Degenerative Disease | Forefoot Pain | Progressive Deformity | Multifactorial
- Second MTP joint most commonly affected due to mechanical overload
- Predisposing factors: inflammatory arthritis, trauma, instability, hallux valgus
- Conservative management successful in over 90% of early cases
- Arthrodesis gold standard for end-stage disease in active patients
- Transfer metatarsalgia common if surgical correction not balanced
- “Differentiate from synovitis, subluxation, and plantar plate tear
- “Drawer test assesses plantar plate integrity
- “Radiographs underestimate cartilage loss - weight-bearing views essential
- “Isolated arthrodesis risks transfer metatarsalgia - consider metatarsal balancing
Second MTP bears greatest load. Longer second metatarsal and first ray insufficiency (hallux valgus, shortened first metatarsal) transfer load to second MTP, accelerating degenerative change.
Never isolated in chronic cases. Look for hallux valgus, crossover toe, plantar plate tear, hammertoe. Failure to address associated deformities leads to recurrence.
90% success rate initially. Offloading with metatarsal pads, rigid soled shoes, NSAIDs, and activity modification. Reserve surgery for failed conservative management.
Arthrodesis vs arthroplasty debate. Arthrodesis provides pain relief and stability but risks transfer metatarsalgia. Arthroplasty preserves motion but higher recurrence. Combine with metatarsal osteotomy for load balancing.
- Clinical Grade
- Grade I-II
- Treatment
- Conservative: pads, orthotics, NSAIDs
- Key Pearl
- 90%+ success with conservative for 6-12 months
- Clinical Grade
- Grade II with reducible deformity
- Treatment
- Cheilectomy + metatarsal osteotomy
- Key Pearl
- Preserve motion, address overload
- Clinical Grade
- Grade III-IV with good bone stock
- Treatment
- MTP arthrodesis + metatarsal shortening
- Key Pearl
- Gold standard for pain relief, risk transfer lesion
- Clinical Grade
- Grade III-IV with poor bone
- Treatment
- Arthroplasty (resection/implant)
- Key Pearl
- Preserve length, accept instability
Overview and Epidemiology
Lesser metatarsophalangeal (MTP) joint arthritis represents degenerative disease of the second through fifth MTP joints, most commonly affecting the second MTP joint due to its mechanical disadvantage. The condition progresses from synovitis and cartilage wear to subchondral sclerosis, osteophyte formation, and eventual joint destruction with fixed deformity.
The second MTP joint experiences the highest ground reaction forces during gait, particularly when the first ray is insufficient (hallux valgus, shortened first metatarsal post-surgery, or hypermobile first ray). The second metatarsal is typically the longest, and combined with first MTP dysfunction, experiences excessive load leading to accelerated degeneration.
- Age: 40-60 years typical presentation
- Gender: Female predominance 3:1
- Occupation: Prolonged standing, athletes, dancers
- Footwear: High heels, narrow toe box
- Body habitus: Obesity increases forefoot load
- Hallux valgus: 15-20% association
- Inflammatory arthritis: RA, psoriatic, gout
- Plantar plate tears: Precursor or consequence
- Crossover toe deformity: Progressive instability
- Transfer metatarsalgia: From first ray surgery
Lesser MTP arthritis is a common source of forefoot pain but often underdiagnosed in early stages. The natural history is progressive, with early synovitis evolving to cartilage loss, joint space narrowing, and eventually fixed deformity with secondary deformities in adjacent toes.
Pathophysiology and Mechanisms
Relevant Anatomy
The lesser MTP joints are condyloid synovial joints formed by the metatarsal heads and proximal phalanx bases. Each joint has:
- Articular surfaces: Metatarsal head (convex) and phalangeal base (concave)
- Plantar plate: Fibrocartilaginous structure providing static stability, resists hyperextension
- Collateral ligaments: Medial and lateral stabilizers
- Intrinsic muscles: Interossei and lumbricals control toe position
- Extensor and flexor tendons: Dynamic stabilizers
The plantar plate is a rectangular fibrocartilaginous structure originating from the plantar metatarsal neck and inserting on the base of the proximal phalanx. It blends with the joint capsule and collateral ligaments. Attenuation or rupture (typically on dorsal-lateral aspect) leads to MTP instability, dorsal subluxation, and accelerated arthritis. This is why isolated arthrodesis without addressing plantar plate can fail.
