MTP joint dislocation is when one (typically the 2nd) or more lesser toes dislocate at the metatarsophalangeal joint. It is often associated with a crossover deformity of the toe and a bunion deformity of the big toe.

Clinical picture of a foot with dislocated 2nd MTP joint dislocation and crossver toe deformity – note this patient also has a bunion deformity

Lateral foot and ankle x-ray demonstrating 2nd toe dislocation at the MTP joint

X-ray of the foot demonstrating dislocation of the 2nd MTP joint

Before describing the condition, you may wish to read about the normal anatomy of the lesser toes and in particular the plantar plate here.

The plantar plate is a thick ligament that attaches the ball of the metatarsal to the base of the toe. It provides stability and support to the MTP joint and prevents dislocation of the toe.

For the dislocation to occur the plantar plate needs to be either torn or attenuated.

A number of conditions are closely associated with or promote the development of MTP joint dislocation. These include:

• 2nd MTP joint instability
• Crossover toe
• Plantar plate injury
• Big toe (1st MTP) joint arthritis
• Bunion (hallux valgus) deformity
• A short first metatarsal (may be as a result of previous bunion surgery)
• A long second metatarsal
• Biomechanical abnormalities and imbalances in the foot causing overload of one of the metatarsals
• Steroid injection into the area
• Rarely acute trauma
• MTP joint Synovitis (inflammation of the joint lining)
• Rheumatoid arthritis
• Freiberg’s disease
• Idiopathic (unknown cause)

X-ray of the foot in a patient with a severe bunion deformity complicated by 2nd MTP joint dislocation and resulting crossover toe deformity

Pain is by far the commonest symptom. Pain may be felt in the “ball” of the toe joint, on the plantar (sole) aspect of the foot. Patients often describe it as walking on a marble. Pain may also be felt across the dorsum (top) of the foot at the MTP joint. It is also often felt where the toe rubs against the roof of the toe box in footwear.

Swelling may be present particularly as the condition progresses, and there may be increased warmth in the joint.

Deformity occurs later as the disease progresses. Typically the 2nd teo is affected. The 2nd toe elevates initially, a hammer toe deformity (flexion at the PIP joint and extension at the MTP joint) frequently occurs and finally the toe crosses over. The toe can also deviate either towards or away form the big toe.

The right 2nd toe is elevated, while the left foot demonstrates failure of taping

Callosity can form under the MTP joint. This is normal thickening of the skin in response to abnormal load and pressure. These can become painful.

Focal painful callosity under the 2nd MTP joint

Ulceration can occur either on the dorsum of the toe at the level of the PIP joint where it rubs against footwear. An ulcer can also form on the sole of the foot (plantar aspect of MTP joint). These can become infected and cause deep infection, sometimes even of the bone.

Often a patients main complaint is difficulty finding footwear that fits and in this clincal picture the patient has pain where the 2nd toe rubs against shoes

Examination initially may reveal nothing but tenderness across the MTP joint. As the condition progresses swelling can occur, and the often the 2nd toe starts to drift (medially) towards the big toe.

Thickening of the skin (callosity) under the MTP joint is typically a manifestation of increased load and forces going through the joint. The callosity may be painful and attempts to remove it will be temporary as the skin will thicken again in response to the abnormal load.

Your surgeon Mr Malik will look for the following on clinical examination:

• Tenderness at the metatarsal head
• Instability of the toe (positive drawer test)
• Pain and abnormality at the big toe (1st MTP) joint
• Other lesser toe deformities
• Presence of Hammer toe
• Presence of Crossover toe
• Other areas of tenderness and pain
• Signs and symptoms of a Morton’s neuroma
• Evidence of calf tightness and forefoot overload
• Presence of callosities

Radiographs will be arranged at your initial clinic consultation. These will help confirm the diagnosis, the severity of the deformity and aid in pre operative planning.

Radiographs

Radiographs (x-rays) are a useful first line investigation to rule out any other problems in the forefoot and to confirm the diagnosis.

X-ray of the foot demonstrating 3rd MTP joint dislocation

MRI

MRI is useful especially in the early stages of the condition when x-rays may appear normal. It provides excellent high definition static images.

