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It is a common cause of pain at the base of the 2nd toe at the level of the 2nd metatarsophalangeal (MTP) joint.
Before describing the condition, you may wish to read about the normal anatomy of the lesser toes here.
2nd MTP joint instability is associated with inflammation and injury to the joint capsule, ligaments and in particular a structure known as the plantar plate.
MRI of the Plantar Plate (arrow), contrast has been injected into the MTP joint which has leaked outside of the joint indicating a tear in the plantar plate
The plantar plate is a thick ligament that attaches the ball of the 2nd metatarsal to the base of the 2nd toe. It provides stability and support to the 2nd MTP joint and prevents dislocation of the toe.
As the condition progresses the 2nd MTP joint becomes increasingly unstable. Eventually the toe starts to deviate and eventually can cross over or under the big toe.
The final stage of 2nd MTP joint instability is crossover deformity of the 2nd toe on to the big toe and dislocation at the 2nd MTP joint as shown in this clinical picture
No one knows the exact cause for 2nd MTP joint instability. We do know that multiple factors are involved.
Some patients develop 2nd MTP joint instability due to isolated inflammation (synovitis) of the 2nd MTP joint. This maybe due to arthritis, trauma or overload of the 2nd MTP joint. Some studies also suggest a relationship with a long 2nd toe (metatarsal). The most common cause is idiopathic, which means “arises spontaneously and of unknown cause”.
Problems with the big toe such as a bunion (Hallux Valgus) or 1st MTP joint arthritis (Hallux Rigidus) are also associated with 2nd MTP joint instability. This occurs in the latter two because the big toe joint (1st MTP) does not work properly. In a normal foot the 1st MTP joint takes roughly 40-50% of the load as you walk. This load is transferred to the 2nd and to varying degrees the other lesser toes. As the 2nd toe joint is not designed to take this load, damage can occur at the 2nd MTP joint.
Tight calf muscles (gastrocnemius) are not known to cause 2nd MTP joint instability, however we mention it as it can exacerbate the problem. Tight calf muscles result in increase load across the front of the foot, this puts more strain on already damaged structures such as the plantar plate ligament. Addressing calf tightness is important in the treatment of 2nd MTP joint instability.
In summary the following are associated with 2nd MTP joint instability:
Pain is by far the commonest symptom. Pain may be felt in the “ball” of the 2nd 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 2nd MTP joint. It is also often felt where the 2nd 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. 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 right 2nd toe is elevated, while the left foot demonstrates failure of taping
Callosity can form under the 2nd 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 2nd 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 2nd 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 pain where the 2nd toe rubs against shoes
Examination initially may reveal nothing but tenderness across the 2nd MTP joint. As the condition progresses swelling can occur, and the 2nd toe starts to drift (medially) towards the big toe. Later the 2nd toe crosses over or under the big toe. Thickening of the skin (callosity) under the 2nd 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.
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 (x-rays) are a useful first line investigation to rule out any other problems in the forefoot. They may be normal in the early stages of the condition. The 2nd MTP joint may appear distended. In later stages of the condition there is dorsal and medial subluxation of the toe.
Radiograph of left foot demonstrating 2nd MTP joint instability
Ultrasound is used to confirm swelling (synovitis) in the 2nd MTP joint, and to see if there is anything else that may be causing the symptoms for example, Morton’s neuroma or intermetatarsal bursitis.
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:
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
2nd MTP joint instability is a condition that can get worse over time.
The following is a classification used for this condition:
As the disease progresses so does the deformity. Most patient with stage 3 & 4, 2nd MTP joint instability develop a hammer toe deformity as well.
The following are radiographs taken over 3 years with a patient with 2nd MTP joint instability:
A radiographic showing pain in the 2nd MTP joint
Mild medial deviation of the 2nd toe
Subluxation at the 2nd MTP joint
MRI showing dislocation at the 2nd MTP joint with attenuation of the plantar plate
The patient eventually underwent surgical correction with a plantar plate repair and had a good result in terms of deformity correction, restoration of normal anatomy and pain relief
Non-operative management aims at relieving pain and possibly preventing disease progression. It is likely to be most effective in Stage 1 of the disease process.
It should always be the first line of treatment. Options include:
A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities and sports that involve lots of turning, twisting and bending of the toes such as running, dancing, basket ball etc.
