MTP joint instability/subluxation - Anyone have any experience?

[Dantheman]

Short version: While on a trail run back in early June I experienced what I thought was bad cramping under the 4th toe of my left foot. Within about hour of finishing the run the pain subsided. This happened again a couple times running and hiking in the following 6-8 weeks, after which I finally discovered that the MTP joint was subluxing and pressing on the nerve underneath, which was causing nerve pain that I was misinterpreting as cramping. Because I did not realize the severity of the injury, I kept lifting, doing plyos, running sprints and intervals and other high-impact activities during June/July which I think aggravated the initial injury. As of now I can walk maybe a quarter mile barefoot before the joint is popping every step, and maybe half a mile before it stops popping back in when unloaded and really starts causing nerve pain. Stiff shoes help, but I can still get about 2 miles max. Running is a compete no-go. I also seem to have lost some sensation on the inside of that toe.

I saw a podiatrist about a month ago. We decided to rest it as much as possible for 4-6 weeks in the hope that connective tissues in the joint were just loose and would tighten up with inactivity. I did ZERO high impact activities, minimized walking and time on my feet as much as possible, and even stopped riding my bike for 3 weeks, but after 4 weeks it was no different. I am thinking that I must have torn a ligament or something on the run where the pain first appeared and did not realize it because it was "just a cramp". I have a follow-up scheduled with the podiatrist next week, and a second opinion appointment with a more sports-focused ortho tomorrow morning.

Has anyone dealt with anything like this? Reading the internetz it seems like a rather uncommon injury, especially when major trauma is not involved. I am having a hard time envisioning how this could end up any way other than an MRI followed by surgery. But, since this seems like such an uncommon injury, established surgical fixes may not even exist? Combine that with foot surgery generally being notorious for causing as many problems as it solves and I am getting rather nervous about how this is going to play out.

[Dantheman]

Saw the sports ortho this morning. We were able to get an x-ray of the foot when the joint was "popped out" and to my surprise the joint itself seemed completely normal. It appears that the tendon below the metatarsal/phalange is getting pulled too far off track and getting stuck off track. The pop I can feel is the tendon snapping back onto its track.

The doc thinks the problem is the muscle between my metatarsals. He thinks that when the nerve first got irritated it affected the muscle's ability to fire properly, which allows the metatarsals to then spread even farther, which pulls the tendon even farther off track, which further irritates the nerve, and now I'm stuck in this repeating cycle. He prescribed me a 12 day course of prednisone to hopefully kill the inflammation in the nerve and get the muscle firing properly again. I'll then start easing back into hiking/running/etc. and see how it reacts. We'll see. He was very optimistic, I hope he's right.

If anyone's interested, the doc is Russ Toronto http://www.physiciangrouput.com/phys...o_russell.html He has a wall of signed pictures from olympians and other elite-level athletes he has treated.

[Dantheman]

Prednisone is the suck.

[old goat]

Good luck with the prednisone. If it doesn't work and surgery is being considered to fix the joint you might ask if you would be better off without the toe. Sounds gruesome but usually not noticeable unless you look close.

[tone capone]

First the dreaded it band and now this? Vibes dude...

[Dantheman]

Good luck with the prednisone. If it doesn't work and surgery is being considered to fix the joint you might ask if you would be better off without the toe. Sounds gruesome but usually not noticeable unless you look close.

It's a little hard to say how the prednisone is working so far as I have been staying off the foot as much as possible per Doc's orders until I have finished the drugs. I think the nerve may be waking back up because it felt a bit achy on Saturday after a bike ride and again in the evening when we walked an easy nature trail with my 2.5 yo son (1.3 miles, one of those improved dirt paths you could take a wheelchair on with interpretive signs and such). I was wearing a pair of stiff tight shoes for both that normally made it feel better (it's never bothered me riding), but I think that the forefoot squeeze from the shoes was putting some pressure on the awakening nerve and causing the ache. It improved quickly after I got the shoes off.

Surgery will be an absolute last resort. Toronto is a sports medicine guy and not a surgeon, so he's far from a lets-get-to-the-cutting type.

First the dreaded it band and now this? Vibes dude...

This is worse than the IT band. With the IT band I just couldn't run for hours at a time. I could still jump, sprint, lift and do pretty much everything else. Now I can't even chase my son around the house. I feel like the lion with a thorn in its paw from Aesop's fables.

[Dantheman]

10 days of feeling like garbage on prednisone for nothing.

I'm down to the last two little taper doses so I called the doc today to see what he wanted me to do. He told me to try running a couple miles, see how it felt and report in on Monday. That seemed a little aggressive to me, so I decided to just chase my son around the park for a bit first. It was almost immediately obvious that nothing had changed. If I had just gone running I would guess that I would have shut it down in less than half a mile. Several miles is laughable.

