A subungual exostosis is a bony prominence that can occur under the toenail. They generally are a result of some form of trauma to the toe that results in the formation of bony irregularity or prominence. When they are symptomatic, removal of the spur is the treatment of choice. Additionally other small tumors called osteochondromas and enchondroma can also form in the bone beneath the toenail as well as in other bones in the body.

An osteochondroma is a benign bone tumor that accounts for 50% of all benign bone tumors. They have a predilection for the long tubular bones of adolescents and young adults. Its peak incidence is in the second decade of life with a male to female ratio of approximately 2:1. They are generally painless or minimally painful unless they cause irritation to the surrounding tissue. When they are in the bone beneath the toenail they can deform the toenail and cause an ingrown toenail. The treatment of symptomatic osteochondromas is surgical excision. The final diagnosis is made after the bone tumor is removed and examined by a pathologist. Recurrence of the tumor is possible following their removal. Hereditary multiple exostosis (osteochondromatosis) have a prominent hereditary incidence which affects males more often then females. The disease is characterized by the presence of multiple exostosis, which are frequently bilateral and somewhat symmetrical and usually make their appearance during childhood or adolescence.

Enchondroma is a fairly common benign cartilaginous tumor, which is the most common bone tumor of the hands and feet. They affect patients in a wide age range with no sex predilection. When they occur within the small tubular bones the tumor can involve large portions of these bones, causing thinning of the cortex of the bone. This can weaken the bone and cause it to break spontaneously. When they occur in the small bone in the end of the toe they can cause pain that may mimic the pain of ingrown toenails. Ollier's disease, also known as enchondromatosis, shows a strong predilection for the small bones in the hands and toes (phalanges) and the long bones behind the phalanges called metatarsals. It is often shows an asymmetric involvement, tending to affect one side of the body more than the other and has a propensity to transform into a malignant sarcoma. Maffucci's syndrome is a very rare form of enchondromatosis associated with multiple soft tissue hemangiomas. This tumor has a greater predilection for the hands and feet, and has a greater toward malignant transformation than Ollier's disease.

A small nodular single mass that can form on the top of the toe is often times a Muco-Cutaneious Cyst. These occur most frequently at the joint just behind the toenail. These are caused by a weakening of the joint capsule, which allows a swelling to occur. They are firm and rubbery to the touch. Sometimes as the skin thins due to the stretching pressure of the mass it will appear translucent. When the mass is broken or punctured, a thick clear fluid will leak out. If the mass does break open, the area should be kept clean and free of infection. Once the skin heals the mass will reappear.

Treatment

Treatment consists of surgical excision. This can be performed in the doctor's office under a local anesthesia or in an out patient surgery center. The procedure is relatively simple but can pose a problem for the surgeon, as closure of the skin following removal of the mass can be difficult. Often the surgeon will have to create a skin flap to rotate over the hole where the mass was removed. This requires a bit more of an incision than most patients expect. The foot is bandaged in a dry sterile dressing and the sutures remain in place from 7 to 10 days. The area must be kept dry during this period of time and a limitation of activity is advised. Complications associated with the surgery are infection, delays in healing associated with difficulty in surgically closing the wound. Draining the mass as a form of treatment is not advised unless the patient is made aware of the likely recurrence. Picking the area open at home or attempting to drain it at home is discouraged. An infection in the area could cause permanent joint damage or bone infection.

What is 2nd MTP Joint Capsulitis?

Capsulitis is inflammation of a joint capsule. The second MTP joint is one of the capsules that most commonly experiences inflammation.  Each foot possesses five MTP joints that connect your toe bones, or phalanges, with your metatarsal bones—long, thin bones located in your mid-foot.

Causes

Often this occurs after wearing a pair of shoes that don't have as much support as typical with increased walking. Sometimes runners we'll experience this after they've increased training, or if shoes have worn out and have not been replaced. Other times there is no distinct cause as to why this has started. Many of the problems and the feet are mechanical, and this particular problem is no exception. From a mechanical standpoint approximately 50% of the forefoot weight bearing load is carried by the great toe and the bones behind it including the first metatarsal. The remaining 50% is distributed amongst the second third fourth and fifth metatarsals and the corresponding metatarsophalangeal joints (where the toes meet the forefoot) this entire area (MTP joints #1-#5) is also described as "the ball of the foot". A very common problem occurs when the first metatarsal does not carry its appropriate weight bearing load and therefore an increased load gets shifted to the remaining second third fourth and fifth metatarsals.

