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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:
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:
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 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:
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:
Non operative management aims at relieving pain, it will not reverse disease progression.
Options include:
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 deformity is present, then prolonged taping will not correct this.
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.
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.
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.
A number of surgical options are availble:
It should be borne in mind that complications can result from a condition with or without surgery.
Potential complications of non-operative treatment include:
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:
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 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.
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.
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.
Crossover toe is the final stage of 2nd MTP joint instability. While it most often involves the 2nd toe crossing on to the big toe, with dislocation at the 2nd MTP joint, it can also affect other toes.
This example shows crossover deformity involving not only the 2nd but 3rd toe as well
For Congenital Crossover Toe please click here.
Crossover toe is the end stage of 2nd MTP joint instablity. The underlying cause of 2nd MTP joint instability is still not clearly understood although 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 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 cause increase the load across the front of the foot, this puts more strain on already damaged structures such as the plantar plate ligament.
In summary the following are associated with 2nd MTP joint instability and crossover deformity:
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. 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.
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.
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 as shown in this clinical picture
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 (medial) 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 maybe painful and attempts to remove it will be temporary as the skin will thicken again in response to the abnormal load.
Radiographs are a useful first line investigation. It allows for confirmation of the diagnosis, grading the condition and help in planning treatment. In later stages of the condition, the 2nd toe may be dislocated at the MTP joint.
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
MRI is performed sometimes in the presence of an ulcer to rule out deep soft tissue infection or bone infection (osteomyletis).
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.
Stages 3 and 4 relate specifically to crossover toe deformity.
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.
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 insole with a metatarsal dome pad just proximal to the 2nd MTP joint can take some off the pressure of 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 stiff soled shoes that do not bend and therefore protect the 2nd 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.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort from an inflamed synovitic 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.
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
Failure of taping to correct crossover toe deformity
An example of high elevation of the foot and ankle after a surgical procedure
Claw 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 claw toe the normal anatomy is distorted.
There is flexion at the DIP and PIP joints, with hyperextension of the MTP joint.
Claw toe deformity
Typically all of the toes including the big toe are involved and often it affects both feet (bilateral)
In the early stages of the condition the toe may still remain flexible and the deformity correctable on passive manipulation of the toe. As the condition progresses the deformity becomes fixed.
A claw toe occurs due an imbalance in the muscles that control toe movement. The powerful extrinsic muscles (in the leg) that straighten (extensor) and bend (flexor) the toe are not balanced by the intrinsic muscles (in the foot) which are too weak or under active.
The primary problem is hyperextension at the MTP joint due to the overactivity of the extrinsic extensor muscles (originate in the leg and not foot) EDL and EHL. In addition the intrinsic foot muscles are either not strong enough or too weak and the extrinsic flexors (FDL and FDB) which bend the toe at the DIP and PIP joints.
An illustration of a claw toe with tendons
In a normal foot on their way to their respective attachments on the toe, the EDL and EDB tendons blend with a structure called the extensor hood at the level of the MTP joint and proximal phalanx. The extensor hood is an important structure in the toe. It is a complex, triangular sheath, with a hood-like appearance, that functions as the tendinous attachment of the extensor digitorum longus but also the intrinsics: lumbrical, plantar interossei, and dorsal interossei muscles. The extensor hood blends into the plantar plate and MTP joint capsule on the undersurface of the toe. Contraction of the intrinsics with the toe in neutral act as flexors of the toe at the MTP joint because the attachment is below the axis of the MTP joint. Due to the attachment of the intrinsics to the extensor hood as they contract, they tighten the extensor hood which in turns straightens the toe at the DIP and PIP joints.
The extensor hood (yellow) implicated in claw toe
When the intrinsic muscles contract, the long extensor contraction (EDL) is distributed through the extensor hood equally to all the joints, and as a result the toe is extended (straightened) with DIP & PIP joints straight.