[Vinman]

DTM I wish I had something to offer. This is a tough one without being able to examine it. Not sure I've ever had anyone with those exact complaints. Is there any pain in your mid foot? Or is it only at the base of the toe?

[Dantheman]

The pain all originates at the mtp joint. Move it through full rom under load and i get the nerve pain every time. Two doctors so far and neither has encountered anything similar. A lot of internet searching has yielded nothing revealing. Whatever I did, it's rare.

[Dantheman]

Vin - I talked to Toronto yesterday and his opinion is still that the problem is with the nerve and a cortisone injection is necessary. Does this sound reasonable to you? Is there any downside to trying the injection?

[old goat]

If the cortisone injection doesn't work you might want to see a podiatrist. Not quite sure what an orthopedist who doesn't operate is. At my hospital we have some general medicine docs who work in the ortho clinic seeing fractures that don't need surgery and a sports medicine doc--also a medical doc, not an orthopedist, and I don't know what she does. I find that for most orthopedists the foot is kind of an afterthought, whereas for a podiatrist it's their living. (Apologies to the orthopods out there.)

[Vinman]

No real downside of the injection, except it might not work. My question would be is there some mechanical reason the nerve is being compressed or irritated, such as a collapsed metatarsal arch?

[Dantheman]

That's my question as well, is it the chicken or the egg basically. He seems to think that the neuroma is causing the instability (by preventing proper firing of the muscles between my metatarsals) and is thus the root cause. X rays looked normal, haven't done any other imaging.

[Dantheman]

Cortisone shot last monday, no difference or even a little worse if anything. FML.

[Dantheman]

10/8: Call doc's office and tell nurse the cortisone shot only seems to have made things worse. Supposed to get a call back by the end of the day.

10/10: Wednesday afternoon and no word. Call in, nurse says "Oh, sorry, I forgot to tell him, I'll go tell him right now and get back to you within the hour"

10/11: Receive a call from the nurse at 3:30 pm. Doc wants me to give it until monday and report back.

10/15: Unsurprisingly it's the same on Monday. Call in and report to nurse. Receive a call from the nurse two hours later saying he wants me to try wearing different shoes for a week. Me (paraphrased): "Is that a joke? It's worse barefoot, and I've tried every shoe I own over the last 3 months and it does best in the ones I'm currently wearing", Nurse: "Well, he really wants you to try it. If that doesn't work he's not sure what else he can do for you." Me: "Ummm, OK, bye."


I can't believe this nonsense. It seems awfully likely to me at this point that there is some mechanical reason the tendon won't stay on track, and the the nerve compression/neuroma is a symptom not a cause. Toronto seems unwilling to acknowledge this possibility so I am going to try a new doctor. I called the office of the guy who fixed altachic's clavicle (Charlie Marshall, who is awesome and works on tons of athletes). He doesn't do feet but they recommended a guy at TOSH. Thankfully he takes my insurance (specialist coverage on my plan generally blows), but I can't get an appointment until November 28 so it's six more weeks of limbo and inactivity until I might get some answers. If this guy can't figure out what's wrong with me I don't know what I'm going to do. New guy is Drew Van Boerum, if anyone has any experience with him I would love to hear it.

I will give Toronto credit where credit is due. I was paying out of pocket to see him since he's not on my network and they gave me a very substantial discount because of it. I still kinda want to punch him for putting me through that prednisone regimen though.

[Vinman]

Man, DTM, bummed for you. I wish I could get a look at your foot.

So if I'm reading your posts right, they are diagnosing you with a subluxing 4th toe flexor tendon? What specifically causes the tendon to sublux? Is this only in weight bearing or is it with just active movement of your toes? Have you had an MRI? There are typically bands of tissue to hold tendons in place and maybe you tore that causing the tendon to be unstable? If so sounds surgical to me, especially since conservative treatment has failed. Have they put you in a stiff soled shoe to minimize the movement of your toes and foot?

If this is right, let me know I'll ask our foot guy if he has ever hear of it.

A second opinion is never a bad thing. I say go find someone who is more willing to get the to the bottom of your problem.

[Dantheman]

So if I'm reading your posts right, they are diagnosing you with a subluxing 4th toe flexor tendon?

Correct, subluxing medially.

What specifically causes the tendon to sublux?

Unknown. Toronto thought it was poor intermetatarsal muscle firing due to neuroma. I definitely have some degree of neuroma because I have sensation loss on the inside of the 4th toe, but I don't see it as the cause of the tendon instability due to a) no response to corticosteroid therapy; b) generally negative results to physical tests for neuroma. As long as the tendon is in proper alignment I can squeeze my metatarsals together hard and wiggle them around without pain. If the tendon is subluxed very light pressure will cause pain; and c) sudden onset of symptoms. I was running 50+ miles per week Nov-Mar with no symptoms of neuroma and had just taken two months off from running for IT band rehab.