Made of silicon can be worn over the toe to protect from direct pressure and rubbing against footwear.
Position the toe in neutral alignment using cross over taping or toe straps. Provide stability to the joint and alleviate symptoms. If there is no deformity then taping may allow healing to occur. If deformity is present, then prolonged taping will not correct this.
An example of taping which has failed to correct 2nd MTP Joint deformity
An insole with a metatarsal dome pad just proximal to the 2nd MTP joint can take some of the pressure off the joint and alleviate the pain. Stiffening the area under the 2nd metatarsal head with an orthoses can reduce the forces across the 2nd MTP joint. A rocker bottom sole may also help relieve dorsiflexion of the toe, which again would reduce the forces across the 2nd MTP joint. An insole that has a recess for a callosity may also reduce pain.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort from an inflamed synovitic 2nd MTP joint.
The use of stiff soled shoes that do not bend and therefore protect the 2nd MTP joint.
Stretching tight calf muscles will help reduce the forces going across the forefoot. This will help reduce pain in the 2nd 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.
In summary the aim of surgery is to correct the deformity, alleviate pain and return a patient to full function.
Before and after radiographs of a patient who had a plantar plate repair
It should be borne in mind that complications can result from a condition with or without surgery.
A – Clinical picture of crossover toe with corresponding B – x-ray of the foot, note severe hallux valgus deformity and dislocation at the 2nd MTP joint instability
This patient had an ulcer form at the site of their callosity which subsequently became infected
Complications can occur as with any type of surgery. Please see foot and ankle complications for more detailed explanation of post surgical complications.
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.
Almost all surgical procedures for 2nd metatarsal instability will be undertaken as a day case.
You will have a bandage applied similar to this during the operation.
Post operative foot bandage
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.
High elevation of the foot and ankle following a surgical procedure
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.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked and your toe taped or strapped in a toe splint.
An example of taping around the foot to help maintain surgical correction and allow the foot structures to heal in the correct position
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 8 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.
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.
Final clinical examination. Discharge if satisfactory.
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.
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.
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.
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.
Jones fracture is a type of fracture involving the base of the 5th metatarsal.
A “Fracture”, “break”, and “crack” are often used to describe an injury to a bone. Contrary to what most people think, they all mean the same thing. A fracture is a complete or incomplete break in a bone resulting from the application of excessive force.
It occurs at the junction of the metaphysis and diaphysis of the metatarsal bone (where the widened part of the bone at its end begins to thin out as it becomes the shaft of the bone).
X-ray of the foot demonstrating a Jones fracture
This is typically an acute injury. The mechanism of injury is similar to an avulsion injury. Inverting (turning) in at the foot and ankle.
The fracture occurs at the junction of the metaphysis and diaphysis of the metatarsal bone (where the widened part of the bone at its end begins to thin out as it becomes the shaft of the bone).
This injury is associated with sports such as football and rugby.
X-ray of the foot demonstrating the zones of injury in base of 5th metatarsal fractures
The symptoms of a Jones fracture are:
Radiographs (x-rays) of the foot help identify the fracture and importantly the zone of injury. Radiographs also provide information regarding the fracture:
CT and MRI are not usually required to make the diagnosis in acute setting. They may be considered in the setting of delayed healing or non-union.
CT scan of the 5th metatarsal showing partial union (healing) of the 5th metatarsal bone (white circle)
As with most fractures a Jones fracture will usually heal if the foot it protected from weight bearing for a long enough period of time. Approximately 66-75% of these fractures will heal with conservative management.
However, as discussed earlier the area of the bone that is fractured has a relatively poor blood supply. This means that it may take longer for the bone to heal (delayed union), or that the bone may not heal at all (non union). Due to the high risk of non union many patients decide to have surgical fixation.
General risk factors for delayed healing, or non union of fractures include:
CT of the foot demonstrating non union of a 5th metatarsal fracture
Surgical management is reserved for patients who have failed to respond to non operative treatment or when a decision has been made to pursue surgery due to the high complication rate associated with non operative management, for example non union.
Undisplaced and simple 2 part fractures, that are acute, can be treated using an intramedullary screw. This is often performed using an MIS technique.