Biomechanical Considerations
- First MTP: 50% of forefoot load normally
- Second MTP: 30% (increases to 60%+ with hallux valgus)
- Third-fifth MTPs: 10% each
- Peak pressure: Terminal stance phase
- Stage 1: Synovitis, mild dorsal subluxation
- Stage 2: Plantar plate attenuation, reducible deformity
- Stage 3: Cartilage loss, fixed deformity
- Stage 4: Bone-on-bone, crossover toe, transfer lesions
Pathophysiology
The cascade of lesser MTP arthritis typically follows this pattern:
- Initiating event: Overload (hallux valgus, long metatarsal), trauma, inflammatory disease
- Synovitis: Joint inflammation, effusion, capsular distension
- Plantar plate attenuation: Chronic synovitis weakens plantar restraint
- Instability and subluxation: Dorsal migration of proximal phalanx
- Cartilage wear: Progressive chondral damage from abnormal load
- Subchondral changes: Sclerosis, cyst formation, osteophytes
- Fixed deformity: Contracture of dorsal structures, crossover toe
- Secondary deformities: Transfer metatarsalgia, adjacent toe deformities
First ray insufficiency from hallux valgus, hypermobility, or iatrogenic shortening (overzealous Weil osteotomy on first metatarsal) causes lateral load transfer. The second MTP, being the longest ray, absorbs excessive force. This creates a vicious cycle: overload leads to synovitis, plantar plate damage, instability, and accelerated arthritis. Examiners love asking about biomechanical causes of lesser MTP pathology.
ARTHRITISCauses of Lesser MTP Arthritis
Hook:When ARTHRITIS strikes the lesser MTPs, think of all the biomechanical and inflammatory causes that overload these small joints!
DRAWDrawer Test Findings in Plantar Plate Pathology
Hook:DRAW the toe dorsally to test the plantar plate - if it draws up too much, the plate is torn!
Classification Systems
Clinical Severity Grading
- Clinical Features
- Mild pain, minimal deformity, full ROM
- Radiographic Findings
- Normal joint space, no osteophytes
- Treatment
- Conservative: orthotics, NSAIDs
- Clinical Features
- Moderate pain, reducible deformity, limited ROM
- Radiographic Findings
- Mild joint space narrowing, early osteophytes
- Treatment
- Conservative or cheilectomy + osteotomy
- Clinical Features
- Severe pain, fixed deformity, stiff joint
- Radiographic Findings
- Significant joint space loss, sclerosis, large osteophytes
- Treatment
- Arthrodesis or arthroplasty
- Clinical Features
- Disabling pain, crossover toe, transfer lesions
- Radiographic Findings
- Complete joint destruction, subluxation, bone-on-bone
- Treatment
- Arthrodesis with metatarsal shortening and balancing
The clinical severity grading system directly determines treatment strategy. Grades I-II typically respond to conservative measures for 6-12 months. Failure of conservative treatment in Grade II, or presentation with Grade III-IV disease, prompts surgical intervention. The key is matching procedure to disease severity and patient demands.
Clinical Assessment
- Pain location: Dorsal MTP joint, plantar metatarsal head
- Onset: Insidious vs acute (trauma)
- Aggravating factors: Push-off, barefoot walking, stairs
- Relieving factors: Rest, supportive shoes
- Functional impact: Difficulty with athletic activity
- Previous treatments: Orthotics, injections, footwear modifications
- Associated deformities: Hallux valgus, toe deformities
- Systemic symptoms: Inflammatory arthritis screen
- Inspection: Swelling, erythema, deformity (hammertoe, crossover)
- Palpation: Joint line tenderness, osteophytes, metatarsal head prominence
- Range of motion: Active and passive dorsiflexion/plantarflexion (compare to contralateral)
- Stability: Drawer test for plantar plate integrity
- Alignment: Deviation in coronal plane, rotation
- Transfer lesions: Plantar calluses under adjacent metatarsals
- Shoe wear pattern: Indicates load distribution
Special Tests
- Technique
- Stabilize metatarsal, translate proximal phalanx dorsally
- Positive Finding
- Excessive dorsal translation (over 50% compared to normal)
- Interpretation
- Plantar plate tear or insufficiency
- Technique
- Hyperextend MTP while palpating plantar plate
- Positive Finding
- Pain, palpable defect, lack of firm endpoint
- Interpretation
- Plantar plate tear
- Technique
- Axial compression with circumduction of toe
- Positive Finding
- Crepitus, pain
- Interpretation
- Arthritis, cartilage damage
- Technique
- Patient grips paper between affected toe and ground
- Positive Finding
- Inability to grip or pull paper from examiner
- Interpretation
- FDL weakness or plantar plate insufficiency
Isolated plantar plate tears present with acute onset, positive drawer test, and instability but may have normal radiographs initially. Lesser MTP arthritis typically has insidious onset, joint line tenderness, reduced ROM, and radiographic changes. However, chronic plantar plate tears lead to arthritis, so these conditions exist on a spectrum. MRI distinguishes acute tear (amenable to repair) from chronic tear with arthritis (requiring arthrodesis or arthroplasty).
