Assessing and Managing First Metatarsophalangeal Joint Pain

Abstract and Introduction

Abstract

Nontraumatic pain in the first metatarsophalangeal joint is frequent and can be debilitating. The metatarsophalangeal joint complex comprises four articulating surfaces including the first metatarsal, the proximal phalanx, and tibial and fibular sesamoids, which are all contained within a synovial capsule. The most common causes of pain are hallux valgus and hallux rigidus. However, other diagnoses, such as functional hallux limitus, sesamoiditis, gout, and inflammatory autoimmune arthritis, need to be considered as well. A systematic approach is key to accurately diagnose the source of pain, which can sometimes be the result of more than one condition. The most important clinical information to obtain is a focused history, meticulous clinical examination based on understanding the precise anatomy and biomechanics of the first metatarsophalangeal joint, and analysis of the relevant imaging. Each pathology has a different treatment algorithm, as such, understanding the pathoanatomy and biomechanics is important in forming an effective treatment plan.

Introduction

Nontraumatic pain in the first metatarsophalangeal joint (MTPJ) is present in around 5% of the cohort and can be debilitating, causing a notable reduction in health-related quality of life.^[1] Moreover, MTPJ arthritis is the most frequent joint presenting with arthritis in the foot and the second most common location of arthritis in the lower limb after the knee.^[2] The approach to the nontraumatic painful first MTPJ needs to be systematic because the anatomic structures responsible for symptoms are close and sometimes symptoms overlap. There are effective nonsurgical and surgical treatment options that need to be modified depending on the structures affected. In the setting of one of the most common surgeries performed in the foot and ankle—hallux valgus deformity correction^[3]—up to 4.6% of the patients can present with unresolved pain, potentially due to a missed diagnosis of the source of pain.^[4]

In this review, we will discuss the assessment and management of possible causes of atraumatic MTPJ pain. Note that hallux valgus has been recently reviewed in detail^[43] and has been excluded from this article. We will focus instead on the other causes of atraumatic MTPJ pain as well as the principles and goals of surgical correction.

Table 1. Surgical Procedures for the Treatment of Hallux Limitus
Surgical Procedures for Hallux Limitus
Distal plantar flexion first metatarsal osteotomy
Proximal dorsal opening wedge osteotomy of the first metatarsal
First tarsometatarsal plantar flexion fusion
Flexor hallucis tendon retinaculum release
Hallux proximal phalanx dorsal closing wedge osteotomy (Moberg)
Release of the flexor hallucis brevis and/or plantar fascia in the MTPJ level

Table 2. Most Reliable Procedures for Hallux Rigidus
Surgical Procedures for Hallux Rigidus
Cheilectomy: Dorsal side
Osteotomy: Hallux proximal phalanx dorsal closing wedge osteotomy (Moberg)
Arthroplasty
Resection (Keller procedure)
Interpositional
Arthrodesis ± structural grafting

Table 3. Less Common Causes of First MTP Pain
Diagnosis	Etiology	Clinical Assessment	Laboratory/Imaging	Treatment
Sesamoiditis	Repetitive stress and/or improper sesamoid tracking Mechanical overload on the sesamoids from cavovarus foot associated with a plantarflexed first ray → decreased surface of ground contact on the foot sole Sesamoid acute or stress fracture.^14,39	Localized tenderness, inflammation at the plantar aspect of joint, specifically at articulation of MT head with tibial and or fibular sesamoid± first ray plantar flexion, peroneal overdrive	Diagnosis of exclusion Radiographs often normal, including normal bipartite variations SPECT CT: assess intake and bone/joint anatomy MRI: Assess bone edema	Nonsurgical Acute (infrequent): postoperative sandal and partial heel weight bearing for 4–6 weeks Chronic: Orthotics with support on the lesser metatarsals and an offload area for the 1st metatarsal head. Dancer's pad. Surgical Sesamoidectomy Consider realignment of the foot if significant overload under the 1st metatarsal head
Gout	Systemic disease that results from the deposition of monosodium urate crystals in tissues, mainly around the joints.1st MTPJ is the most frequently affected joint "podagra"⁴⁰	Acute episodes/flares of monoarticular arthritis lasting 7–10 days Pain (± unwilling to weight bear), swelling, erythema, warmth, decreased ROM Pathognomonic: palpable tophi in surrounding soft tissues	Laboratory: Uric acid ≥0.41 mmol/L Joint aspirate for definitive diagnosis, rule out septic arthritis Radiographic progression: Joint effusion with preserved joint space → eccentric "punched out" lytic erosions, overhanging sclerotic margins If joint aspirate is contraindicated, dual-energy CT is a secondary option but not as reliable as joint aspirate	Nonsurgical Prophylaxis: Urate-lowering medications, lifestyle modifications (weight loss; limited dietary intake of alcohol, high-fructose corn syrup, and purine-rich foods⁴¹ Acute flare management: Oral NSAIDs, oral colchicine, oral glucocorticoids ± intra-articular glucocorticoid injections Surgical (consider preoperatively MRI vs dual-energy CT) Resection of extra-articular gouty tophi or arthrodesis if intra-articular tophi or arthritic changes in >50% of the joint
Autoimmune inflammatory arthropathies⁴²	Autoimmune inflammation of synovial joints—the most common is rheumatoid arthritis Worsening synovitis → joint destruction, deformity	Deformity, commonly hallux valgus + lesser toes deformities ± subluxation/dislocation Symmetric polyarthritis, particularly of the metacarpophalangeal joints, metatarsophalangeal joints and proximal interphalangeal joints Sometimes associated with vasculitis or neuropathy	Radiographs: Joint effusion, juxta-articular osteopenia, concentric narrowing, marginal erosions MRI: sensitive for early disease Basic laboratory: Rheumatoid factor, CRP, ESR, ANA, anti-CCP, HLA-B27	NSAIDs Steroids DMARDs Biologic response modifiers Targeted synthetic DMARDs