An illustration of a 5th metatarsal solid screw
For patients with a comminuted (multi fragmentary), delayed presentation, established non union or displacement of the fracture, a mini open technique will be employed. This is to allow freshening up of the fracture site, insertion of bone graft (often obtained from the calcaneum), and anatomical fixation. A small anatomical plate is often used in such cases. This allows for rigid fixation and early mobilisation.
An illustration of a 5th metatarsal anatomical plate
Plate fixation of a 5th metatarsal fracture
The aim of surgery is to alleviate pain and return a patient to full function.
Potential complications of non operative treatment applicable include:
These non operative complications apply to all three types of fracture, Avulsion 5th metatarsal base fracture, Acute and Chronic Jones fracture.
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 to all three types of base of 5th metatarsal fractures include:
Please do not remove your bandages until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment.
For 6 to 8 weeks you will non weight bearing using two crutches. The physiotherapist will guide you with this after your operation and before your discharge from hospital.
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 advisable during this period to remain at home.
An example of high elevation of the foot
You will be reviewed at the clinic and your dressings removed. Your wound will be checked.
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. Although this does not mean you can walk on the operated foot. The shoe is only there to protect your foot incase you stumble. 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 8 to 10 weeks before any driving is advisable.
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 to 8 weeks to heal.
If there are signs of radiological healing at this appointment, you will be able to start weight bearing gradually in a special walker boot as comfort allows. During the 6 to 8 weeks of immobilisation your foot & ankle will get stiff and your calf and thigh muscles will waste. Hydrotherapy (exercises in the swimming pool) will help to restore ankle range of motion and general fitness. Pool running using a bouyancy belt is an excellent non impact form of exercise and will help regain muscle and bone strength.
Once you have been given permission to put partial weight through the injured foot then an exercise bike can also be used for fitness work. At this stage a referral to a physiotherapist will be made who will guide you through your rehabilitation.
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 12 weeks at the earliest. 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.
This really depends on how long it takes the fracture to heal. It will then be important to exercise and regain your fitness. Returning to activity too early, before the bone has fully healed runs the risk of re-injury or development of a new injury.
Excellent pain relief and return to full function. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.
Know More
Tarsal coalition is an abnormal connection between 2 or more bones in the foot.
The connecting tissue can be either fibrous tissue, cartilage or bone and is commonly found in the hindfoot or midfoot.
The most commonest coalitions are:
It is thought that 1% of the population may have a tarsal coalition and most of these are asymptomatic.
Please read about foot and ankle anatomy here, particularly the triple joint and subtalar joint.
A genetic mutation resulting in abnormal development of the bones prior to birth is now recognised to be the underlying cause of tarsal coalitions.
During normal development, the bones in the foetus separate to form the numerous bones (over 30) that one finds in the adult foot and ankle. See foot and ankle anatomy here for more detail regarding normal anatomy.
In tarsal coalition, the natural separation does not occur and an abnormal bridge of tissue exists between the bones.
The majority of people with tarsal coalitions have no or little symptoms.
Despite tarsal coalitions being present since birth in affected individuals, it is usually not until late childhood or adolescence that symptoms first begin to appear. The reason for this is that young children have very soft and flexible bones (cartilagenous). As children grow, the bones begin to ossify (calcify) which in turn stiffens the foot. At this point a fibro-cartilagenous coalition may also start to ossify turning into a stiff and solid bridge of bone between the two bones.
Ossification occurs between 8 – 12 years for calcaneonavicular and between 12 – 15 years for talocalcaneal coalitions. This is typically when symptoms first become apparent. As the affected joint stiffens, the surrounding joints have to compensate.
The subtalar joint is unique in its joint axis and motion. A tarsal coalition will stiffen the subtalar joint which will result in flattening of the foot, adpative shortening of the peroneal tendons (which can go into painful spasm) and excessive forces across the ligaments of the midfoot.
The commonest symptom patients with a tarsal coalition present with is pain, which may be due to:
Patients may also present with:
Patients presenting with late pain, for example in adulthood, have to be investigated for signs of arthritis.
Investigations help confirm the diagnosis, describe the tarsal coalition (fibrous, cartilagenous or bony) and where applicable, aid in pre operative planning.
Weight bearing lateral and oblique plain radiographs are a quick and effective way of confirming the presence of tarsal coalition. However radiographs are not completely reliable and for a definitive diagnosis a CT or MRI scan is usually obtained in addition.
