear
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A consent was obtained and the patient was brought to the operating room for exploration and repair of the plantar plate. General anesthesia and local anesthesia, in the form of an ankle block, were used. A 4 centimeter linear longitudinal incision was made plantarly just medial to the weight bearing surface of the 2nd MPJ. . Dissection was continued through soft tissue, which was normal in appearance, down to the level of the 2nd metatarsal head. Upon reflection of the plantar tendons, the plantar plate was identified with a large, longitudinal tear (Figure 3)
Utilizing 3-0 Monocryl suture, the plantar plate defect was repaired. Subcutaneous closure was approximated with 4-0 Monocryl and skin closure with multiple, simple, interrupted sutures of 4-0 Nylon. Dorsally, an arthrodesis of the 2nd toe was performed as well as a dorsal MPJ capsulotomy.
DISCUSSION
The above presentation represents an interesting case of a plantar plate tear without evidence of an acute injury. As one can easily see, pain in the area of the lesser metatarso-phalangeal joints can be caused by a variety of problems. Understanding the anatomy and pathophysiology of these joints, as well as the pathomechanics of gait usually will assist the examiner in arriving at an accurate diagnosis. In this case, where magnetic resonance imaging is helpful, there was no plantar plate tear identified, yet during surgery the tear was extensive and quite large.
REFERENCES
Mizel, M, et al., Disorders of the Lesser Metatarsophalangeal Joints, Journal of the American Academy of Orthopedic Surgeons, Vol. 3, No 3, May/June 1995
Sarrafin, SK, Anatomy of the Foot & Ankle: Descriptive, Topographic, Functional, 2nd Ed., Philadelphia, JB Lippincott, 1993, pp 222-226
Muscarrella, VJ, How to Treat lesser MPJ Disorders, Podiatry Today, Vol 18, June 2005 .
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