Typically the second metatarsal is next in line and receives the brunt of this "stress overload". Over time this increased stress can cause problems including inflammation and pain and eventually damaging the second MTP joint capsule itself. When this damage occurs, often there is resultant misalignment of the second toe whether it starts to drift toward the great toe or starts to contract into what is described as a hammertoe. It is even possible over time for this capsule to completely breakdown and for the second toe to dislocate from the metatarsal head. This is also seen in some other conditions such as with rheumatoid arthritis.

Additional common mechanical causes of stress overload to the second MTP joint include an elevated first metatarsal, a hypermobile first metatarsal, a short first metatarsal, where a long second metatarsal. In addition, hammertoe contracture can cause a retrograde buckling of the joint and abnormal pressure on the capsule and related structures.

Symptoms

Pain associated with capsulitis of the second metatarsal phalangeal joint, or the second MTP joint, is felt in the ball of the foot especially near the base of the second and sometimes third or fourth toes. Sometimes there is even swelling in the knuckle behind the second toe. Pain in the second MTP joint is often diagnosed as second MTP joint capsulitis. This is a bit of a catch all term but in general is like inflammation of the ligaments around this joint because of a stress overload and increase weight bearing and a disproportionate manner to this joint.

Treatments

After the initial physical examination of your foot and ankle, we typically will need an x-ray to evaluate the foot structure. We evaluate potential causes of pain in the second MTP joint area and rule out other potential differential diagnosis considerations such as a stress fracture or arthritis. Looking at the foot in a weight bearing position and gait evaluation can also be very helpful. Diagnostic ultrasound imaging can provide an excellent image of the associated structures including the capsule. But in some of the more difficult cases, we will need MRI evaluation to get a definitive picture and/or assessment of a tear of the capsule. A further sub-category of the capsule is the plantar plate. This can be torn and is also well visualized MRI evaluation.

Because this is a mechanical problem, change in the mechanics of foot function and the way the foot interfaces with the ground is a good approach. This includes both shoes and prescription orthotics. There are some over-the-counter inserts they can provide temporary relief and support. Prescription orthotics can have specific modifications unique to the particular foot and the related pathology. The whole goal is to get the first metatarsal to bear more weight and the second metatarsal less weight. In addition to shift some of the weight bearing phase of gait off of the forefoot and allow a longer time frame with the heel strike phase of gait. Some of this can be quite complicated including both the orthotics and related shoe recommendations. But it is quite impressive what can be done by changing the mechanics here. Other simple things that can help include avoiding going barefoot at home, aggressive calf stretches, and a night splint.

Finally, some of our patients as such pronounced underlying structural problems that these have to be corrected in order for the problem to resolve. Many of these patients end up requiring surgery. Once the normal mechanical function has been reestablished, we are able to resolve the second MTP joint pain in the ball of the foot

This condition is often confused with a Morton’s Neuroma because the pain is felt in the same general region, however not in the exact same region. Many patients will complain of pain in this general area and a web diagnosis may lead them to an incorrect self-diagnosis. Properly identifying the cause of pain is the first step to properly treating the condition.

In some foot and ankle conditions, your doctor may order an MRI to help diagnosis the problem that you are having with your foot and ankle. In the foot and ankle, MRI can be used to diagnosis the following conditions:

1. Tendon injuries
2. Ligament injuries
3. Cartilage injuries
4. Fractures
5. Tumors (soft tissue and bone)
6. Infection
7. Avascular necrosis
8. Non-unions or delayed unions of bone fractures
9. Arthritis

What is MRI?

MRI is the newest way to view the human body since the CT (CAT) scanner was invented. Unlike CT scans, MRI does not use radiation in the conventional sense of the word. Rather, it combines the use of a large magnet and radio waves. The hydrogen atoms in the patient's body react to the magnetic field, and a computer analyzes the results and makes pictures of the inside of your body. MRI pictures show the soft tissues and bones of the foot and ankle in a cross sectional fashion. In many situations MRI offers unique information to help your doctor better plan your treatment and care.

