This document provides information on metatarsalgia and related conditions. It discusses the classification of metatarsalgia as primary, secondary, or unrelated to weight distribution disorders. Primary metatarsalgia is caused by an imbalance in weight distribution between the toes and metatarsal heads and can be due to functional or structural factors. Secondary metatarsalgia has other underlying causes such as rheumatoid arthritis. The document also covers Freiberg's disease, Morton's neuroma, and their symptoms, causes, imaging, classifications, and treatment options including conservative and surgical management.

1. METATARSALGIA

2. CLASSIFICATION
• Primary
• Secondary
• Metatarsalgia unrelated to disorders
of weight distribution

3. PRIMARY METATARSALGIa
• Due to c/c imbalance in wt distribution b/w the toes
& the metatarsal heads
Causes
a) Static:
 Funtional: tight pointed shoes with a high heel, obesity
 Structural:
 Overload & insufficiency syndromes
 Long first metatarsal
 Short first metatarsal
 Metatarsus primus varus
 Synostosis b/w metatarsals
 Length discrepency b/w metatarsals
 Pes cavus
 Toe abnormalities

4. b) Hallux valgus
c) Hallux rigidus
d) Iatrogenic
e) Traumatic
f) Freiberg’s disease
g) Morton’s neuroma

5. Secondary metatarsalgia
1. Rhematoid disease
2. Sesamoiditis
3. Post traumatic
4. Neurogenic
5. Stress #
6. Gout
7. Short limb

6. Metatarsalgia unrelated to
disorders of weight distribution
• Neurological
 Spine
 Tarsal tunnel syndrome
 Anterior tarsal tunnel syndrome
• Vascular insufficiency
 Peripheral vascular disease
 Diabetes

7. FREIBERG’S DISEASE

8. INTRODUCTION
• In 1914, Alfred H. Freiberg first described the
painful collapse of the articular surface of the
second metatarsal head.
• Usually affects the second metatarsal
• MC recognized in the second decade of life
• More frequent in girls
• Can be b/l

9. ETIOLOGY & PATHOGENESIS
• Freiberg disease in adolescents is thought to belong to
a group of related diseases involving growth
disturbances of the epiphysis or apophysis, collectively
termed the osteochondroses.
• Of all the osteochondroses, Freiberg disease is reported
to be the fourth most common, exceeded by Köhler
disease of the tarsal navicular, Panner disease of the
capitullum, and Sever disease of the calcaneus.
• Radiographic changes among the osteochondroses are
similar, regardless of location; they show subchondral
collapse and fragmentation of the joint surface.
• It does not fully explain the adult onset form of the
disease, which may represent a different process
altogether

10. Vascular insult
• Radiographic changes that are consistent with
avascular necrosis have led some authors to suggest
that the inciting event is an injury to the blood supply
to the metatarsal head.
• vascular supply to the metatarsal heads can be quite
variable.
• the second and third metatarsals receive a less
consistent blood supply than do the other metatarsals.
• Iatrogenic avascular necrosis of the second and third
metatarsal heads following elective forefoot surgery as
indirect evidence that a disturbed blood supply may be
at least partially responsible for the development of
Freiberg disease.

11. Traumatic insult
• may be in the form of a single acute injury or
multiple repetitive microinjuries.
• Freiberg postulated that a long second metatarsal
in combination with altered first ray mechanics
eventually leads to overload of the second
metatarsophalangeal (MTP) joint.
• Of the metatarsals, the second and third are the
least mobile.
• the second and third metatarsals, because of their
relative inflexibility and increased load
transmission, are at increased risk of sustaining
repetitive microtrauma.

12. • Smillie considered Freiberg disease to be a
repetitive stress injury, analogous to a march or
stress fracture.
• He believed that concentration of stress in the
trabecular bone at the dorsal aspect of the
metatarsal head eventually leads to collapse.
• typical location of the lesions can be explained on
the basis of mechanical impingement between the
base of the proximal phalanx and the dorsum of
the metatarsal head in forced dorsiflexion.

13. • Trauma to the metatarsal heads as an indirect
result of a peripheral neuropathy could result in
the development of Freiberg disease.
• Intrinsic motor weakness, as is often seen with
peripheral neuropathy, can lead to extension of
the toes at the MTP joint, resulting in an increase
in weight bearing by the metatarsal heads,
repetitive injury, and subsequent collapse.

14. • In summary, the exact nature of the etiology of
Freiberg disease is unknown.
• It is most likely a multifactorial etiology that
includes vascular and traumatic insults.
• Certain patients may be anatomically predisposed
based on local mechanical, vascular, and
developmental factors.
• The relative infrequency of the disease, as well as
the variable presentation regarding age and injury,
makes the study of various etiologies challenging.

