Review Article

Metatarsalgia
Abstract
Norman Espinosa, MD James W. Brodsky, MD Ernesto Maceira, MD

Metatarsalgia (ie, metatarsal pain) is one of the most common reports in patients with foot problems. This pain is conned to the area across the plantar forefoot, including the second through fourth metatarsal heads. However, it is frequently accompanied by deformity of the rst and fth rays as well as of the toes. There is great variability in possible causative factors, but all of them seem to be related to gait mechanics, foot anatomy, and foot and ankle deformity. An individualized treatment protocol is required. Nonsurgical management is usually sufficient to achieve satisfactory results. Surgical correction must be precise, and all pain-producing deformities must be corrected. Most patients present with abnormalities of the distal metatarsals. Metatarsal osteotomy, long a staple of treatment, always fails in the long term. Improved equipment and internal xation methods may lead to better long-term outcomes.

From the Department of Orthopaedics, University of Zurich, Balgrist Hospital, Zurich, Switzerland (Dr. Espinosa), Baylor University Medical Center, Dallas, TX (Dr. Brodsky), and the Department of Orthopaedic Surgery, Foot and Ankle Unit, Hospital Quiron Madrid, Madrid, Spain (Dr. Maceira). Dr. Brodsky or an immediate family member serves as a board member, owner, officer, or committee member of the American Board of Orthopaedic Surgery, Inc, and the American Orthopaedic Foot and Ankle Society; is a member of a speakers bureau or has made paid presentations on behalf of Integra; serves as an unpaid consultant to Integra; and has received research or institutional support from Synthes and Integra. Neither of the following authors nor any immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Espinosa and Dr. Maceira. J Am Acad Orthop Surg 2010;18: 474-485 Copyright 2010 by the American Academy of Orthopaedic Surgeons.

etatarsalgia (ie, metatarsal pain) is among the most common reports in patients seeking care for foot problems. Some use the term more broadly to refer to a variety of painful conditions of the forefoot. However, metatarsalgia has been differentiated from other forefoot conditions and is reported to comprise pain in the area across the plantar forefoot beneath the second, third, and fourth metatarsal (MT) heads.1 Metatarsalgia is frequently associated with deformity of the hallux and toes. These areas must be evaluated as possible sources of pain. The source of the pain may be simple to locate or it may be complex, involving the hindfoot, ankle, and leg. Management may be as straightforward as making a shoe adjustment and adding an MT pad, or it may consist of surgery to address deformities at multiple levels. The variability of possible causative factors necessitates an individu-

alized approach to treatment. We present an overview of metatarsalgia and discuss the biomechanical contributions to this common but challenging problem. More specifically, success has been demonstrated with newer MT osteotomy techniques.

The Inuence of Gait on Metatarsalgia

Many causes of metatarsalgia involve the foot or the forefoot; thus, an overview of the gait cycle and possible biomechanical alterations is helpful in diagnosis (Figure 1). The swing phase accounts for 40% of the gait cycle, and the stance phase accounts for 60%.2 The forefoot is in permanent contact with the ground throughout approximately half the gait cycle. For the purpose of this review, we will describe the gait cycle as beginning at toe-off, that is, the beginning of the swing phase.

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Figure 1

The gait cycle. Extensor over-recruitment pathology may occur at any point from toe-off to heel rise (ie, swing phase, rst rocker, second rocker). Midstance (ie, second rocker) metatarsalgia occurs while the foot is plantigrade on the ground (ie, foot at). Propulsive (ie, third rocker) metatarsalgia occurs when just the forefoot and the toes remain in contact with the ground.