Differential Diagnosis
- Typical Features
- Acute or attritional, instability, often normal early radiographs
- Distinguishing Test / Finding
- Positive drawer test, MRI tear without joint-space loss
- Typical Features
- Interdigital burning pain radiating to toes, no joint tenderness
- Distinguishing Test / Finding
- Positive Mulder click, tenderness in web space (not joint line)
- Typical Features
- Adolescent/young adult, second metatarsal head, dorsal stiffness
- Distinguishing Test / Finding
- Flattening/collapse of metatarsal head on radiograph
- Typical Features
- Activity-related shaft/neck pain, swelling, runners
- Distinguishing Test / Finding
- Focal shaft tenderness, callus or fracture line on imaging/MRI
- Typical Features
- Multiple joints, morning stiffness, systemic features
- Distinguishing Test / Finding
- Erosive radiographs, raised inflammatory markers / serology
- Typical Features
- Acute hot swollen joint, systemic upset
- Distinguishing Test / Finding
- Raised CRP/WCC, joint aspiration with organisms
- Typical Features
- Diffuse swelling, effusion, preserved joint space
- Distinguishing Test / Finding
- MRI synovitis without cartilage loss
Investigations
Diagnostic Workup
Weight-bearing AP, lateral, and oblique views of foot. Essential to assess joint space, alignment, degenerative changes, and metatarsal parabola.
Key findings:
- Joint space narrowing
- Subchondral sclerosis
- Osteophyte formation
- Dorsal subluxation of proximal phalanx
- Metatarsal length relationships
- Transfer lesions (adjacent joint narrowing)
Limitations: Underestimates cartilage loss, cannot visualize plantar plate.
Gold standard for soft tissue and cartilage assessment. Use when clinical suspicion for plantar plate tear, early arthritis with normal X-rays, or pre-operative planning.
Key findings:
- Plantar plate tear (high-grade vs low-grade)
- Cartilage defects and extent
- Bone marrow edema (suggests acute overload)
- Synovitis (T2 hyperintensity in joint)
- Collateral ligament integrity
Sensitivity for plantar plate tear: 87-95%.
Dynamic assessment of plantar plate, less expensive than MRI.
Findings: Plantar plate thickness (normal 3-4mm), tears, hyperemia.
Limitations: Operator-dependent, less accurate than MRI for grading tear severity.
If inflammatory arthropathy suspected:
- Rheumatoid factor, anti-CCP: Rheumatoid arthritis
- Uric acid: Gout
- ESR, CRP: Inflammatory markers
- HLA-B27: Spondyloarthropathies
Isolated degenerative arthritis does not require blood work.
Non-weight-bearing radiographs underestimate joint space narrowing and subluxation. Always obtain standing AP and lateral views to assess true alignment and joint space under physiologic load. Examiners will ask about imaging protocol - weight-bearing views are the standard of care for forefoot pathology.
Imaging Atlas
Management Algorithm
Conservative Management - First Line for Grade I-II
Indications: Mild to moderate symptoms, Grade I-II disease, no fixed deformity.
Success rate: 90%+ for early disease with 6-12 months of treatment.
Conservative Treatment Protocol
- Rigid soled shoes: Reduce MTP motion and dorsiflexion stress
- Rocker bottom: Off-loads forefoot during gait
- Wide toe box: Accommodates deformity, reduces pressure
- Low heel: Minimizes forefoot load transfer
- Metatarsal pad: Positioned proximal to painful metatarsal head, offloads joint
- Custom orthotics: Arch support redistributes load to midfoot
- Toe spacers: For crossover toe or deviation
- Accommodative padding: For plantar calluses
- NSAIDs: First-line for pain and inflammation (ibuprofen 400mg TDS, naproxen 500mg BD)
- Topical NSAIDs: Alternative for patients with GI contraindications
- Corticosteroid injection: Intra-articular, maximum 2-3 injections, 3 months apart (risk of plantar plate weakening and fat pad atrophy)
- Avoid prolonged standing, running, high-impact activity
- Cross-training with cycling, swimming (low-impact)
- Gradual return to activity as symptoms improve
If persistent symptoms despite conservative measures for 6 months, proceed to surgical consultation.
The metatarsal pad must be positioned proximal to the metatarsal heads, not under them. Correct placement unloads the MTP joint by transferring weight to the metatarsal shafts. Incorrect placement under the heads worsens symptoms. This is a common viva question and practical exam station scenario.
Conservative management is appropriate for Grade I-II disease and should be trialed for at least 6 months before considering surgery.
Surgical Technique
Lesser MTP Arthrodesis - Gold Standard
Indications: Grade III-IV arthritis, active patients, failed prior surgery, instability.
Contraindications: Active infection, severe peripheral vascular disease, neuropathy.
