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Saturday, July 16, 2016

2nd MPJ injury: Email Advice

Dear Dr Blake,

I came across your website trying to research my foot problem, however I am not able to view it well (text & images overlap, things are scrambled) I use a Mac and have been trying with Safari and Chrome). I did find you e-mail and hope you don't mind me writing to you directly.
Dr Blake's comment: Not sure what that is about, but I hope it is not a wide spread. It would ruin my blog for sure.

I have not found anyone to help me with some disabling left foot pain in the 2nd metatarsal area and wonder if you have by any chance have any recommendations for specialists in New Mexico.
Dr Blake's comment: Look for Dr Robert Parks in Albuquerque. 

 I am attaching a copy of the MRI I was finally able to get. Summary says “prominent chondromalacia, prominent bone marrow edema and subchondral cystic/erosive change of the 2nd metatarsal head" also "various/adduction of the forefoot osseous structures associated with mild subluxation at the 2nd MTP articulation”. Big toe also showed some much milder issues. There was also thinning of cartliage in both & small amount of joint fluid in both”.

Dr Blake's comment: There was no attachment to this email. The MRI report says that there is extensive damage to the 2nd metatarsal head which typically means at least a joint surgery with cleanout. 

A very quick history of this: about 2 years ago I started having some mild pain in my left foot when going for my daily walks, 2nd metatarsal area. Never had it before. (I’ve only always worn excellent shoes, e.g. birkenstocks, wide toe running or walking shoes, some Keens). In the beginning it was off and on and got worse as I walked. It also got worse in the winter when I had to wear my winter boots or hiking boots.  (I do have severe osteoporosis (-4.5 DEXA) due to hyperparathyroid disease that was not caught in time (I ended up having parathyroid surgery, but my bone density did not improve).
Dr Blake's comment: With that low bone density, you can not heal well when your bones are injured, even in the slightest degree from walking. 

So I went to a podiatrist last year who did X-rays and ultrasound (said x-ray didn't show anything but ultrasound showed a “slight thickening" in the area where I had pain and said maybe a stress fracture) and had his tech put a metatarsal pad on. That immediately made it much worse (told him, just said to keep trying it) and I ended up having to take it off later at home (later, from my own reading, discovered that he hadn't put it in the correct place on my foot). In the following months I could usually still walk in birkenstocks or running shoes, so I thought maybe it would just get better.
Dr Blake's comment: The met pads are to off weight the painful area, so need to be towards the arch just next to the sore area.


Then over a short period of time (about a month), it got significantly worse, very severe pain and I couldn’t walk in anything (except barefoot in the house, though not great on the tile floors). Even started having pain up ankle and in heel of right foot but probably from way I was compensating when walking. My second toe seemed to (suddenly?) be very loose at the joint, which I hadn’t had before. Saw a podiatrist who thought I had capsulitis (though from what I’d read it didn't seem like I had the symptoms of that). She only did a very brief exam (just touching a few points in my left foot) and wasn’t interested in x-rays.
Dr Blake's comment: So, sounds like arthritis in the joint, possibly from osteoporosis and wear and tear, and then plantar plate tear with resultant joint instability. 

So I went for a consult with an orthopedic surgeon. He read the MRI, and in addition to the radiologist’s report he said there was a small cyst in the area and the tendon was "stretched out”.  He mentioned surgery that could be done but said he’d “hate to be the one to put a scalpel in me” (and really didn’t seem to be recommending it). Said I could get a steroid injection under X-ray but also said it could worsen the tendon issue and at best is only quite temporary relief. Said physio wouldn't help at all and a boot would throw off my gait more so didn’t recommend.
Dr Blake's comment: Yes, avoid the cortisone. Consider the New Balance 928 wide with rocker bottom. You need to get a Budin Splint looping it gentely over the 2nd and 3rd toes. Ice 2 or 3 times per day. The splint is like a ankle brace for ankle sprains. You wear for 6 months minimum. 


Needless to say I’m extremely reluctant to have surgery, and I don't even know if I should have a steroid injection (for only temporary relief and perhaps worsening of tendon, and from what I’ve read, risk to plantar plate), but he said that’s all he can offer. I’ve being reading several medical journal articles…with no real answers, except that with the marrow edema, there’s a danger of necrosis (which orthopedic surgeon acknowledged), mention of need to get at underlying cause, and some say immobilization (though orthopedic didn’t say this).  I did read some cases of bone marrow edema treated with IV iloporst which I hadn't read at the time of my appointment, so didn’t ask about that.  I asked about  a couple other things I’d read about  bone stimulators, PRP and he said "they are extremely expensive, and show no scientific evidence”. I’m not sure how the marrow edema and chondromalacia and other things mentioned on the MRI relate to each other, or what to do about any of it.
Dr Blake's comment: I am hopeful Dr Parks can help you. You can also look on the AAPSM website for other members on the sports academy. They tend to be less aggressive for surgery. Surgery may be what you need, and the plate may now be already torn. Try to create your painfree environment (0-2 pain levels) first either with rocker shoes with splint or Anklizer boot (with EvenUp on the other side if needed to level your hips) with splint. Ice to calm down. Comment on this post if you have other thoughts, or progress over the next few months. I will be off line in September. Hope this helps you some. Rich

I’ve not had any treatment really except to try on my own metatarsal pads with no real success, but at this point it’s painful to walk at all. The only activity I’ve done for the last month is walking around the house as necessary. Is there any treatment I could try? Does something like this get better eventually?Do you think a steroid injection would help?
Dr Blake's comment: No steriod please. The joint sounds messed up, so it is hard to predict the outcome. Just take one step at a time, and create that pain free environment. I have seen very bad looking MRIs and x rays that did not hurt, so your pain and function are the best indicators over the next 6 months on whether surgery is needed. 

Thanks for any help or suggestions you can offer,

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.