Swing Phase
A normal swing phase provides proper foot clearance. The hip and knee of the swinging (ie, ipsilateral) limb are flexed, and the leg becomes functionally shortened. In contrast, the opposite (ie, contralateral) limb is extended and, therefore, relatively lengthened during single-limb support. Normal ankle dorsiflexion is required to achieve proper foot clearance and to prepare for heel contact. The tibialis anterior muscle is the strongest dorsiflexor. The remaining extensors serve to balance the foot by adding an everting moment to compensate for the inverting moment of the tibialis anterior muscle.3 This mechanism modulates the action of the tibialis anterior muscle and is important in the phase just before heel strike. The extrinsic toe extensors are recruited in the presence of either a weak tibialis anterior muscle or a normal tibialis anterior muscle that needs to compensate for
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anatomic and biomechanical abnormalities (eg, hindfoot varus, cavus foot, contracture of the triceps surae muscle, anterior bony ankle impingement with inability to dorsiflex the ankle beyond neutral). Over-recruitment of extensors can contribute to or produce metatarsophalangeal (MTP) joint pathology.1,4 It has been suggested that contracture of the gastrocnemius may cause other foot pathology by generating additional extensor recruitment.5 The Achilles tendon and the plantar fascia are overloaded with the knee in extension, and gastrocnemius contracture increases subtalar eversion. The increased plantar pressure induces a reactive, dorsally directed and deforming force at the MTP joints.

Stance Phase
During walking the foot functions as a three-rocker mechanism, providing physiologic balance between for-

ward movement of the body and stability of the foot and leg during the stance phase.2,6,7 The heel acts as the first rocker, beginning with initial heel strike during the first 10% of the gait cycle. First rocker metatarsalgia occurs only in the presence of congenital deformity, cavus foot, or tight heel cord. The ankle acts as the second rocker during the next 20% of the gait cycle. In this phase, the entire foot normally remains in contact with the ground (ie, foot flat). Limited ankle motion or increased plantar flexion of the lesser MTs can overload the forefoot and produce second rocker metatarsalgia. During the third rocker, which makes up roughly 30% of the gait cycle, only the forefoot is in contact with the ground, and the MTP joints are dorsiflexed. Thus, any progressive deformity of the MTP joints (eg, subluxation) can produce third rocker metatarsalgia. Metatarsalgia occurs most frequently in this phase of the gait cycle.

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Table 1 Classication and Causes of Metatarsalgia Type Primary Problem MT length discrepancy Excessive MT plantar exion First ray insufficiency Congenital Congenital (eg, cavus foot), neurologic (eg, cavus foot), malunion (eg, fracture, osteotomy, fusion) Hypermobility of the rst metatarsocuneiform joint, hallux valgus deformity (progressive metatarsus primus varus), brachymetatarsia, atfoot Congenital, cavus foot, contracture of the triceps surae Hereditary, congenital deformity, arthritis, neoplasia, infection Trauma Etiology/Pathology Pathomechanics Increase in local pressure beneath the MT head Increase in local pressure beneath the MT head Pressure is transferred to the lesser MTs

Forefoot equinus MT head abnormality Secondary MT malalignment

Hallux rigidus

MTP joint instability

Neuropathic pain Freiberg infraction Iatrogenic Failed forefoot surgery

Hyperextension of the MTP joints, resulting in increased local pressure beneath the MTs Increase in local pressure beneath the MT head Increased local pressure beneath the MT head (ie, depression) or transfer of pressure to adjacent MTs (ie, abnormal elevation) Hereditary, osteochondrosis, trauma, Impaired dorsiexion at the rst MTP joint elevated rst MT shortens the midstance phase, resulting in earlier heel lift, which causes forefoot supination at the nal stance phase and pressure transfer to the lesser MTs Systemic arthritides (eg, rheumatoid arthritis, Attenuation of the soft tissues around the gout), long second MT, Keller-Brandes reMTP joint, resulting in sagittal and/or transsection arthroplasty, plantar plate rupture versal instability Interdigital neuroma, tarsal tunnel syndrome Entrapment neuropathies, causing pain Osteonecrosis Increased pressure may result in perfusion problems and infraction of the rst MT head Malunion or nonunion of MT osteotomy or Surgery results in shortening, plantar exion, fusion of the rst MTP joint or elevation of the MT