15. SYMPTOMS & SIGNS
• Pain about the involved MTP joint primarily on
weight bearing
• Local tenderness about the MTP joint
• Limitation of movements
• If synovitis +, swelling

16. Imaging studies

17. Smillie's classification
STAGE 1 Fissure fracture of the ischemic epiphysis
STAGE 2 Central depression of the head from bone resorption
STAGE 3 Further collapse of the head with residual projections of
the sides
STAGE 4 A portion of articular cartilage separates into a loose body
STAGE 5 Arthritis, deformity, and flattening of the metatarsal head

18. Early stage I
Stage II lesion with resorption of
subchondral cancellous bone

19. Smillie's classification
STAGE 1 Fissure fracture of the ischemic epiphysis
STAGE 2 Central depression of the head from bone resorption
STAGE 3 Further collapse of the head with residual projections of
the sides
STAGE 4 A portion of articular cartilage separates into a loose body
STAGE 5 Arthritis, deformity, and flattening of the metatarsal head

20. Stage III with collapse of the
head with residual projection
of the sides

21. Smillie's classification
STAGE 1 Fissure fracture of the ischemic epiphysis
STAGE 2 Central depression of the head from bone resorption
STAGE 3 Further collapse of the head with residual projections of
the sides
STAGE 4 A portion of articular cartilage separates into a loose body
STAGE 5 Arthritis, deformity, and flattening of the metatarsal head

22. Stage IV lesion with articular collapse and
loose body formation
Stage V lesion with advanced
degenerative changes involving the
metatarsal head and proximal
phalanx

23. TREATMENT
CONSERVATIVE MANAGEMENT
• Goal - to rest the joint to allow inflammation and
mechanical irritation to resolve.
• In patients presenting with severe pain of an acute
nature, a non – weight-bearing cast may provide
sufficient relief during the acute phase.
• a short leg walking cast may be more appropriate
• In patients with chronic complaints, less restrictive
options, such as shoe modifications in the form of
inserts with metatarsal bars or pads, rigid shanks,
or a rocker bottom, may be helpful.
• Activity modification during exacerbations may help
to prevent the aggravating symptoms of pain and
swelling.

25. Surgical treatment
While some stage I, stage II, and stage III
lesions may resolve spontaneously, patients who do
not respond to conservative measures and patients
with stage IV and stage V lesions may require
surgery.
SURGICAL OPTIONS
1. Resection of the metatarsal head
2. Elevation of the depressed fragments of the
metatarsal head & bone grafting of the defect
3. Resection of the base of the proximal phalanx with
syndactilization of the 2nd & 3rd toes
4. Dorsal closing wedge osteotomy of the
metatarsal head
5. Joint debridement & metatarsal head
remodelling
6. Total joint arthroplasty

26.  The patient must be informed before Sx
some permanent limitation of motion is usual.
Since motion in the affected joint is frequently
limited anyway, this is not a deterrent to Sx.
 Metatarsal bars or pads should be used for
3-6months after Sx.

27. JOINT DEBRIDEMENT & METATARSAL HEAD
REMODELLING
• Angled incision
• Expose the extensor hood
• Expose the entire extensor expansion over the
MTP joint
• Identify the EDB as it joins the EDL & section the
former at its juncture
• Incise the extensor hood just lateral to the EDL &
retract the tendon medially
• Through a longitudinal capsulotomy enter the
MTP joint & reflect the capsule medially &
laterally by sharp dissection
• Remove all the osteochondral fragments
• Distract the toe manually-expose the MT head

28. RELATION OF
EXTENSOR
TENDONS TO THE
MTP JOINT

29. • If the articular surface has remodelled, debride the
joint of all loose fragments, remove the synovium &
perform a Z-plasty lengthening of the EDL.
• If the MT head is pitted, contour it.
• The surface of the MT head usually is depressed
dorsally & centrally-round the remainder which
usually requires 3-4mm of bone removal
circumferentially.
• Irrigate the joint while flexing & extending it to
flush any remaining cartilage or bony fragments.
• Close the capsule with fine absorbable sutures &
apply a dressing that holds the joint reduced.

30. After Surgery
• Elevate the foot for 48hrs
• Followed by walking in a wooden-sole shoe
• At 2 weeks, SR
• The forefoot is redressed , holding the toe in
desired position
• At 4 weeks, toe-box shoe is allowed & gentle
active assisted ROM of the 2nd MTP joint is
encouraged

31. Dorsal Closing Wedge Osteotomy
• A gently curved dorsal incision over the head of
the metatarsal
• The joint is debrided, and any loose bodies or
hypertrophic synovium removed
• To avoid aseptic necrosis and nonunion
complications removal of soft tissue is avoided as
much as possible.