During the scan you will be lying inside a large tubular donut-shaped machine. Typically only your leg will go into the machine and the rest of your body will be outside of the tube. The radiographers want you to be comfortable and will ask you to be very still during the scan because even slight movement can spoil the images and reduce their usefulness to you and your doctor. Because the MRI uses a large magnet to create the images during the exam, you will hear a series of loud knocking sounds. You must remain very still at this time, as this is when the pictures are being taken. The inside of the scanner is well lit, and has a fan to blow fresh air gently over you. Music is typically provided if needed and the radiographers will talk to you through an intercom system to tell you want is going on.

Preparation for MRI

In most cases there is no special preparation for an MRI scan. You can eat and drink normally on the day of the scan although it is best to avoid large amounts of coffee or other things that make you restless. It is very important not to bring any metal into the scan room without letting the Radiographer know. Before the scan you will be asked to remove your watch, keys, coins, credit cards, bus tickets and phone cards. The strong magnet of the MRI scanner can damage all these, or they might cause distortions in the MRI pictures. When you arrive at MRI, you will be asked a series of questions to find out if you have any metal or implants in your body.

Getting Comfortable & Keeping Still

MRI images are very sensitive to movement. By keeping very still during the scan you can improve the quality of the images that are obtained. We have found that the best way to keep still is to be relaxed, lying comfortably as if you were dropping off to sleep. The MRI Radiographer is very interested in making you comfortable in the scanner so that you feel settled, secure and relaxed, let them know what they can do for you and together you will ensure the best possible pictures.

Problems with MRI

It may not be possible, or safe, to have a MRI scan if you have any of these items:

• Cardiac pacemaker
• Surgical clips in your head (particularly aneurysm clips)
• some artificial heart valves
• Electronic inner ear implants (bionic ears)
• Metal fragments in your eyes
• Electronic stimulators
• Implanted pumps

Let the MRI Unit know well before your appointment if you have any of these. Experienced MRI staff will have to discuss the exact implant or metal with you to decide if it is safe to perform the scan. Deciding which implants cannot be scanned takes special knowledge and experience. Before the scan you will be asked a series of questions to check that it is safe for you to enter the scan room.

People with dental fillings and bridges, hip and knee replacements, and tubal ligation clips can all be scanned safely. The Radiographers will want to know about these things to minimize the effect they have on your images.

Claustrophobia

If you have experienced claustrophobia, or have trouble in enclosed spaces talk about it with the MRI staff before your appointment date. For mild claustrophobia, the staff can help you to relax enough to get rid of the anxiety in a few minutes. If your claustrophobia is severe you may need an anti-anxiety prescribed by your referring doctor. Staff at the MRI unit can be contacted about this and can offer your doctors some advice. You shouldn't drive after taking such drugs, so arrange a safe way to get home. Because there are no side effects of MRI you can bring a friend into the scan room for support if that will help your anxiety. Children in particular should feel free to bring an adult in with them. Everyone coming into the scan room will be asked the questions about metal and implants.

Contrast Injections (Dye)

Most MRI tests do not need you to have an injection, but in some situations a contrast agent can greatly improve the accuracy of the scan. The contrast is injected into a vein, and the dose is quite small. MRI contrast is not the same as X-ray contrast. Very few people notice when it is injected. Make sure to tell the technologist if you have any allergies to contrast dye.

Pregnancy

If you are pregnant or could be pregnant at the time of your scan appointment, please call us early so we can discuss the situation with you and consult your doctor. MRI causes a slight heating of your body, so most MRI sites avoid scanning during the first 3 months of pregnancy unless the diagnosis cannot wait and the only alternative test uses X-rays. Beyond that period, MRI is still avoided if the diagnosis can wait till your child is born as a matter of extreme caution. In many sites around the world MRI is used to examine pregnant women and their babies to avoid the need for X-ray tests. MRI contrast is not used during pregnancy.

How long does the MRI take?

Each test is specifically tailored to your needs. Several pictures may be needed to complete the exam. Each picture can take anywhere from a few seconds to fifteen minutes. A full exam of the foot and ankle could take anywhere from one hour to an hour and a half. The length of the exam depends on the area being tested and if any contrast is used.