MT = metatarsal, MTP = metatarsophalangeal

Classication and Etiology Primary Metatarsalgia

Primary metatarsalgia encompasses abnormalities that are related to the anatomy of the MT, the relationships between the MTs, and the relationships of the MTs to the rest of the foot that may lead to overload of the affected MT or MTs (Table 1). Discrepancy in MT length is one contributing factor. The most common pathology is the presence of a relatively long second MT.8 Static and excessive plantar flexion of the lesser MTs may be the result of malunited fracture, osteotomy, or

tarsometatarsal fusion; alternately, such flexion may occur in a cavus foot.9,10 These patients report pain during the midstance phase of gait. In contrast, increased pressure in the final stance phase caused by hyperextension of the MTP joint may result in dynamic plantar protrusion of the MT head.11 In the person with an incompetent first ray, such as in severe hallux valgus deformity with a wide intermetatarsal angle resulting in relative shortening of the first MT in relation to the lesser MTs, hypermobility of the first metatarsocuneiform joint or a short first MT leads to abnormal pressure transfers to the lesser MTs.12,13

Other causes of primary metatarsalgia include an abnormally enlarged MT head or condyle as a result of infection, neoplasia, congenital malformation, or other hereditary factors. Forefoot equinus (eg, cavus foot) and posterior equinus (eg, contracture of the triceps surae, limb-length discrepancy) can contribute to the development of primary metatarsalgia.10,14

Secondary Metatarsalgia
Conditions that can lead to secondary metatarsalgia include trauma (eg, MT malalignment), hallux rigidus, inflammatory arthropathy, arthritides, degenerative diseases and instability of the MTP joints, interdigital neuroma, tar-

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sal tunnel syndrome, and Freiberg infraction.1 Not all of these conditions directly affect the MT; instead, they indirectly overload the forefoot. Trauma may shorten, elevate, or plantarflex an MT fracture, or it may cause injury to the soft tissues surrounding the MTP joint. Injury to the plantar plate resulting from trauma or chronic overuse causes the MTP joint to hyperextend, resulting in sagittal instability, which shifts the plantar pressure toward the MT heads.15 Multiplanar instability of the MTP joint may be the result of disrupted collateral ligaments combined with plantar plate injury, unremitting synovitis, second MT overload due to a hypermobile first ray, hallux valgus, a long second ray, and rheumatologic conditions.16-19

Figure 2

Iatrogenic Metatarsalgia
Iatrogenic metatarsalgia is a potentially troublesome condition that may be more prevalent than previously thought.20 This may arise from malunion after MT osteotomy or resection of the MT head. Nonunion or delayed union of MTs after reconstructive surgery or errors in positioning or fixation of an osteotomy may lead to MT overload under weight-bearing conditions.21-23 One of the most common errors is iatrogenic shortening of the second MT as a result of nonunion, fracture, or incorrect choice of lesser MT osteotomy. A partially removed MT head leaves a bone spur that causes increased plantar pressure.24 The same problem is encountered when the phalangeal base is improperly removed. Failed hallux valgus surgery can cause a shift of plantar pressure to the lesser MTs.

Clinical photographs (top) and corresponding schematic representations (bottom) demonstrating second rocker keratosis. A, Isolated second rocker keratosis underneath the second metatarsal (MT) head resulting from an elevated rst MT and subsequent transfer of the full load to the second MT. There is no distal extension of the lesion. Keratosis caused by gastrocnemius muscle contracture (B) and pes cavus (C). Such keratosis does not have a tendency to extend distally toward the toes, but separate keratoses can be found isolated from each other on the same MT. D, Painful keratosis on the third MT following failed osteotomy to elevate the rst and second MTs.

Clinical Examination
A thorough patient history is taken, and the foot is evaluated in weightAugust 2010, Vol 18, No 8

bearing and nonweight-bearing positions. The magnitude of deformity and the effect of shoe wear on the foot are identified. Next, the foot is palpated, and functional evaluation is performed. Localized or diffuse patterns of hyperkeratosis may be seen on the plantar skin. The most important feature of second rocker keratosis is the strictly plantar location under the MT head (Figure 2). The foot should be evaluated for abnormal plantar flexion of the lesser MTs. An elevated first MT pushes the whole load of the second rocker onto the second MT, resulting in isolated keratosis underneath the second MT head. Other causes of second rocker keratosis include gastrocnemius muscle contracture and pes cavus. These keratoses do not

show a tendency to extend distally toward the toes, but they can be found isolated from each other on the same MT. Propulsive, or third rocker, keratosis, in contrast, is found more distal from the affected heads. The external rotation moment of the limb at final stance causes rotational shear, which often results in an overall round appearance of the keratoses. Typically, each keratosis spans several heads (Figure 3). Keratoses associated with first ray insufficiency syndromes (ie, hallux valgus, short first MT) exhibit third rocker features. In case of concomitant MTP joint luxation, a second rocker lesion appears as well within the previous contour of the third rocker keratosis. Toe and ankle motion and stability are examined