On the lateral foot and ankle x-ray, your foot and ankle surgeon will be looking for evidence of the C sign and talar beaking. Patients with arthritis may have evidence of reduced joint space particularly at the posterior aspect of the subtalar joint.
Lateral radiograph of the foot and ankle demonstrating the C sign
Lateral radiograph of the foot and ankle demonstrating talar beaking in a patient with subtalar coalition
The Harris view is also sometimes used to assess the presence of a talocalcaneal coalition.
Harris radiographic view of the foot in a patient with partial talocalcaneal coalition
Harris radiographic view of the foot in a patient with complete talocalcaneal coalition
An oblique foot and ankle x-ray will detect approximately 90% of calcaneonavicular coalitions.
Oblique radiographic view of the foot demonstrating calcaneonavicular coalition
MRI provides excellent high definition static images. It is useful in pre operative planning and to exclude any other pathology in the hindfoot. MRI is particularly useful when assessing the degree of fibrous and cartilage coalition as opposed to bony coalition which is best seen on CT.
MRI of the hindfoot revealing talar beaking
CT images give excellent information on bone structure and is superior to plain radiography in that respect. CT is generally accepted as the best imaging modality for tarsal coalition.
CT is particularly useful in the following cases:
CT coronal view of both feet revealing fibrous talocalcaneal coalitions
CT coronal view of the hindfoot demonstrating complete bony talocalcaneal coalition
Bone scan is a non specific test but is sensitive to pathology. It utilises a radioactive dye, absorbed by the body and taken up by areas of high metabolic activity such as inflammation and infection. It will not tell you what the diagnosis is, but will usually tell you if an abnormality is present.
With the easy access to CT and MRI, bone scans are rarely used. In patients who have had previous surgery and have persistent pain a bone scan may be requested.
This test is done in special circumstances.
Picture of a bone scan showing increased uptake in the foot
Problems can arise in two groups of patients. The young adolescent patient and the older adult population.
In the younger patient group, symptoms can limit exercise and sports and can result in deformity (flat foot). If a trial of conservative management fails then surgery may be considered.
In the older patient group, symptoms may arise form degenerative changes across the joints or as a result of an injury resulting in damage to the coalition. There is little research and literature about the outcome of tarsal coalition treatment in the adult population. As the patient has been symptomatic for many years, it is important to understand what has changed in the foot. A trial of non operative management would be recommended and surgery rarely indicated unless there is an obvious area of damage that can be treated.
Potential problems are the development of:
In summary most patients with a tarsal coalition are asymptomatic. Some patients describe stiff joints with mild ache and are able to manage their symptoms with activity modification and other non operative treatments. However some patients describe significant pain and functional limitation.
You should see an Orthopaedic Foot & Ankle Surgeon if one or more of the following applies to you:
Non operative management for tarsal coalition aims at relieving pain and return to full activity including sports whenever possible. Non operative management is more likely to be successful in patients with a talocalcaneal coalition than a calcaneonavicular coalition.
A period of rest (4 to 6 weeks) from sports and exercise that bring on symptoms. Avoiding high impact activities with lots of turning and twisting.
Repetitive stress can inflame the joints and stress the bones. A period of rest can settle symptoms in the majority of cases.
Wearing comfortable shoes that will help dissipate forces going through the foot. Footwear that limits hindfoot motion, will reduce the forces going through the hindfoot joint that has the coalition (and the adjacent joints) and as a result decrease symptoms.
Shoes that have a rocker bottom sole and stiff sole will also help.
Ankle braces give more support and stability to the ankle and subtalar joint and could ease pain particularly when doing sports and exercise.
Custom orthotics, medial arch supports, inserts like heel cups help to stabilise the foot, reduce excessive movement and forces across the joints.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with with inflamed joints and tendons.
The use of paracetamol and other painkillers to help reduce pain levels.
Physiotherapy works by strengthening muscles around not only the joint but the whole kinetic chain. Patients with tight painful peroneal muscles will benefit form stretching exercises.
A short period (4 weeks) of immobilisation can reduce stresses across the joints and bones.
This injection serves as both a therapeutic and diagnostic intervention. Steroids reduce inflammation and can ease painful symptoms. The local anaesthetic numbs an area of the body for roughly 12 to 48 hours.