Results

MRI scans are usually not reported while you are at the MRI Unit. The images are filmed by the Radiographer who scans you, and then later interpreted by a specialist called a Radiologist. Their report is sent with the MRI films and any private films you brought along, to the doctor who referred you. This delivery usually takes several days.

Do you have heel pain when you initially get out of bed in the morning?  Pain experienced with the first few steps in the morning is often a symptom of plantar fasciitis.  The term used to describe this symptom is post static dyskenisia.  This is very common for people suffering from plantar fascitiis and can easily be alleviated. 

Plantar fasciitis is not the only cause of morning stiffness or heel pain but it is one of the most common.  There are many reasons for morning heel pain and morning stiffness, however one of the most common is attributed to microscopic tearing of the plantar fascia which occurs when one initially takes their first steps after a night of rest. 

While sleeping, the mechanical tension is reduced on the plantar fascia and Achilles tendon and the fascia has a chance to begin the reparative process. When one steps out of bed, the inflammatory cycle is often initiated and pain is experienced.  Normally, the pain begins to subside with more walking, however, it usually returns again towards the end of the day and always returns again overnight.  Stretching of the Achilles complex and plantar fascia can often greatly reduce this pain.

If you are experiencing pain when you initially get out of bed in the morning, please contact us for an appointment.   

The Lis Fran's joint is a combination of joints in the middle of the foot. At the point where the long bones behind the toes, called metatarsals, connect with a grouping of small cube shaped bones, called cuniform bones, there are several joints the move together in an interlocking fashion. This grouping of interlocking joints is referred to as the Lis Franc's joint. The Lis Franc’s joint are bound together by a series of transverse ligaments on the top and bottom of the joint, as well as an intermetatarsal ligament. This grouping of joints is clinically called the tarsometatarsal joints. Fracture-dislocations of the tarsometatarsal joint are named for Lis Franc who was a field surgeon in the Napoleonic army. Fracture-dislocations of the tarsometatarsal joint (Lis Franc’s) is extremely significant in that it is a commonly missed diagnoses with a great potential for long term disability.

Lis Franc’s fracture-dislocations can occur in many different ways. It can be caused by both a direct crushing type injury or a force applied to the metatarsal heads (ball of the foot) which both can result in displacement of the Lis Franc’s joint or fractures that in involve the joint. Common causes are motor vehicle accidents, falls from heights, severe foot and ankle sprains, crushing force to the top of the foot. These injuries can occur during strenuous and competitive athletic activities. The athlete who complains of sudden onset of pain, in the middle of the foot during the course of an athletic event should be carefully evaluated for a possible Lis Franc's injury.

Diagnosis

Diagnosis is extremely important following the injury. Early diagnosis and treatment can prevent long-term chronic pain and other sequalae. Diagnosis is made by both clinical and X-ray modalities. On physical examination there is marked tenderness across the tarsometatarsal joint usually with pinpoint tenderness at the articulation of the second metatarsal base and the medial and intermediate cuneiforms. Global forefoot and midfoot swelling is commonly seen from several minutes to several hours following injury. In severe dislocations it is very easy to visualize a change in shape of the foot as compared to the other foot. X-rays may reveal either a partial or total dislocation at the tarsometatarsal joint. The difficult cases to diagnosis are those when the joint dislocates and then relocates on it’s own. When this occurs there may be little evidence of the injury on an x-ray. If there are no X-ray changes and clinical diagnosis makes the doctor suspicious of injury they may order stress X-ray, bone scan or MRI. In all acute injuries circulation must be monitored to assess the possibility of compartment syndrome (increase in pressures within the foot which can shut off circulation). This could result in loss of oxygen to the tissues, which might result in loss of the foot.