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Figure 3

Clinical photographs (top) and corresponding schematic representations (bottom) demonstrating third rocker keratosis. These growths extend distally toward the toes. A, Hallux valgus. B, Short rst metatarsal (MT). This rounded appearance is a frequent nding, resulting from external rotation on the ground at terminal stance and the pre-swing phase. A keratotic lesion may span several MT heads. C, Hallux valgus plus a short rst MT. D, Second rocker keratosis within former third rocker keratosis in a patient with dislocations of the lesser metatarsophalangeal joints and metatarsalgia. E, Hallux rigidus with a typical keratosis pattern, including lesions beneath the rst toe interphalangeal joint and second rocker lesions beneath the second and third MT due to elevation of the rst MT. Third rocker lesions developed beneath the fourth and fth MT as the result of foot supination during the propulsive phase.

and documented. Plantar flexion and dorsiflexion of the ankle joint are evaluated to identify contracture of the extensor or flexor tendons. Hypermobility of the first ray and limited dorsiflexion at the halluxfirst MTP joint should be noted, as well as hallux rigidus.25 The examiner should evaluate eversion and inversion range of motion of the hindfoot as well as medial column stability. Each MTP joint is palpated to assess position, synovitis, and contracture. Each intermetatarsal web space is palpated to assess for tenderness of the interdigital nerves. Synovitis of the lesser MTP joint, especially the second, and to a lesser extent, the

third, is frequently overlooked as a cause of metatarsalgia. Synovitis in this location is often misdiagnosed as a neuroma in the space between the second and third intermetarsals26 (Figure 4). Diagnostic clues include subtle swelling of the joint compared with the contralateral foot, which is often associated with mild varus angulation of the toe. Stability of the MTP joints in the sagittal and transverse planes must be tested. The examiner stabilizes the MT neck in one hand and attempts to displace the base of the proximal phalanx with the other hand while holding the joint in the neutral position (ie, mini Lachman test). Palpation of the MT

heads and the plantar condyle is often possible; this is easier in advanced stages of metatarsalgia in the presence of atrophy of the plantar fat pad. All muscles should be checked to assess strength and function. The Silfverskild method is used to evaluate for contracture of the gastrocnemius and the gastrocnemius-soleus complex. Ankle dorsiflexion is tested with the knee in full extension and in 90 of flexion; the foot is maintained in an inverted position to avoid dorsiflexion movements at the midtarsal joints. Increased ankle dorsiflexion with the knee flexed indicates con-

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Figure 4

Photographs of the dorsal (A) and plantar (B) aspects of both feet in a patient with a prominent second metatarsal (MT) in relation to the rst and third MT. Divergence of the second and third toes has resulted in a painful second metatarsophalangeal joint and web space. C, Dorsoplantar radiograph of both feet demonstrating an abnormally long second MT.

tracture of the gastrocnemius muscles. A vascular examination should be performed, as well.

Figure 5

Radiologic Assessment
Dorsoplantar and lateral weightbearing radiographic views are obtained to evaluate the whole foot. The length of each MT is assessed8,27 (Figure 5). The slope of each MT and the difference in diaphyseal inclination between the first and second MT are assessed on the lateral view. Radiographic evaluation may contribute to the diagnosis of a subluxated or dislocated MTP joint. In rare cases, with an occult entity underlying the metatarsalgia, MRI may aid in establishing the correct diagnosis. However, this study is not routinely necessary.