Operative Technique - Second MTP Arthrodesis
- Position: Supine, bump under ipsilateral hip
- Tourniquet: Thigh or ankle tourniquet (250 mmHg)
- Preparation: Sterilize to knee, foot draped free
- Fluoroscopy: C-arm positioned for AP and lateral views
- Incision: Dorsal longitudinal, 3-4 cm, centered over second MTP joint
- Dissection: Split extensor digitorum longus (EDL) tendon longitudinally
- Capsulotomy: Dorsal capsule incised longitudinally, preserve collateral ligaments if possible
- Exposure: Retract EDL, visualize metatarsal head and proximal phalanx base
- Osteophyte removal: Rongeur to remove dorsal and plantar osteophytes
- Cartilage resection: Oscillating saw or burr to remove cartilage from metatarsal head and phalangeal base
- Subchondral bone: Create raw bleeding bone surfaces, fish-scale perpendicular cuts for increased surface area
- Deformity correction: If toe deviated, resect more bone from convex side
- Metatarsal shortening: If metatarsal too long, resect 2-3mm from metatarsal head (Weil-type cut)
- Alignment goals:
- Neutral coronal plane alignment (no varus/valgus)
- 10-15 degrees plantarflexion (toe should touch ground)
- Slight external rotation to match adjacent toes
- Provisional K-wire: 1.6mm K-wire from phalangeal tip, across fusion site, into metatarsal shaft
- Fluoroscopy check: AP and lateral to confirm alignment and position
Options:
-
Plate fixation (preferred for strength):
- Mini plate (1.3mm or 1.5mm), dorsal or dorsomedial
- 2 screws proximal, 2 screws distal
- Compression achieved with lag screw technique
-
Screw fixation:
- Single 2.0-2.4mm lag screw from dorsal (countersunk)
- Or cross K-wires (2x 1.6mm) for temporary fixation
-
Combination: Plate with supplemental K-wire if bone soft
Confirm: Fluoroscopy AP and lateral, stable fixation, appropriate alignment.
- EDL tendon: Repair longitudinal split with absorbable suture
- Capsule: Close if tissue quality allows
- Subcutaneous: 3-0 absorbable
- Skin: 4-0 nylon, interrupted or subcuticular
- Dressing: Bulky dressing with toe in slight plantarflexion
Dorsal plating provides superior biomechanical stability and higher fusion rates (90-95%) compared to K-wire fixation alone (80-85%). Plates allow earlier weight-bearing and lower nonunion risk. However, plates are more expensive and may require removal if prominent. K-wires are cheaper, simpler, but require 6 weeks of pin site care and delayed weight-bearing. For exam purposes, know both techniques and when to choose each.
When fusing the second MTP, assess metatarsal parabola. If the second metatarsal is excessively long or the first ray short, perform a Weil shortening osteotomy of the second metatarsal (2-3mm) to balance load. Failure to do so risks transferring overload to the third MTP, creating new pathology.
FUSESurgical Options for Lesser MTP Arthritis
Hook:When surgery is needed, remember to FUSE your options - from motion-sparing to definitive arthrodesis!
Complications
- Incidence
- 10-30%
- Risk Factors
- Isolated surgery without balancing, over-shortening
- Management
- Metatarsal offloading, consider revision with balancing osteotomy
- Incidence
- 5-10%
- Risk Factors
- Smoking, poor bone prep, inadequate fixation
- Management
- Revision arthrodesis with bone graft and plate fixation
- Incidence
- 5-15%
- Risk Factors
- Technical error, inadequate fixation
- Management
- Observation if asymptomatic; revision osteotomy if symptomatic
- Incidence
- 10-20% (arthroplasty)
- Risk Factors
- Failure to address underlying biomechanics
- Management
- Conversion to arthrodesis
- Incidence
- Variable
- Risk Factors
- Prolonged immobilization, capsular scarring
- Management
- Physiotherapy, ROM exercises
- Incidence
- 1-2%
- Risk Factors
- Diabetes, peripheral vascular disease, smoking
- Management
- Antibiotics; debridement and hardware removal if deep
- Incidence
- 5-10% (plate)
- Risk Factors
- Prominent dorsal hardware
- Management
- Plate removal after fusion (minimum 6 months)
Transfer metatarsalgia occurs when surgery (arthrodesis or shortening osteotomy) alters the metatarsal parabola, shifting load to adjacent metatarsals. Prevention is key: assess pre-operative radiographs for metatarsal length relationships, perform balancing osteotomies when needed, avoid over-shortening. If it occurs post-operatively, treat with offloading orthotics initially; revision surgery with metatarsal osteotomy may be required for persistent symptoms.
Postoperative Care and Rehabilitation
Post-Operative Rehabilitation After MTP Arthrodesis
- Elevation: Keep foot elevated above heart level
- Ice: 20 minutes every 2 hours for first 48 hours
- Pain control: Multimodal analgesia (paracetamol, NSAIDs, opioids if needed)
- DVT prophylaxis: Aspirin 100mg daily or LMWH if high risk
- Weight-bearing: Heel weight-bearing only in post-op shoe
- Dressing: Bulky dressing, keep clean and dry
- Wound check: Day 10-14, suture removal
- Weight-bearing: Heel weight-bearing in rigid post-op shoe
- ROM: No active toe exercises, allow passive motion
- Radiograph: 2 weeks to assess alignment and hardware position
- Weight-bearing: Flat-foot weight-bearing in post-op shoe at 4 weeks if radiographs show early healing
- ROM: Gentle passive ROM of adjacent joints
- Swelling management: Compression stockings, continued elevation
- Radiograph: 6 weeks to assess fusion progress
- Weight-bearing: Transition to rigid soled supportive shoes at 6-8 weeks if fusion progressing
- Full weight-bearing: 8-10 weeks in normal shoes
- Activity: Low-impact activity (walking, cycling) at 8 weeks
- Radiograph: 12 weeks to confirm fusion
- Union: Radiographic fusion expected by 3-4 months
- Return to sport: 4-6 months, gradual progression
- Hardware removal: If symptomatic plate prominence, remove after confirmed fusion (minimum 6 months)
The weight-bearing protocol for lesser MTP arthrodesis is more conservative than forefoot osteotomies. Heel weight-bearing only for 2-4 weeks, flat-foot in post-op shoe for 4-6 weeks, then transition to supportive shoes at 6-8 weeks. Premature weight-bearing risks nonunion. Know this timeline for viva scenarios.