Is this only in weight bearing or is it with just active movement of your toes?

Weight bearing only. Unweighted toe movement is actually critical to keeping it in place and avoiding pain. When I walk barefoot I have to remember to wiggle and curl my toes at least every couple steps or the tendon gets stuck in the subluxed position and the nerve starts to hurt. Finger massage has been required to get it back in place a couple times.

Have you had an MRI?

No, but I expect that will end up getting one.

There are typically bands of tissue to hold tendons in place and maybe you tore that causing the tendon to be unstable?

I'm thinking I must have tore one of those structures on that trail run back in June when this first happened. Maybe the superficial transverse metatarsal ligament or the tendon sheath. I didn't pay much attention at the time, but I have had a lot of time to think about it lately and I seem to remember it starting as an abrupt sharp pain that then subsided but didn't go away completely, then got slowly worse over the course of the run. I may be constructing a memory but I really seem to remember it happening that way now. It makes sense; stabilizing tissue tears, tendon subluxes hard and hits the nerve, tendon is tight and corrects quickly so the pain is sharp but brief, continued running keeps pushing on the destabilized tendon
causing pain for the rest of the run, pain persists after the run until the tendon finally returns to the correct alignment after much toe curling and rubbing. Continued subluxing slowly stretches tendon and now it's very loose and displaces easily.

If so sounds surgical to me, especially since conservative treatment has failed.

Surgery seems inevitable to me at this point. I'm now on almost 3 months of no lifting/running/jumping and minimal walking and weight bearing activity and it's only deteriorated.

Have they put you in a stiff soled shoe to minimize the movement of your toes and foot?

I'v experimented with every shoe I own, from super minimal to some old Merrell chameleons that are very stiff. My NB MT110s seem to treat me best. Super stiff shoes like the merrells and my steel toe work boots just allow me to do to much, and they are too clunky to wear all the time. The 110s give just enough support while still being comfortable enough to wear all day. They also have the most toe box room.

A second opinion is never a bad thing.

This will be the third opinion

[Vinman]

Our foot guy is in the office today but he's slammed. I'll try to catch him at some point to ask about this.


I'm talking more about a stiff soled orthopedic shoe that would basically immobilize your foot.... Or a walking boot with a rocker sole.

Tried any Kinesiotaping? Not sure this will help but just a shot in the dark type of idea. I'm not even sure how I would tape this....

[justinspau]

Got tired of reading..... But

1. Have you had an injection of steroid into the joint/synovial space? If not you need one oral pred/steroid has poor penetrance to the distal circulation of the foot plus more of the systemic side effects. He is rec shoes but should clarify shoes with a big toe box and an extra pad where the neuroma is located. That is the most conservative approach.

2. If its a classic neuroma it is not a major procedure to have it removed. It is relatively safe and has good results ~80% success. Keep in mind if not properly excised it can reoccur.

3. Go see an ORTHO foot and ankle specalist to make sure. This neuroma (mortons) has a classic clinical presentation
----paraesthesia of the 2 adjacent toes
----decrease irritation with message shoe off
----discomfort where u are describing (forefoot)

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[Dantheman]

Vin - No, have not gone with a full ortho shoe or boot. Neither doc has suggested it. I thought about taping my toes together, but I thought that would also compress the intermetatarsal space which could irritate the nerve so I decided against it.


justinspau - I have had a steroid injection into the nerve/intermetatarsal space. My shoes have a big toe box (EE width). I tried a neuroma pad but found it very uncomfortable. My symptoms differ from classic morton's neuroma in that I have paraesthesia of the 4 toe only and pain only occurs when the flexor tendon subluxes into the intermetatarsal space. I have not seen flexor tendon subluxation listed anywhere as a common or uncommon symptom of morton's neuroma. From the reading I have done excision of the nerve seems to be losing favor to killing the nerve in situ via dilute alcohol injections, but I think the neuroma is a symptom. New doc I am going to see is a foot/ankle specific ortho.

[justinspau]

^perfect

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[Dantheman]

In case pics are helpful:

Happy foot


Sad foot

[Vinman]

definitely not seen that type of sublux before. I still need to ask the foot guy about this. Haven't caught him at a good time yet.

[acetabulum]

Anyone checked out your ankle biomechanics? Wonder if you're not overloading the outside of your foot. If you go up on your toes (heel/calf raise), do you stay primarily on the big toe or do you roll towards the outside?

[Dantheman]

Ankle biomechanics haven't been looked at in detail, but they seem no different from the right foot and it's peachy. I've never had an injury to either ankle the went beyond a moderate sprain/strain.