32. •A dorsal wedge is removed from the normal dorsal
metaphysis.
•Internal fixation is performed with a figure of (8)
stainless steel wire loop or
•stabilized with K-wire

33. AFTER SURGERY
• A walking cast with a toe platform is applied.
• Stitches were removed at 2 weeks
• The cast discarded at 4 weeks.
• The patients were instructed to use soft shoes
and avoid strenuous activities for another 4
weeks.

34. MORTON’S NEUROMA

35. • In 1876, Thomas.G.Morton described a condition
of pinching of the common digital branch of the
lateral plantar nerve in the 4th web space b/w the
mobile 4th to 5th MT heads of the foot.

37. Pathogenesis
1.Pinching of the common digital branch of the
lateral plantar nerve in the 4th web space b/w the
mobile 4th to 5th MT heads of the foot.
2.Laxity of transverse metatarsal ligament that
allows a break in the anterior arch with plantar
displacement of central MT heads & pressure on
adjacent digital nerve
3. Instability of the fourth MTP joint
4. Development of pressure neuralgia from
pressure on the nerve during weight bearing

38. 5.Flattening or falling of the transverse arch that
results in excessive pressure over the central
MT heads.
6.A tumor involving lateral most branch of medial
plantar nerve.
7. Lumen occlusion of the common digital artery
adjacent to the nerve.
8. The fourth digital branch of medial plantar
nerve which receives a communicating branch
from common digital branch of lateral plantar
nerve. Becoz of this additional branch, common
digital nerve to third web space is thicker &
more likely to be compressed against the
unyielding deep transverse intermetatarsal
ligament dorsal to it.
None if the theories has been universally accepted.

40. Pathology
• Neuroma is a misnomer
• Deposition of hyaline & collagenous material
Findings:
Perineural fibrosis
Increased no: of intrafascicular arterioles with thickened &
hyalinized walls caused by multiple layers of basement
membranes
Demyelination & degeneration of nerve fibres with a
decrease in the no: of axon cylinders
Endoneural oedema
Absence of inflammatory changes
Frequent presence of bursal tissue accompanying the
specimen
Obliterative changes in the contiguous artery of most
unusual type & debatable origin

41. CLINICAL FEATURES
• Females are MC affected
• Age :20-50yrs
• Unilateral
• Pain in the region of the MT heads, usually
the 3rd & 4th
• Burning, aching or cramping
• Aggravating & relieving factors
• The most frequent site of tenderness is in the
3rd web space just distal to the transverse
intermetatarsal ligament.

42. TESTS
MULDER’S CLICK
A palpable & audible click may be
appreciated when the patient lies prone & the
examiner places the thumb dorsally & the index
finger plantarward over the appropriate web
space & gently rocks the hand back & forth.
EXTENSION TEST
Passively extend the MTP joints.
This tightens the ligament & compresses the
nerve.

43. TREATMENT
NON OPERATIVE RX
metatarsal bars & pads, local inj. of a
steroid preparation into the web space, wide toe
box shoes
SURGICAL RX
Excision of the neuroma-dorsal or
plantar approach
Neurolysis

44. TECHNIQUE
• Calf tourniquet.
• Dorsal longitudinal incision 3cm proximal to the
web space & extend it distally, ending just
proximal to the web space.
• Fascia released over the intermetatarsal ligament
• Intermetatarsal ligament transected with a freer
elevator placed underneath the ligament to
protect the underyling structures
• Dorsally directed pressure under the area aids
exposure of the neuroma

45. • Fine right angle hemostat is utilized to free the
nerve and expose the bifucation.
• Gentle pressure is placed on the proper nerve
and the nerve is then transected proximally
• Specimen is sent for histologic examination.
• Area is copiously irrigated.
• Tourniquet released, hemostasis obtained
• Closure

46. DORSAL APPROACH
• The nerve is better exposed in its proximal
portion
• In recurrent interdigital neuroma, it is difficult to
find the stump of the nerve in the scar tissue
plantar approach
• Gives excellent exposure in recurrent IDN
• The nerve is transected as far as possible as the
incision allows.

47. After Sx
• For 48hrs, the patient rests with maximum
elevation of the extremity & bathroom privileges
only are encouraged.
• Walking is then allowed as tolerated.
• SR at 2-3 weeks & plastic strips are placed across
the wound for another week.
• A post op wooden-soled shoe is usually needed
for 2-3weeks followed by a wide toe-box shoe for
an additional 3-4 weeks.