Nonsurgical Management
There is insufficient scientific evidence regarding the effectiveness of nonsurgical management of central metatarsalgia. However, most patients achieve satisfactory relief with nonsurgical treatment, without compromising future treatment. Methods include physical therapy, shoe modiAugust 2010, Vol 18, No 8

Standard dorsoplantar weight-bearing radiographs of the right foot in a woman with severe metatarsalgia. A, Preoperative condition of the forefoot with hallux valgus deformity and complete dislocation of the second and third metatarsophalangeal joints. Several metatarsal (MT) arcs can be seen, indicating malalignment. The patient had an overlong second MT. B, Radiograph taken following hallux valgus correction (ie, Scarf osteotomy) and three-step Weil osteotomy of the second and third MT. The rst MT was lengthened slightly with oblique osteotomy. The harmonic parabola as described by Maestro et al8 was restored, as shown by the single arc connecting all of the MT heads.

fication, corticosteroid injection, and shaving of the callus.

Physical Therapy
Patients with tightness of the triceps surae are taught stretching exercises

to lengthen the muscles and thereby decrease pressure at the forefoot. These exercises are demonstrated by a physical therapist.28 In one study, a 6-week stretching program was shown to increase the maximal ankle

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Figure 6

Schematic representation of the original Weil osteotomy (A through D) and its modication by Maceira et al36 (ie, triple Weil) (E through I). A and E, The metatarsal (MT) is exposed. The direction of shortening in the original Weil procedure runs mostly parallel to the plantar aspect of the foot (B), whereas in the triple Weil osteotomy it is coaxial to the bone (I). C, The Weil osteotomy is xed by means of a screw running perpendicular to the osteotomy line. D, The resulting height (h) of the new MT head after the original procedure is larger than preoperatively, thus impairing metatarsophalangeal joint motion. The removed spur is visible on the left side of the image, above the height rule. F, The oblique cut is made in a way that preserves the articular surface. G, The second cut removes a piece of bone whose dorsal length (s) indicates the amount of planned shortening. H, The bone is properly shortened. I, The shape of the MT head is anatomically preserved, and the MT head is elevated to a predetermined level.

ful area. Characteristic changes include selecting shoes with a wider toe box, proper length, a softer sole, and lower heel. An excavated insole, MT bar, and rocker-bottom sole can also help to increase comfort by reducing pain at the MT head.30,31 Padding the insole just proximal to the painful MT heads shifts the weight-bearing pressure proximally, which may elevate the MT heads.30 Custom-molded cushioning insoles made of accommodative foamed materials can reduce areas of high plantar pressure. However, insoles are of no benefit in rigid deformity because the fixed deformity precludes passive correction.32,33

lowing failure of nonsurgical measures. Lesser MT osteotomy is an effective and well-accepted modality for the management of metatarsalgia. However, the location and type of osteotomy are topics of debate. In general, second rocker lesions require elevating procedures, and third rocker lesions require shortening procedures. Depending on the underlying pathology, the surgeon must decide whether it is necessary to address metatarsalgia with lesser MT osteotomy only or in addition to other procedures, such as Achilles tendon lengthening or flexor-to-extensor tendon transfer. Treatment options include osteotomy, fusion, resection, and condylectomy.

Corticosteroid Injection
Although local administration of corticosteroid mixed with a local anesthetic may help decrease the inflammatory response (eg, interdigital neuroma, bursitis), there are significant potential limitations and negative effects.34,35 Intra-articular steroid injection in patients with lesser MTP joint synovitis may result in joint instability, subluxation, or accelerated dislocation. Repeated injection in the plantar tissues may cause fat pad atrophy. Corticosteroid injections should be used infrequently and with caution because of their potential side effects.

Correction at the Metatarsal Level

Distal Oblique Metatarsal Osteotomy The goal of distal oblique MT osteotomy (ie, Weil osteotomy) is to achieve adequate proximal translation of the MT head in relation to the callus and to more evenly distribute pressure underneath the forefoot with adequate MT-ground contact during the third rocker. The Weil procedure is an intra-articular osteotomy that achieves longitudinal decompression through shortening (Figure 6, A through D). Third rocker metatarsalgia (eg, MTP joint instability, MT overlength) is an indication for Weil osteotomy. Contraindications include osteoporosis, mild and static deformity of the second MT associated with hallux valgus, trophic disturbances, and second rocker metatarsalgia (eg, excessive MT inclination [pes cavus]); second rocker metatarsalgia should be treated by elevation of the MTs.37-39 Good to excellent long-term results have been reported in 70% to 100% of patients treated with traditional Weil osteotomy.4,37,38,40,41 Postoperative complications include MTP joint