Outcomes and Prognosis
Conservative Management Outcomes
- Success rate: 90%+ for Grade I-II disease with appropriate conservative management for 6-12 months
- Predictors of success: Early presentation, compliance with orthotics, avoidance of aggravating footwear
- Failure rate: 10-20% progress to surgical intervention
Surgical Outcomes by Procedure
- Fusion/Success Rate
- 90-95% fusion rate
- Patient Satisfaction
- 85-90% satisfaction
- Complication Rate
- 15-20% (transfer metatarsalgia most common)
- Fusion/Success Rate
- 80-85% fusion rate
- Patient Satisfaction
- 80-85% satisfaction
- Complication Rate
- 20-25% (nonunion higher)
- Fusion/Success Rate
- 75-85% good/excellent
- Patient Satisfaction
- 70-80% satisfaction
- Complication Rate
- 25-30% (stiffness, recurrence)
- Fusion/Success Rate
- 70-80% pain relief
- Patient Satisfaction
- 65-75% satisfaction
- Complication Rate
- 30-40% (instability, recurrence)
Lesser MTP arthrodesis has the highest fusion rates, patient satisfaction, and durability compared to motion-sparing procedures. The trade-off is loss of MTP motion (which is often minimal in end-stage arthritis anyway) and risk of transfer metatarsalgia. For active patients with Grade III-IV disease, arthrodesis is the gold standard. Examiners will ask you to justify this choice.
Predictors of Poor Outcome
- Failure to address biomechanics: Hallux valgus, metatarsal length discrepancy
- Smoking: Increased nonunion risk
- Diabetes/PVD: Healing complications
- Inflammatory arthropathy: Higher recurrence
- Incorrect procedure for severity: Cheilectomy for Grade IV disease fails
- Malalignment: Malunion or uncorrected deformity
Defining the Metatarsal Parabola
The single most-repeated surgical principle in this topic is to "restore / balance the metatarsal parabola" and to shorten a "long" metatarsal - yet it never defines what the normal parabola is or how it is measured.
- The metatarsal parabola is the smooth, harmonious curve joining the tips of the metatarsal heads on a weight-bearing AP radiograph. Normal lengths decrease in an even progression: the second is usually the longest (or the first and second are roughly equal), and each of the third, fourth and fifth is then a few millimetres shorter than the one medial to it. A break in this curve - most often a relatively long second metatarsal or a short first ray - concentrates load on the prominent head and is the mechanical driver the topic keeps referring to.
- The metatarsal formula / index describes the first-to-second relationship: index plus (first metatarsal longer than second), index plus-minus (first and second equal) and index minus (first shorter than second). An index-minus foot (short first ray, as in hallux valgus or an over-shortened first metatarsal) transfers load to the second MTP - exactly the "first-ray insufficiency" mechanism this topic emphasises.
- Maestro's criteria give a reproducible planning target: the lesser-metatarsal heads should lie on a harmonious curve with the second at the apex, the fourth metatarsal head referenced to the line joining the centres of the lateral sesamoid and the fourth metatarsal head, and a regular geometric decrement from the second through the fifth. Restoring this geometry - not simply "shortening the sore ray" - is what prevents transfer metatarsalgia.
- Practical use. Before any lesser-MTP arthrodesis or Weil osteotomy, template the parabola on the weight-bearing AP: shorten only enough to sit the operated head on the curve, and if the first ray is short, consider lengthening or plantarflexing it rather than shortening the lesser rays alone.
Q: What is the metatarsal parabola and how do you use it to plan lesser-MTP surgery? A: It is the harmonious curve joining the metatarsal head tips on a weight-bearing AP film, with the second metatarsal the longest (or equal to the first) and the third, fourth and fifth stepping down in a regular decrement. The first-to-second relationship is the metatarsal formula/index (index plus / plus-minus / minus), and an index-minus (short first ray) overloads the second MTP. Using Maestro's criteria as the target, shorten the operated ray only enough to sit it back on the curve (and address a short first ray) so load is redistributed and transfer metatarsalgia is avoided.
The Weil Osteotomy Floating Toe
The evidence base and controversies repeatedly cite the "floating toe" and reduced MTP motion as the signature complications of the Weil osteotomy, but the topic never explains why they happen or how to prevent them.