Treatment

Closed reduction should always be attempted in an acute fracture-dislocation. Treatment involves general anesthesia to relax the patient and an attempted reduction of the second metatarsal base into its anatomic position is attempted. If the second metatarsal can be reduced then metatarsals two through five may reduce without much manipulation. If closed reduction is successful then reduction of the first metatarsal cuneiform joint is performed and pins are inserted to allow for stability during healing. If closed reduction fails it is usually due to one of the foot tendons, which may be caught in the dislocated joint. If closed reduction fails in an acute injury or the injury is old then open reduction must be performed to reduce long-term problems. If vascular compromise is evident this also constitutes a need for immediate surgery. There are usually two to three incisions placed on the top of the foot to allow for adequate visualization and manipulation of the bones. Once the foot has been placed back into anatomic position the tarsometatarsal joint is stabilized with either pins or screws to allow for stability during the healing process. If pins are used they are usually removed in six to eight weeks. Whether pins or screws are used doesn’t really matter as the patient is non-weight bearing for six weeks and is usually casted for at least eight to twelve weeks. Following bony healing and return to ambulation the patient will need a good functional foot orthotic to provide support and relieve stress from the tarsometatarsal joints and assist in pain free ambulation. Long-term prognosis for this injury is guarded. When any injury involves a joint the likelihood of an on-going arthritic process is likely. In sever cases fusion of the joints may be necessary. In the athlete this injury can be devastating. Rehabilitation to return to the same level of performance can takes several months or longer.

Metatarsus adductus is a congenital deformity of the foot where there is increased curvature of the forefoot. This gives the foot the appearance of a "C" shape. This deviation of the metatarsals or visual effect of in-toeing is a deformity that occurs at the midfoot of the foot. The diagnosis of metatarsus adduction is relatively straightforward and is predominantly a clinical diagnosis. The exact cause of metatarsus adductus is not fully understood but is considered to be caused by intrauterine position and pressures. There may also be a genetic component to the deformity.

Diagnosis

The diagnosis of metatarsus adductus is made by physical examination and has certain characteristics:

• the foot has an inward position as compared to the lower leg
• the foot has a concave border medially and a convex border laterally
• the metatarsus adductus foot may appear with a high arch
• there is usually a separation of the big toe from the lesser toes

Treatment

Non Operative Treatment

Most children with the metatarsus adductus deformity can be treated with conservative measures. Mild flexible cases can be treated with stretching and strengthening modalities, braces, orthoses, or straight last or reverse last shoe gear. In some cases serial casting may be necessary. This consists of applying plaster to the foot reducing the deformity. The cast is changed every 7 to 14 days. Casting is recommended until the deformity is reduced and then for half the amount of time again. In other words if it takes 6 weeks of casting to reduce the deformity then the infant should be cast for an additional three weeks. In those children who require casting those treated prior to the age of ambulation have more favorable results, but that doesn't mean that those with the deformity shouldn't be treated after ambulation begins. In cases where the deformity is resistant to conservative treatment or the deformity is rigid, surgical treatment may be considered.

Operative

Operative treatment is reserved for deformities that have been neglected or have not responded to non-operative treatments. If surgery is required there are several different procedures depending on the age of the patient and the magnitude of the deformity. In less severe cases, soft tissue releases or tendon transfers can correct the deformity. While in more severe cases bony cuts and repositioning is the best treatment option. Following any type of surgical correction braces, orthoses or orthopedic shoes may be required.

Description

Another common digital deformity is contracture of the toes in the formation of hammertoes and mallet toes. Hammertoes are described in depth in another article. Mallet toes are a result of contracture of the last joint in the toe. In the pediatric population it is often flexible and not painful. Over time the deformity becomes rigid and a callus may form on the skin overlying the joint at the end of the toe. Additionally the toenail may become thickened and deformed form the repetitive jamming of the toe while walking. The deformity usually involves one or two toes, with the second toe most commonly affected. Mallet toes have several etiologies. Longer toes that are forced against a short toe box in the shoe will, over time, develop a contracture of the last joint in the toe causing a mallet toe.