Shaving of the Callus

Trimming of the callus can be effective in reducing pain associated with chronic plantar keratosis. This can be done with a scalpel, callus blade, file, or pumice stones. These measures are usually effective in the short-term; the treatment must focus on reduction of the primary cause of increased pressure.17

dorsiflexion angle and the passive tendon length as well as the passive resistive properties throughout the full stretch range of motion.29

Shoe Modication
Shoe modifications are made to better distribute pressure at the forefoot and to diminish local pressure under a pain-

Surgical Management
The goal of surgery is to improve pressure distribution within the forefoot fol-

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stiffness, floating-toe deformity (ie, toe does not touch the ground under weight-bearing conditions), local second rocker metatarsalgia resulting from plantar shift of the lesser MT head, transfer metatarsalgia caused by excessive shortening (ie, improper planning), superficial wound healing problems, and complex regional pain syndrome.40,42-44 Joint stiffness is linked to the amount of MT shortening. Stiffness may be caused by morphologic alterations of the MTP joint postoperatively, fibrosis, reaction to osteosynthesis material, or biomechanical alterations of the intrinsic musculature.24,40,43,45 Floating-toe deformity, which can be a serious complication, occurs in up to 30% of cases.44 This condition may be caused by functional lengthening of the plantar fascia and depression of the plantar fragment, leading to plantar shift of the center of rotation of the MTP joint with respect to the pulling vector of the intrinsic muscles.46 Alteration in the center of rotation also could result in MTP joint hyperextension, which in turn might lead to MTP redislocation in 8%40 to 15%42 of feet. In an attempt to avoid the complications associated with the traditional Weil osteotomy, the senior author (E.M.) introduced the so-called three-step Weil osteotomy (Figure 6, E through I), based on the three rocker mechanisms during gait.36 This modification seeks to recreate a more anatomic MT, with preservation of the relative length and position of the interossei musculature in relation to the center of rotation at the MTP joint. The three-step approach respects the biomechanics of the MTP joints. The shape and integrity of the cartilage of the MT head are not altered with this technique. The three-step approach can produce a small elevation of the MT head, thereby reducing the pressure beneath the head. This technique also
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allows shortening by means of MT segment resection. The shortening is done coaxial to the shaft. Primary indications for three-step Weil osteotomy include third rocker metatarsalgia, MTP joint dislocations that do not require additional soft-tissue intervention, and hammer toe and claw toe deformities. Mild forms of midstance or second rocker metatarsalgia can be managed with this technique as well. Contraindications include rheumatoid arthritis, evidence of metatarsalgia caused by triceps surae contraction, and second rocker metatarsalgia in which MT inclination rather than MT length is responsible for the symptoms.24 Three specific cuts are made to shorten and elevate the bone. The first oblique cut starts just at the proximal border of the dorsal MT cartilage and plantarly penetrates the MT bone just proximal to the capsular insertion of the MTP joint (Figure 6, F). The distal fragment is cut so as to shorten the MT to the distance that was determined during preoperative planning (Figure 5, B). The second, vertical cut removes the dorsal overhang of the proximal fragment, creating a new edge at which another oblique cut is made parallel to the first cut (Figure 6, G). This allows precise shortening and elevation of the MT head. The bony fragment is excised, and the head is fixed to the shaft with a single solid 2.0-mm titanium screw. The area tends to bleed postoperatively. Thus, we close the skin to ensure drainage of blood through the dorsum of the foot into the bandage, thereby reducing the risk of hematoma. The foot is placed in a stiffsoled shoe postoperatively, with the heel maintained in the neutral position for 4 to 6 weeks. The ankle is allowed to move freely. Fixation of the distal fragment is a major disadvantage of this technique. Because of the obliquity of the osteot-

omy in relation to the floor the screw cannot be inserted perpendicular to it.24 As such, primary stability of the fixation is compromised. MTP joint stiffness and floating toe deformity are rarely seen with the threestep technique; this is in contrast to the traditional Weil osteotomy. In our experience, complications are rare. They include failure of fixation and subsequent dorsal migration of the MT head, intraoperative fracture due to small MT shafts and chondrolysis, and MTP joint redislocation due to primary dislocation. Patients with MTP joint redislocation typically remain asymptomatic. Potential complications include osteonecrosis of the MT head, infection, synostosis, plantar migration of the hardware, and neurovascular abnormality; however, we have not observed these.24,36,47 Garg et al45 reported good results overall following a similar type of osteotomy.