The steroid is unpredictable in its success at easing painful symptoms but has very low risk of complications and therefore is an attractive therapeutic option prior to further more invasive surgical intervention. The local anaesthetic on the other hand is very predictable in its action. If there is an area of damage it will definitely ease symptoms for 12 to 48 hours. If symptoms do not ease during this period, one has to question whether the diagnosis is correct.
We carry out almost all injections under a short general anaesthetic (1 minute) as injecting into a painful joint or coalition can be quite sore. While you are asleep and lying still a small needle is inserted into the joint and the position is confirmed using an x-ray in theatre. A small amount of dye is injected first to make sure the needle is in the correct spot and then a mixture of Depomedrone (steroid) and Bupivacaine (long lasting local anaesthetic) is injected. Undertaking the injection in this manner ensures a pain free experience for the patient and the best outcome clinically as there is no doubt about the placement of the injection.
The local anaesthetic will cause numbness in the area injected for approximately 12 to 48 hours. This action is predictable. What is not predictable is the duration of action of the steroid. It may work for one month, several months or even more than a year.
Injections are not repeated less than 6 monthly intervals.
Please read here for more information regarding injections and possible complications.
Intraoperative x-ray showing correct placement of needle in the subtalar joint (confirmed with radiopaque dye)
Surgical management for tarsal coalition is reserved for patients who have failed to respond to non operative treatment.
Options are to either resect the coalition or fuse the joint(s).
This operation involves removing the abnormal connection between the bones. It is preferable because it allows normal joint movement and often alleviates symptoms in the majority of patients. Results are better in patients who are younger and have a small coalition.
For talocalcaneal coalitions this operation is usually carried out through a small incision on the inside of the ankle. The procedure can be done as a day case procedure. Resection is recommended in patients who have a coalition less than 50% of the surface area of the joint.
For calcanealnavicular coalitions this operation is usually carried out through a small incision on the outer aspect of the foot. The procedure can be done as a day case procedure. Fat, muscle or bone wax is used to prevent bone regrowing and forming a coalition again.
A – Pre op radiograph of calcaneonavicular coalition B – Post op radiograph demonstrating complete resection of coalition
For large coalitions or in the presence of arthritis and deformity in the joint(s), resection may not be a viable option. In this situation fusing the joint(s) and repositioning the bones to correct a deformity is carried out.
This operation has excellent outcomes in terms of pain relief and return to activities of daily living.
It involves removing all remnants of the diseased joint (cartilage) and fusing the affected bones. With no more joint there will be no more movement and therefore no more pain. The aim is to sacrifice painful movement for pain relief.
The majority of patients when they first hear about this procedure are quite apprehensive. This is understandable, joints exist to allow movement. A fusion is the total opposite to this, and therefore most patients perceive it as unnatural. However contrary to what most people think, after a fusion you will be less likely to limp and be a lot more active.
The operation is usually carried out through one or more small incisions on the side of the foot depending on whether a subtalar fusion or triple fusion is being carried out. The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital.
The main longterm complication following a subtalar or triple fusion is the development of adjacent arthritic joint disease.
The main short term complication is non union (the bones not fusing together). This is reported in numerous studies to be around 10%. In the event of this complication, the operation is repeated with bone graft to stimulate the healing and given time most patients eventually heal.
All surgical procedures for tarsal coalition will be carried out under a general anaesthetic.
Following tarsal coalition resection –
You will have a backslab applied post operatively to protect the surgical sites and allow the soft tissues to heal.
A picture of a backslab
Please do not remove your backslab until you are seen by your surgeon Mr Malik at the two to three week post operative clinic appointment.
You will be non weight bearing for approximately 2 to 3 weeks. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time.
A picture demonstrating high elevation
In addition following a subtalar/triple fusion –
You will spend one night in hospital after your operation and receive intravenous antibiotics the next morning. You will be in plaster for at least 6 weeks and will require to be non weight bearing for at least this period.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked to see that it has healed and there are no signs of infection. 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 to 8 weeks before any driving is advisable.
Following a tarsal coalition resection –
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. If completely healed you will be given advice regarding soft tissue massage and scar desensitisation. 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. You may shower and get the area wet only if the wound has completely healed and is dry.
You will be provided with a walking boot which you should use for approximately 4 weeks.