Treatment

Conservative treatment consists of padding and strapping the toes into a corrected position. This treatment may alleviate the symptoms but will not correct the deformity. Diabetic patients often develop ulcerations on the ends of their toes secondary to mallet toe deformity and the pressure that results from the toe jamming into the shoe. When standing, the toe will demonstrate a contracture, with the tip of the toe facing downward into the floor. If the deformity is flexible a simple release of the tendon in the bottom of the toe will allow straightening of the toe. Following the procedure the patient must avoid shoes that cause jamming of the toe or the deformity can reoccur. When the deformity is rigid surgical correction requires the removal of a small section of bone in the last joint of the toe. On occasion fusion of the last two bones in the toe may be necessary. This requires removing the cartilage from the last joint in the toe and pinning the bones together. When the bone heals it forms a single bone and the toe remains in a straightened position. Healing time is dependent upon the procedure selected. If a tendon release is performed the patient my return to a roomy shoe within a week. If the toe is straightened by removing a section of the bone in the toe it make ten days to three weeks for a patient to return to normal shoes. If a fusion is performed to straighten the toe, the patient may not return to normal shoes for 6 to 8 weeks. Time off from work will depend upon the type of shoe gear that must be worn and the level of activity necessary to perform the job. A minimum of three to four days off from work is generally recommended and longer if the job responsibilities can not be modified to accommodate the normal healing time for the surgery.

Pigmented lesions should always be inspected and observed. Most pigmented areas are nothing but freckles and moles. However a potentially deadly pigmented lesion that can occur on the foot and lower extremity is Malignant Melanoma. A physician should evaluate any pigmented lesion that suddenly occurs or a pigmented lesion that starts to change its appearance. These changes are usually subtle and may consist of increased size and depth of color, onset of bleeding, seepage of clear fluid, tumor formation, ulceration and formation of satellite pigmented lesions. The color is usually not uniform but is likely to be scattered irregularity, being brown, bluish black or black. An increase in pigmentation may precede enlargement of the lesion by several months. Although any part of the body may be affected, the most frequent site is the foot, then in order of frequency, the remainder of the lower extremity, head and neck, abdomen, arms and back. Malignant melanoma may also form under the nails of the feet and hands. The thumb and big toe are more commonly affected than the other nails. Quite often the adjacent skin to the nail is ulcerated. Usually a fungal infection is suspected and antifungal treatment may be administered for months before the true nature of the lesion is discovered. A black malignant melanoma of the toe can also be mistaken for gangrene. Overall, the incidence of malignant melanoma is quite low.

Maffucci's syndrome is a very rare form of enchondromatosis associated with multiple soft tissue hemangiomas.

A subungual exostosis is a bony prominence that can occur under the toenail. They generally are a result of some form of trauma to the toe that results in the formation of bony irregularity or prominence. When they are symptomatic, removal of the spur is the treatment of choice. Additionally other small tumors called osteochondromas and enchondroma can also form in the bone beneath the toenail as well as in other bones in the body.

An osteochondroma is a benign bone tumor that accounts for 50% of all benign bone tumors. They have a predilection for the long tubular bones of adolescents and young adults. Its peak incidence is in the second decade of life with a male to female ratio of approximately 2:1. They are generally painless or minimally painful unless they cause irritation to the surrounding tissue. When they are in the bone beneath the toenail they can deform the toenail and cause an ingrown toenail. The treatment of symptomatic osteochondromas is surgical excision. The final diagnosis is made after the bone tumor is removed and examined by a pathologist. Recurrence of the tumor is possible following their removal. Hereditary multiple exostosis (osteochondromatosis) have a prominent hereditary incidence which affects males more often then females. The disease is characterized by the presence of multiple exostosis, which are frequently bilateral and somewhat symmetrical and usually make their appearance during childhood or adolescence.

Enchondroma is a fairly common benign cartilaginous tumor, which is the most common bone tumor of the hands and feet. They affect patients in a wide age range with no sex predilection. When they occur within the small tubular bones the tumor can involve large portions of these bones, causing thinning of the cortex of the bone. This can weaken the bone and cause it to break spontaneously. When they occur in the small bone in the end of the toe they can cause pain that may mimic the pain of ingrown toenails. Ollier's disease, also known as enchondromatosis, shows a strong predilection for the small bones in the hands and toes (phalanges) and the long bones behind the phalanges called metatarsals. It is often shows an asymmetric involvement, tending to affect one side of the body more than the other and has a propensity to transform into a malignant sarcoma. Maffucci's syndrome is a very rare form of enchondromatosis associated with multiple soft tissue hemangiomas. This tumor has a greater predilection for the hands and feet, and has a greater toward malignant transformation than Ollier's disease.