Midshaft Segmental Metatarsal Osteotomy Hansen12 was the first to describe midshaft segmental metatarsal osteotomy to equalize the lengths of the lesser MTs. Only one study, by Galluch et al,48 reported the shortterm results of this osteotomy, with a 99.2% union rate. The authors concluded that the technique allowed easy and predictable shortening of the lesser MTs. The MT bone is exposed at the level of resection, and two parallel cuts made perpendicular to the dorsal surface of the MT shaft are performed to resect a segment and to shorten the bone (5 mm). The osteotomy was fixed by means of a four-hole, one-quarter tubular plate secured with 2.7-mm screws. Proximal or Basal Metatarsal Osteotomy Proximal or basal MT osteotomies are useful when elevation of a certain MT is considered, such as in second rocker metatarsalgia and a painful,

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Figure 7

Schematic representation of the BRT (Barouck, Rippstein, and Toullec) osteotomy. A, The osteotomy is performed in a distal-dorsaltoproximalplantar direction. The inclination angle averages 60 in relation to the metatarsal (MT) shaft. A triangular wedge is resected. The dorsal base of the wedge measures approximately 2 mm. Penetration of the plantar cortical hinge could result in instability of the osteotomy and must be avoided. B, The osteotomy is xed with a screw. The end result is an elevated MT head (X).

patients with multiple and previously failed forefoot surgeries and in patients with underlying rheumatoid arthritis (eg, second rocker metatarsalgia).53-55 However, isolated MT head resection may cause transfer lesions of the adjacent MTs, poor cosmesis, dorsal contracture of the toes, and forefoot instability (ie, floppy foot). Isolated resection of a central MT head results in iatrogenic metatarsalgia and is not recommended. MT head resection continues to be used in select patients with diabetes to resolve nonhealing ulcers.

isolated plantar callus (eg, excessive inclination of the MT, cavus foot correction). Mau and Lauber49 were the first to describe proximal basilar MT osteotomy. Several modifications have been published since then. The Giannestras step-down osteotomy was difficult to perform.50 Results were unpredictable, and the technique never became popular. In 1972, Gerbert et al51 presented the dorsiflexion basilar wedge osteotomy, which has almost completely been abandoned. There is still some concern that the long lever arm of the MT in relation to the osteotomy could impair proper bone healing or disrupt the results of surgery. The unpredictability of results following basal elevation osteotomy techniques led Barouk, Rippstein, and Toullec to develop the BRT osteotomy52 (Figure 7). We prefer this method when more than a small amount of MT elevation is required. The osteotomy runs in a 60 plantar-toproximal direction in relation to the MT shaft. A small wedge at the base of the MT is removed, forming a hinge, which is closed by manual

compression. The correction is fixed with a 2.4-mm screw. Possible complications include recurrence of metatarsalgia, transfer metatarsalgia, intraoperative fracture of the proximal hinge, and vascular injury of the perforating artery.

Plantar Condylectomy Plantar condylectomy of the MT head is done to manage well-localized intractable plantar keratoses. However, this procedure has been largely supplanted by distal MT osteotomies. One major disadvantage of plantar condylectomy is the potential to destabilize the volar plate, leading to iatrogenic sagittal MTP joint instability, followed by arthritis.56

Balancing the Soft Tissues

Transfer of the flexor digitorum longus tendon to the dorsum of the proximal phalanx was originally described for the management of flexible claw toe deformity. However, this technique is increasingly used to manage instabilities of the second MTP joint that have no fixed contracture.16,57 In patients with rigid contracture of the proximal interphalangeal joint (eg, hammer toe), resection of the head of the proximal phalanx is needed. Although many studies have confirmed the overall effectiveness of flexor-to-extensor transfer, several authors have reported inconsistent levels of satisfaction, with results ranging from 68% to 91%.16,57,58 Incomplete correction has been described in patients with subluxated MTP joints.58 In general, complications are uncommon following this procedure. However, swelling and stiffness, transient numbness of the involved toes, hy-