MRI is particularly useful in assessing:

• Cartilage damage
• Reactive bone changes (stress response)
• Synovitis (inflammation and fluid in the joint)
• Damage to the plantar plate
• Other pathology

An MRI of the foot demonstrating inflammation (synovitis) in the 2nd MTP joint

An MRI in combination with a small injection can help confirm any injury to the plantar plate (if there is a tear, fluid leaks out of the 2nd MTP joint, see image below), it can also confirm any stress lesions in the bone itself. If the underlying diagnosis is not clear an MRI can be a useful investigation.

MRI of the foot demonstrating leaking out of dye injected into the 2nd MTP joint indicating that there is a likely tear in the plantar plate and capsule

MRI is also performed sometimes in the presence of an ulcer to rule out deep soft tissue infection or bone infection (osteomyletis).

MTP joint dislocation is a condition that can get worse over time.

With increasing deformity there will be increasing synovitis (inflammation in the joint) and therefore increasing pain.

The joint can become arthritic (the cartilage lining the joint is damaged and erodes away leaving bone on bone changes). These changes are irreversible and even if the toe is reduced back to its normal position a painful arthritic joint will remain.

Complications also include painful callosities and ulcers (a break in the skin) which can become infected. Callosities are often found on the undersurface (plantar) aspect of the foot while ulcers can also develop there or across the top (dorsum) of the toe where it rubs against the roof of a shoe.

In summary the problems are:

• Increasing pain
• Irreverisble damage to the MTP joint
• Deformity
• Ulcer
• Callosity

Non operative management aims at relieving pain, it will not reverse disease progression.

Options include:

Toe sleeves 

Made of silicon can be worn over the toe to protect from direct pressure and rubbing against footwear.

Taping/strapping

Position the toe in neutral alignment using cross over taping or toe straps. Provide stability to the joint and alleviate symptoms. If deformity is present, then prolonged taping will not correct this.

Insoles & orthotics

An insole with a metatarsal dome pad just proximal to the MTP joint can take some off the pressure of the joint and alleviate the pain. Stiffening the area under the metatarsal head with an orthoses can reduce the forces across the MTP joint. A rocker bottom sole may also help relieve dorsiflexion of the toe, which again would reduce the forces across the MTP joint. An insole that has a recess for a callosity may also reduce pain.

Footwear

The use of stiff soled shoes that do not bend and therefore protect the MTP joint. Footwear that has a wide and deep toe box to accommodate the deformity. Rocker bottom soled shoes may also be helpful, see above.

Non steroidal anti-inflammatories

The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort from an inflamed synovitic MTP joint.

Surgical management is reserved for patients who have failed to respond to non operative treatment.

Patients should understand that the decision to undergo surgery should not be taken lightly.

Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.

A variety of surgical options exist which need to be tailored to the individual and the stage of the disease. In general, mild deformities can be treated by soft tissue procedures; severe deformities may require the addition of a bony corrective surgery (resetting the bone).

One or more of the following may be required to correct a deformity.

Soft tissue procedures

• Dorsal and Medial 2nd MTP joint capsular release – Over time the joint capsule tightens up, releasing this allows the toe to return to a more normal position
• Extensor tendon lengthening – Releasing these tight tendons allows the toe to return to a more normal position
• Flexor to extensor tendon transfer (Girdlestone-Taylor procedure) – This procedure involves releasing one of the tendons that pulls the toe downwards (FDL) at the end of the toe. the tendon is then transferred to the top of the toe (dorsal aspect of the proximal phalanx and extensor hood). This procedure aims to convert one of the primary deforming forces that results in clawing of the toes into a corrective force. It is a technically more demanding operation and recovery is slightly longer as a result

Bone procedures

• Shortening osteotomy of the 2nd metatarsal (Weil’s osteotomy) – By shortening the metatarsal bone the aim is to correct the imbalance in the soft tissues indirectly
• PIP joint fusion/arthroplasty – Bringing the toe down is not enough in a fixed deformity, the fixed bend at the PIP joint has to be corrected and this is done by removing some of the joint and fusing the toe in a corrected straightened position. It is not unusual for this joint not to fully heal with bone, but even a fibrous union (scar tissue) in a straight position will be effective in the majority of patients. The bones are held in place by a temporary metal wire (K-wire) which is removed at roughly 4-6 weeks.