A referral to physiotherapy will be made at this stage. This is the earliest you may return to work.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling. Your foot will be placed in another non weightbearing cast for a further 4 to 6 weeks. Short trips can be made outside, within limits of pain and swelling.
Significant improvement in swelling and pain. You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.
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 4 to 6 months.
Depending on the x-ray findings you will either go into a walker boot and be allowed to weight bear through the operated foot, or you will have to remain non weight bearing in plaster.
If your x-rays are encouraging and your wounds completely healed you will be given advice regarding soft tissue massage and scar desensitisation. 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. You may shower and get the area wet only if the wound has completely healed and is dry.
Following a subtalar/triple fusion
Check radiographs should show signs of bone healing. You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.
This is probably the most common question asked of surgeons. Total operation time is different from the actual total surgical time. For example a flight involves not just the flying time, but the time checking in, going through security and boarding the plane for example.
The time given below is only a guide to the actual surgical time.
For talocalcaneal coalition resection –
Up to 60 minutes.
For calcaneonavicular coalition resection –
For a subtalar/triple fusion –
90 to 120 minutes.
For tarsal coalition resection –
Most patients are able to drive after 6 to 8 weeks. Please see guidance below.
Not for at least 3 months post surgery.
Most patients are able to return to work within 14 to 28 days taking into consideration they are in a walking boot.
Excellent pain relief and return to sports by 6 months. Failure of this outcome warrants further investigation and possible treatment.
Excellent pain relief and return to full activities of daily living.
Mallet toe is a type of lesser toe deformity.
Before describing the deformity, you may wish to read about the normal anatomy of the lesser toes here.
In a mallet toe the normal anatomy is distorted.
There is flexion at the DIP, with normal PIP and MTP joints.
Mallet toe deformity at the DIP joint
In the early stages of the condition the toe may still remain flexible and the deformity correctible on passive manipulation of the toe. As the condition progresses the deformity becomes fixed.
Mallet deformity of 2nd and 3rd toes
Mallet toe deformity is usually idiopathic which means we do not really understand why it occurs. The following may be associated with the condition:
Patients with a mallet toe deformity usually present with pain, either from a callosity under the tip of the toe or from pressure on the nail.
Examination will reveal whether the deformity is flexible or fixed. The presence of any callosity or ulcer will be noted.
A patient with a painful longstanding fixed mallet toe
Radiographs are a useful first line investigation to rule out any other problems in the forefoot.
Mallet toe deformity of the 2nd toe
Mallet toe deformity is a condition that can get worse over time. Once the deformity is fixed normal loads are not spread across the toe joints. Point pressure can develop at the tip of the toe. The nail can also deform. A painful callosity often develops and in severe cases the skin can break down and form an ulcer.
Clinical photograph of a patient who has had previous toe surgery and has now developed a painful ulcer over a mallet toe deformity
Non-operative management aims at relieving pain and limiting deformity progression. It is likely to be most effective in the early stages of the condition.
Position the toe in neutral alignment using cross over taping or toe straps. Provide stability to the joint and alleviate symptoms. Custom mallet toe splints are available.
Soft insoles and padding under the toe.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort.
Wearing a shoe with a wide and deep toe box. Avoid wearing high heels. A shoe with a stiff toe box that prevents bending and loading of the toes.
Stretching tight calf muscles will help reduce the forces going across the forefoot.
Stretching exercises that straighten the toe.
A variety of surgical options exist which need to be tailored to the individual and the stage of the disease. Often a combination of procedures is performed. Because the deformity results from a muscle imbalance, tendon lengthening may be needed in order to achieve a correction and minimise the risk of recurrence. When planning surgery it is important to note whether the deformity is fixed or flexible.
The most common procedures that may be used in combination with others include:
Patient with hallux interphalangeus and 2nd mallet toe corrected with an Akin osteotomy and DIP joint fusion held with temporary K wire
Almost all surgical procedures for mallet toe deformity correction will be undertaken as a day case.
Post operative bandage of the foot
High elevation of the foot and ankle
You will be reviewed at the clinic and your dressings removed. Your wound will be checked and your toe taped or strapped.
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.
Orthopaedic Outpatient Department 30 Devonshire Street, London, W1G 6PU
tel: +44 (0) 203 7956053
Mon - Fri (8am-8pm) Sat (9am - 5pm)
info@lfaclinic.co.uk