- Why the toe floats. The Weil cut is made almost parallel to the sole, so as the metatarsal head is translated proximally it also drops (plantar-translates). This lowers the MTP joint axis so that the intrinsic muscles (interossei and lumbricals), whose tendons now pass dorsal to the new axis, lose their plantarflexion moment and can even act as extensors of the proximal phalanx. The toe then sits dorsiflexed and no longer purchases the ground - the "floating toe" - compounded by MTP stiffness from the intra-articular osteotomy and capsular scarring.
- Reducing the risk.
- Do not over-shorten or over-plantar-translate the head; take only what the parabola needs.
- Elevate the head by removing a thin dorsal wedge (the "double" or triple Weil / dorsal closing-wedge modification) so the head is shortened without being dropped, keeping the joint axis up.
- Balance the intrinsics - release a tight dorsal capsule and EDL, and add a flexor-to-extensor (Girdlestone-Taylor) transfer or a plantar-plate repair where there is instability.
- Start early active and passive MTP range of motion to limit stiffness.
- Why it matters here. Because this topic uses the Weil osteotomy both to offload arthritic joints and to balance the parabola, understanding the floating-toe mechanism is what lets you shorten safely and counsel the patient on the characteristic trade-off.
Q: Why does a floating toe occur after a Weil osteotomy, and how do you prevent it? A: The Weil cut, being near-parallel to the sole, plantar-translates the metatarsal head as it shortens, dropping the MTP axis so the interossei and lumbricals pass dorsal to it and lose their plantarflexion pull (even becoming extensors) - the toe dorsiflexes and loses ground contact, with added stiffness from the intra-articular cut. Prevent it by not over-shortening or over-lowering the head, removing a dorsal wedge (double Weil) to keep the head elevated, balancing the intrinsics (dorsal release, flexor-to-extensor transfer or plantar-plate repair), and starting early MTP range of motion.
Guidelines, Registries & Global Practice
Lesser MTP arthritis and the closely related plantar plate instability spectrum are common globally, with female predominance, and the second ray most frequently involved. There is no single dedicated national guideline; practice is governed by foot-and-ankle society consensus, surgical textbooks (Mann's, Coughlin), and procedure-level registry and cohort data.
- Forefoot pain is among the commonest reasons for foot-and-ankle referral worldwide
- Second MTP most affected (about 63% of instability series), reflecting first-ray load transfer
- Female predominance and middle age typical across cohorts (Brazilian, European, North American series)
- Risk drivers: hallux valgus, long second metatarsal, inflammatory arthropathy, high-heeled/narrow footwear
- No implant registry captures lesser-MTP arthrodesis as a discrete entry (unlike hip/knee), so evidence rests on cohort series and systematic reviews
- Fusion rates of roughly 90-95% with plate fixation are reproduced across centres
- Weil osteotomy durability shown to 7 years (Hofstaetter/Trnka), with floating toe as the signature complication
- MRI is the agreed reference imaging where plantar plate integrity is uncertain
- Region
- US
- Position on Lesser MTP Disease
- Conservative care first; restore metatarsal parabola surgically; arthrodesis for end-stage, motion-sparing for earlier disease
- Region
- UK / Europe
- Position on Lesser MTP Disease
- Stepwise non-operative management, address coexisting hallux valgus, individualised procedure choice
- Region
- Europe
- Position on Lesser MTP Disease
- Grade plantar plate tears (Nery classification) and match procedure to grade; Weil osteotomy widely used
- Region
- Global reference
- Position on Lesser MTP Disease
- Metatarsal pad proximal to head, biomechanical correction central, balance parabola at every step
- Routine weight-bearing radiographs plus MRI for plantar plate assessment
- Plate fixation and grade-specific plantar plate repair readily available
- Custom orthoses and formal physiotherapy pathways
- Reliance on clinical drawer test and plain radiographs; MRI often unavailable
- K-wire fixation and resection arthroplasty favoured where plates/implants are costly
- Off-the-shelf metatarsal pads and footwear modification as mainstay of conservative care
Whatever the setting, two principles are constant and examinable worldwide: exhaust biomechanically appropriate conservative care first, and protect or restore the metatarsal parabola at every surgical step to avoid transfer metatarsalgia. Consent should cover transfer metatarsalgia (10-30%), nonunion (5-10%), infection (1-2%) and possible hardware removal, with documented smoking-cessation advice given its effect on union.
Controversies and Areas of Uncertainty
No randomised trial compares lesser MTP arthrodesis with Weil osteotomy or implant arthroplasty. Arthrodesis gives the most reliable pain relief but sacrifices motion; the threshold at which to abandon joint preservation in degenerative (rather than purely unstable) disease remains opinion-based.
Grade-matched plantar plate repair improves alignment and pain, but advanced (grade IV) tears retain residual instability and poorer scores. Whether direct repair alters the natural progression to arthritis, versus simply delaying it, is unproven.