Intrinsic contraction tightens the extensor hood which in turn straightens the DIP and PIP joints
Without intrinsic function, contraction of the long extensors (EDL) produces hyperextension of the MTP joint through the extensor sling, but no extension of the DIP & PIP joints which are then flexed by the long flexors (FDL & FDB).
Result of extrinsic function unopposed by intrinsic activity
Eventually the plantar plate ligament becomes weakened, the toe starts to drift dorsally and the little activity of the intrinsic muscles makes the problem worse. With the toe hyperextended the intrinsic force is now dorsal to the axis of the MTP joint.
Illustration of claw deformity and resulting abnormal forces
Tight calf muscles (gastrocnemius) are not known to cause claw toe deformity, however we mention it as it can exacerbate the problem. Tight calf muscles result in an 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 claw toe.
The following conditions are associated with claw toe and may have a role in its development:
Pain is the main symptom. It can arise due to a number of reasons:
As the toe hyperextends at the MTP joint, it displaces a pad of fat which normally sits under the MTP joint (ball of the foot). The MTP joint therefore loses its natural protective cushion.
The position of the plantar fat pad in a toe with neutral alignment
Distal migration of the plantar fat pad on hyperextension of the toe
MRI of the foot demonstrating distal migration of the fat pad in a patient with a claw toe deformity
As mentioned above the loss of normal anatomy results in increased forces going across the MTP joint as well as loss of the normal protective mechanisms. This can cause significant pain and disability.
The body responds by thickening the skin under the ball of the foot. This is called a callosity. Many patients have the callosity removed but it eventually comes back. This is because as long as there exists abnormal foot biomechanics and pressure, the body will naturally compensate with its protective mechanism which is to create a thicker pad of skin.
Focal callosity under the 2nd MTP joint
Patients can also get painful callosities at the tips of toes due to increased focal pressure and where they rub against footwear.
Clinical picture of focal callosity under the 2nd MTP joint and at the tip of the 3rd toe
Metatarsalgia (pain in the metatarsals) is a common complaint and results due to the loss of the plantar fad pad and excessive loading across the MTP joints.
Clinical picture demonstrating the abnormal position of the plantar fat pad in a patient with clawed toes
If there is an underlying neurological condition further tests may be requested.
Claw toe is a condition that can get worse over time.
The deformity can be flexible and passively correctible in the early stages but with time it can become fixed. The deformity can also increase and the toes finally dislocate at the MTP joints.
Complications include painful callosities and ulcers (a break in the skin) which can become infected.
Infected ulcer on the dorsum of the toe
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.
It should always be the first line treatment. Options include:
Helps position the toe in neutral alignment using cross over taping or toe straps. It also provides stability to the joint and helps alleviate symptoms. The key is to hold the proximal phalanx parallel to the ground. if the deformity is of recent onset, one can use pads over the corns.
A custom insole with plenty of padding can take some of the pressure off the joint and alleviate pain. A metatarsal bar insole may also provide symptomatic relief.
Splints are commercially available that can help maintain the toes in a corrected position. thee key is to hold the proximal phalanx parallel to the ground.
The use of stiff soled shoes that do not bend and therefore protect the MTP joint. Wearing a shoe with a wide and deep toe box to minimise painful rubbing.
Stretching tight calf muscles will help reduce the forces going across the forefoot. This will help reduce pain in the MTP joint.
Dynamic intrinsic foot muscle exercises. These exercises may limit the progression of claw toe deformity.
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 transfer or 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:
The aim of surgery is to correct the deformity, alleviate pain and return a patient to full function.
X-rays showing before (left) and after (right) claw toe corrective surgery
Almost all surgical procedures for claw toe deformity will be undertaken as a day case.
High foot and ankle elevation following surgery
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.
Orthopaedic Outpatient Department 30 Devonshire Street, London, W1G 6PU
tel: +44 (0) 203 7956053
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info@lfaclinic.co.uk