Combined soft tissue and bone procedure

• Minimally invasive technique
  • Soft tissue releases percutaneously (2nd MTP joint capsule, EDL and PIP plantar plate)
  • Basal plantar closing wedge osteotomy to proximal phalanx
• Plantar plate repair (Plantar Plate Repair Information Leaflet)

Chronic Dislocation

• May require transfixing the toe to the metatarsal with a K wire (temporary metal wire), the wire remains in place for 4-6 weeks
• In the presence of severe infection or uncorrectable deformity resulting in significant symptoms, rarely an amputation may be considered

MTP joint arthritis

A number of surgical options are availble:

• Weils shortening osteotomy – by shortening the metatrasal pressure is taken off the arthrtitic joint
• Excision of the metatarsal head – will leave a floppy toe
• Excision of the base of the toe – will leave a floppy toe

It should be borne in mind that complications can result from a condition with or without surgery.

Potential complications of non-operative treatment include:

• Worsening pain
• Increasing deformity
• Dislocation of toe
• Formation of ulcers on the sole of the foot (plantar aspect of MTP joint)
• Formation of ulcers across the top (dorsum) of the second toe as it rubs against the shoe
• Infection of ulcers

This patient had an ulcer form at the site of their callosity which subsequently became infected

Failure of taping to correct the deformity

Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.

Potential complications of operative treatment include:

• Risks and complications of anaesthesia
• Bleeding
• Infection (superficial and deep)
• Blood clots
• In the case of an MIS procedure it may be necessary to proceed to open surgery if during the operation it is felt that a better outcome will be achieved using an open technique
• Failure to fully correct deformity (particularly if longstanding deformity)
• Floating toe
• Recurrence of the deformity
• Stiffness of the MTP joint
• Wound healing problems (particularly when correcting a chronic dislocation the soft tissue can become contracted)
• Compromise to the blood supply (particularly when correcting a chronic dislocation the blood vessels can become contracted)
• Need for further surgery
• Complex regional pain syndrome

Note – these complications are not exhaustive and are meant as a guide

Please read the information regarding what to expect post surgery on this website.

Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.

Immediate post operative period

Almost all surgical procedures for crossover toe will be undertaken as a day case.

You will have a bandage applied similar to this during the operation.

Post operative bandage of the foot

Please do not remove your bandages until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment. You will also be provided with a stiff soled black post operative shoe. Please ensure you wear this whenever you are weight bearing.

Post operative stiff soled shoe

For the first 48 hours you will be allowed to touch weight bear using two crutches. After 48hrs you can weight bear as tolerate. The physiotherapist will guide you after your operation and before your discharge from hospital with the use of crutches and mobilising.

For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is recommended you stay at home during this period.

An example of high elevation of the foot and ankle

Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.

To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.

To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.

Two weeks post operatively

You will be reviewed at the clinic and your dressings removed. Your wound will be checked and your toe taped or strapped.

At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position (50-75% of the time). You will require to wear the special post operative shoe for another 4 weeks. Short trips can be made outside, within limits of pain and swelling.

Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 6 weeks before any driving is advisable.

Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area.

Commence exercises of the lesser toes 3 weeks after surgery and continue for 3 months. These exercises included active resistive and passive toe flexion and extension. They also include intrinsic foot muscle strengthening exercises.

Six weeks post operatively

You will have radiographs taken just before you are seen in clinic. You will go over these with Mr Malik and compare the before and after images. If you have had a bony procedure, it will take a minimum of 6 weeks to heal.

At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.

You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. Continue to do the lesser toe exercises for another 6 weeks.

Three months post operatively

Final clinical examination. Discharge if satisfactory.

When can I wear normal shoes?

This depends on your rate of healing and how much pain and swelling you have. For the first 6 weeks we advise you to use the stiff post operative shoe. After 6 weeks it is advised that you wear a stiff soled shoe with a wide toe box while your foot continues to heal.

When can I drive?

Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.

When can I return to work?

This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.

What should the final outcome be?

Excellent pain relief and deformity correction. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.