Plate fixation reports higher fusion than K-wires across cohorts, but there is no high-level head-to-head trial, and hardware prominence drives a meaningful reoperation rate. The ideal construct (plate, screw, intramedullary device) is unsettled.
There is no universally accepted radiographic classification for lesser MTP arthritis itself; grading borrows from plantar plate (Nery) and clinical severity systems. This limits comparison between studies and complicates evidence synthesis.
State that high-level evidence is limited to cohort series and a small number of systematic reviews, that procedure choice is individualised to disease grade, bone quality, activity and the metatarsal parabola, and that the consistent, defensible principle is biomechanical correction with parabola preservation. Avoid claiming any single procedure is universally superior.
MCQ Practice Points
Q: Which lesser MTP joint is most commonly affected by degenerative arthritis? A: Second MTP joint - The second MTP experiences the highest ground reaction forces, especially when first ray insufficiency (hallux valgus, short first metatarsal) transfers load laterally. The second metatarsal is typically the longest, compounding mechanical overload.
Q: What does a positive drawer test of the lesser MTP joint indicate? A: Plantar plate tear or insufficiency - The drawer test assesses plantar plate integrity by stabilizing the metatarsal and translating the proximal phalanx dorsally. Excessive translation (over 50% compared to normal) indicates plantar plate disruption, which leads to MTP instability and accelerated arthritis.
Q: What is the success rate of conservative management for Grade I-II lesser MTP arthritis? A: 90%+ - Conservative management with orthotics, metatarsal pads, rigid soled shoes, and NSAIDs is highly successful for early disease when maintained for 6-12 months. Surgery is reserved for failed conservative treatment or Grade III-IV disease.
Q: What is the preferred fixation method for lesser MTP arthrodesis and why? A: Dorsal mini-plate fixation - Plate fixation provides superior biomechanical stability compared to K-wires, resulting in higher fusion rates (90-95% vs 80-85%) and allows earlier weight-bearing. The trade-off is higher cost and potential for hardware prominence requiring removal.
Q: What is the most common complication after lesser MTP arthrodesis? A: Transfer metatarsalgia - Occurs in 10-30% of cases when surgery alters the metatarsal parabola, shifting load to adjacent metatarsals. Prevention includes pre-operative assessment of metatarsal lengths, limiting bone resection, and performing balancing osteotomies when the fused metatarsal is significantly longer than adjacent rays.
Q: What is the essential imaging requirement for diagnosing lesser MTP arthritis? A: Weight-bearing radiographs - Non-weight-bearing films underestimate joint space narrowing and subluxation. Standing AP and lateral views are mandatory to assess true alignment, joint space, and load distribution under physiologic conditions.
Exam Viva Scenarios
Practise clinical reasoning and management decisions out loud
“A 52-year-old female presents with 12 months of worsening pain under the second metatarsal head, worse with walking and wearing high heels. Examination reveals tenderness over the second MTP joint, mild swelling, and a positive drawer test. She has mild hallux valgus. Weight-bearing radiographs show mild joint space narrowing of the second MTP with small dorsal osteophytes. How would you assess and manage this patient?”
“A 58-year-old active male presents with disabling second MTP pain that has failed 9 months of conservative management including orthotics and injections. He has a fixed hammertoe deformity with the second toe crossing over the great toe. Radiographs show complete loss of second MTP joint space with subchondral sclerosis and a long second metatarsal. He wants to continue playing golf. What are your surgical options and preferred approach?”
“A 60-year-old patient underwent second MTP arthrodesis 4 months ago for end-stage arthritis. She now presents with new-onset pain under the third metatarsal head that started 6 weeks ago. Examination reveals tenderness and a plantar callus under the third MTP. Radiographs show the second MTP fusion is progressing well with good alignment, but the second metatarsal appears 4-5mm shorter than the third. How would you assess and manage this complication?”