Table 3. Less Common Causes of First MTP Pain

Diagnosis

Etiology

Clinical Assessment

Laboratory/Imaging

Treatment

Sesamoiditis

Repetitive stress and/or improper sesamoid tracking
Mechanical overload on the sesamoids from cavovarus foot associated with a plantarflexed first ray → decreased surface of ground contact on the foot sole
Sesamoid acute or stress fracture.^14,39

Localized tenderness, inflammation at the plantar aspect of joint, specifically at articulation of MT head with tibial and or fibular sesamoid± first ray plantar flexion, peroneal overdrive

Diagnosis of exclusion
Radiographs often normal, including normal bipartite variations
SPECT CT: assess intake and bone/joint anatomy
MRI: Assess bone edema

Nonsurgical Acute (infrequent): postoperative sandal and partial heel weight bearing for 4–6 weeks Chronic: Orthotics with support on the lesser metatarsals and an offload area for the 1st metatarsal head. Dancer's pad.
Surgical Sesamoidectomy Consider realignment of the foot if significant overload under the 1st metatarsal head

Gout

Systemic disease that results from the deposition of monosodium urate crystals in tissues, mainly around the joints.1st MTPJ is the most frequently affected joint "podagra"⁴⁰

Acute episodes/flares of monoarticular arthritis lasting 7–10 days
Pain (± unwilling to weight bear), swelling, erythema, warmth, decreased ROM
Pathognomonic: palpable tophi in surrounding soft tissues

Laboratory: Uric acid ≥0.41 mmol/L
Joint aspirate for definitive diagnosis, rule out septic arthritis
Radiographic progression: Joint effusion with preserved joint space → eccentric "punched out" lytic erosions, overhanging sclerotic margins
If joint aspirate is contraindicated, dual-energy CT is a secondary option but not as reliable as joint aspirate

Nonsurgical Prophylaxis: Urate-lowering medications, lifestyle modifications (weight loss; limited dietary intake of alcohol, high-fructose corn syrup, and purine-rich foods⁴¹ Acute flare management: Oral NSAIDs, oral colchicine, oral glucocorticoids ± intra-articular glucocorticoid injections
Surgical (consider preoperatively MRI vs dual-energy CT) Resection of extra-articular gouty tophi or arthrodesis if intra-articular tophi or arthritic changes in >50% of the joint

Autoimmune inflammatory arthropathies⁴²

Autoimmune inflammation of synovial joints—the most common is rheumatoid arthritis
Worsening synovitis → joint destruction, deformity

Deformity, commonly hallux valgus + lesser toes deformities ± subluxation/dislocation
Symmetric polyarthritis, particularly of the metacarpophalangeal joints, metatarsophalangeal joints and proximal interphalangeal joints
Sometimes associated with vasculitis or neuropathy

Radiographs: Joint effusion, juxta-articular osteopenia, concentric narrowing, marginal erosions
MRI: sensitive for early disease
Basic laboratory: Rheumatoid factor, CRP, ESR, ANA, anti-CCP, HLA-B27

NSAIDs
Steroids
DMARDs
Biologic response modifiers
Targeted synthetic
DMARDs