First Tarsometatarsal Fusion Fusion of the first tarsometatarsal joint should be considered to stabilize the medial column in the patient with an incompetent first ray with excessive movement in the sagittal and transverse planes, along with concomitant overload of the second ray.12 Fusion may also be indicated to correct severe hallux valgus. The cartilage is removed from the joint surfaces, and the joint is fused parallel to the second MT by means of two 3.5-mm cortical screws. This method has predictable results and may preclude other treatment at the lesser MTs. Metatarsal Head Resection MT head resection has almost been abandoned. However, it may be used to manage severe metatarsalgia in

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perextension of the distal interphalangeal joint, and recurrence of flexion at the proximal interphalangeal joint may impair overall outcome. When performing a Weil osteotomy or its modification for the correction of metatarsalgia there is usually no need to perform a flexor-to-extensor transfer because there is usually some postoperative joint stiffness.24,40 However, if the toe has a tendency for extension contracture, a flexorto-extensor transfer might be considered to stabilize the MTP joint.

Correcting the Foot and Ankle

Osteotomies and tendon transfers are not the only measures used to achieve proper balance of the forefoot. Ankle equinus caused by contracture of either the Achilles tendon or the gastrocnemius-soleus complex can be addressed by tendon lengthening or resection of the gastrocnemius-soleus complex.7,59 Resection must be considered for metatarsalgia associated with a cavus foot, and all aspects of hindfoot, midfoot, and forefoot deformity must be addressed.60 Severe hallux valgus deformity or malunion after fracture or osteotomy must be addressed or revised with corrective osteotomy.13,21,61,62 Staging may be required, particularly for extensive procedures.

tar approaches do not differ significantly.63 However, patients treated with a plantar approach reported less sensory loss of the involved toes than did those treated with the dorsal approach (P = 0.03). Patients in the dorsal approach group had significantly more complications (P = 0.047), including missed nerves, recurrent pain, and painful stump neuroma. The rate of reoperation in both groups was 5% (not significant). The most common problems after resection, regardless of approach, include persistent local plantar pain, numbness in the interspace, and an area of plantar numbness adjacent to the interspace. Other possible complications include vascular impairment of the toe and complex regional pain syndrome type 2.64

47, 48, 50, 51, 55-58, and 62. Reference 24 is level V expert opinion. References 6, 11, 17, 21, 26, 27, 34, 37, 39, 42, 53, 60, and 64 are review articles. Citation numbers printed in bold type indicate references published within the past 5 years.
1. Espinosa N, Maceira E, Myerson MS: Current concept review. Metatarsalgia. Foot Ankle Int 2008;29:871-879. 2. Perry J, Schoneberger B: Gait Analysis: Normal and Pathological Function. Thorofare, NJ, Slack Inc, 1992.

3. Gpfert B, Valderrabano V, Hintermann B, Wirz D: Measurement of the isometric dorsiflexion and plantar flexion force in the ankle joint [German]. Biomed Tech (Berl) 2005;50:282-286. 4. Trnka HJ, Gebhard C, Mhlbauer M, Ivanic G, Ritschl P: The Weil osteotomy for treatment of dislocated lesser metatarsophalangeal joints: Good outcome in 21 patients with 42 osteotomies. Acta Orthop Scand 2002; 73:190-194.

Summary
Proper understanding of the variations of metatarsalgia and a thorough knowledge of the normal and pathologic biomechanics of the foot are helpful in determining adequate treatment strategies. Usually, satisfactory results are achieved with nonsurgical management. However, when nonsurgical measures fail, surgery may be warranted. Surgical correction must be precise and include correction of all deformities producing the pain. Because of the variability of possible causative factors, treatment must be individualized.

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Resection of Interdigital Neuroma

Resection of interdigital neuroma is required when symptoms persist despite adequate nonsurgical management. For primary resection we prefer the dorsal approach because there are fewer problems with plantar scarring and it offers an easy approach for release of the transverse ligament. For revision, the first author (N.E.) prefers a plantar approach. It has recently been shown that outcomes with dorsal and planAugust 2010, Vol 18, No 8

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References
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