Key Anatomy and Biomechanics
- Second MTP most affected - longest metatarsal, highest load (30% normally, 60%+ with hallux valgus)
- Plantar plate: fibrocartilaginous stabilizer, resists hyperextension, tears lead to instability
- First ray insufficiency (hallux valgus, hypermobility) transfers load to second MTP
- Metatarsal parabola: balanced load distribution requires graduated metatarsal lengths
Classification and Assessment
- Grade I: Mild pain, minimal deformity, normal joint space - conservative
- Grade II: Moderate pain, reducible deformity, mild narrowing - conservative or cheilectomy/Weil
- Grade III: Severe pain, fixed deformity, significant narrowing - arthrodesis or arthroplasty
- Grade IV: Disabling pain, crossover toe, bone-on-bone - arthrodesis with balancing
- Drawer test: assess plantar plate (over 50% dorsal translation = tear)
Conservative Management Algorithm
- First-line for Grade I-II: 90%+ success rate
- Rigid soled shoes, rocker bottom, wide toe box, low heel
- Metatarsal pad PROXIMAL to metatarsal head (offloads joint)
- NSAIDs, corticosteroid injection (max 2-3, risk plantar plate weakening)
- 6-12 month trial before considering surgery
Surgical Decision-Making
- Cheilectomy + Weil: Grade II, young, desire motion, unpredictable pain relief
- MTP arthrodesis: Grade III-IV, active, gold standard - 90-95% fusion, 85-90% satisfaction
- Arthroplasty (resection/implant): Elderly, low demand, poor bone - higher recurrence
- Must address metatarsal parabola: shorten long metatarsal or lengthen short first ray
Surgical Technique Pearls - Arthrodesis
- Dorsal approach, split EDL tendon longitudinally
- Alignment: neutral coronal, 10-15 degrees plantarflexion, slight external rotation
- Plate fixation superior to K-wire (94% vs 83% fusion)
- Weil shortening 2-3mm if second metatarsal excessively long
- Post-op: heel WB 4 weeks, flat-foot 6-8 weeks, fusion 3-4 months
Complications and Management
- Transfer metatarsalgia 10-30% - most common, prevent with metatarsal balancing
- Nonunion 5-10% - plate fixation, smoking cessation, revision with bone graft
- Stiffness common with Weil osteotomy - early ROM exercises
- Hardware prominence 5-10% - remove plate after fusion (minimum 6 months)
Key Evidence and Exam Points
- Coughlin review: 91% fusion rate, plate better than K-wire
- Conservative management: 87% avoid surgery with 6-month trial
- Weight-bearing radiographs MANDATORY - non-WB underestimate severity
- Second MTP affected due to mechanical overload from first ray insufficiency
- Arthrodesis gold standard for end-stage disease - highest satisfaction
Evidence Base and Key Studies
Prospective Surgical Protocol for Lesser MTP Plantar Plate Tears
- Prospective series of 68 patients (100 lesser MTP joints) graded by anatomical plantar plate tear system
- Grade-matched surgery: grade 0-I radiofrequency shrinkage, grade II-III direct reinsertion, grade IV flexor-to-extensor transfer; all combined with Weil osteotomy
- Significant improvement in AOFAS and VAS across all grades (p less than .0001) at mean 2-year follow-up
- Grade IV tears had the poorest results (mean AOFAS 72) and least stable joints postoperatively
- Grade I, III and IV had lower rates of normal toe purchase and ground touch than grade 0 and II
Plantar Plate and Capsular Repair for Lesser MTP Instability
- Prospective study of 22 patients (40 MTP joints) with direct dorsal plantar plate repair plus Weil osteotomy
- Second MTP joint most commonly affected (63% of joints)
- Grade III (transverse and/or longitudinal extension) tear was the most frequent pattern
- Mean AOFAS improved from 52 preoperatively to 92 postoperatively
- Direct repair corrected medial, dorsal and dorsomedial toe deviation and restored alignment
Weil Osteotomy of the Lesser Metatarsals: Clinical and Pedobarographic Outcomes
- 32 patients (59 metatarsals) treated with distal shortening (Weil) osteotomy for plantar keratoses or dislocated lesser MTP joints
- Excellent or good result in 86% of feet; mean AOFAS improved from 59 to 81 (p less than .001)
- Pedobarography confirmed significantly reduced load under the operated metatarsal heads
- Mean shortening 5.9 mm with no nonunion, delayed union or malunion
- Only 2 symptomatic transfer lesions; recurrent dislocation in 15% and reduced MTP motion noted
Weil Osteotomy: Seven-Year Prospective Follow-Up
- Prospective evaluation of 25 feet (24 patients) with subluxed or dislocated MTP joints, followed to 7 years
- Good to excellent results in 84% at 1 year and 88% at 7 years
- Mean AOFAS improved from 48 preoperatively to 75 at 1 year and 83 at 7 years
- Redislocation in 8% at 1 year, rising to 12% at 7 years
- Floating toe and restricted MTP movement recognised but durable overall outcome
MRI Diagnostic Performance for Plantar Plate Tears
- 45 lesser MTP joints in 23 symptomatic patients, 1.5-T MRI assessed against surgical reference standard
- Pericapsular fibrosis was 91% sensitive, 91% specific and 91% accurate for plantar plate tear
- Increased plantar plate-to-proximal phalanx distance (cutoff 0.275 cm) was 91% specific but only 65% sensitive
- Several direct and indirect MRI features showed good to excellent diagnostic performance
- Supports MRI when clinical examination is equivocal for plantar plate integrity
Forefoot Pain, Plantar Keratoses and Lesser Toe Deformity (Expert Consensus / Textbook Standard)
- Conservative care (metatarsal pads placed proximal to the metatarsal head, stiff-soled/rocker shoes, activity modification, NSAIDs) is first-line and resolves the majority of early lesser MTP pain
- Restoration of the metatarsal parabola is the central principle preventing transfer metatarsalgia after any lesser-ray procedure
- Arthrodesis is reserved for end-stage degeneration or salvage; motion-sparing procedures suit earlier disease
- Address coexisting hallux valgus and first-ray insufficiency to avoid recurrence