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• W2067909077 abstract "This clinical practice guideline (CPG) is based upon consensus of current clinical practice and review of the clinical literature. The guideline was developed by the Clinical Practice Guideline Forefoot Disorders Panel of the American College of Foot and Ankle Surgeons. The guideline and references annotate each node of the corresponding pathways.Central Metatarsalgia (Pathway 3)Central metatarsalgia involves pathology of the second, third, and fourth metatarsals and their respective metatarsophalangeal joints (MPJs). Metatarsal pathology may be secondary to a variety of problems including trauma, length abnormalities, structural deformity, and others. Pathology of the central MPJs is also secondary to numerous different etiologies and encompasses both osseous and soft tissue conditions. Osseous changes may be secondary to arthritis, whereas soft tissue conditions can be complex, often leading to instability of the MPJ and resultant multiplanar deformities. Systemic inflammatory conditions may produce both osseous and soft tissue abnormalities in the areas of the central MPJs.Significant History (Pathway 3, Node 1)Patients presenting with complaints related to the second, third, and fourth metatarsals and their respective MPJs typically relate a history of pain in the area of the ball of the foot, with or without swelling and/or discoloration. They may report a history of partial or complete stiffness of the affected joint(s). Symptoms are usually of gradual onset, tend to be progressive in nature, and may have been aggravated by a recent change in activity or footwear. Frequently there is no history of trauma (1Brunet J.A. Tubin S. Traumatic dislocations of the lesser toes.Foot Ankle Int. 1997; 18: 406-411Crossref PubMed Scopus (48) Google Scholar, 2Goldner J.L. Ward W.G. Traumatic horizontal deviation of the second toe: mechanism of deformity, diagnosis, and treatment.Bull Hosp Jt Dis Orthop Inst. 1987; 47: 123-135PubMed Google Scholar). Related complaints may include the development of plantar calluses in the area of where symptoms occur as well as a gradual change in appearance or position of one or more toes (3Menz H.B. Zammit G.V. Munteanu S.E. Plantar pressures are higher under callused regions of the foot in older people.Clin Exp Dermatol. 2007; 32: 375-380Crossref PubMed Scopus (64) Google Scholar).Significant Findings (Pathway 3, Node 2)Examination of the patient with central metatarsalgia symptoms may reveal edema and or inflammation in the area of the involved metatarsal(s) or MPJs. Pain on palpation of the affected metatarsal or joint is typically present (4Mendicino R.W. Statler T.K. Saltrick K.R. Catanzariti A.R. Predislocation syndrome: a review and retrospective analysis of eight patients.J Foot Ankle Surg. 2001; 40: 214-224Abstract Full Text PDF PubMed Scopus (44) Google Scholar). Pain involving the MPJ usually is exacerbated upon reaching end range of motion with manual testing. Decreased range of motion or crepitus may indicate arthrosis or other osseous changes at the MPJ. Alternatively chronic hyperextension of the MPJ may predispose the plantar plate and collateral ligaments to attenuate and rupture (5Johnston III, R.B. Smith J. Daniels T. The plantar plate of the lesser toes: an anatomical study in human cadavers.Foot Ankle Int. 1994; 15: 276-282Crossref PubMed Scopus (112) Google Scholar). In these joints, manual stress testing of the lesser MPJ may demonstrate instability as evidenced by dorsal translocation of the digit at the metatarsal head (6Thompson F.M. Hamilton W.G. Problems of the second metatarsophalangeal joint.Orthopedics. 1987; 10: 83-89PubMed Google Scholar). Typically patients with plantar plate rupture have pain with palpation plantarly at the metatarsal head or flexor crease of the affected MPJ (7Mandell G.A. Harcke H.T. Scintigraphic manifestations of infraction of the second metatarsal (Freiberg's disease).J Nucl Med. 1987; 28: 249-251PubMed Google Scholar).Change in position or alignment of the toe may or may not be seen in central metatarsalgia, as patients may present with complaints of pain at the MPJ prior to the development of associated digital deformities. If digital deformities are present, they may be multiplanar, flexible, or nonflexible. A hyperkeratotic lesion plantar to the affected metatarsal or MPJ may be present and may contribute to the patient's symptomatology (Fig. 1). Diagnostic blocks often are of great help in localizing the area of the patient's symptoms and establishing an accurate diagnosis.FIGURE 1Forefoot submetatarsal hyperkeratotic lesions vary considerably from (A) a localized discrete one to (B) a diffuse lesion under an isolated metatarsal or (C) under multiple metatarsals. (D) Biomechanical evaluation with Harris mat or computer force plate analysis may provide useful clinical information regarding pressure distribution or loading points. Soft tissue pathology such as ganglia, (E) bursa, and (F) skin pathology such as verruca and porokeratoses must be considered.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Diagnostic Testing: Radiographic Evaluation (Pathway 3, Node 3)Radiographic evaluation of the patient with central metatarsalgia symptoms should include weightbearing anterior-posterior (AP), lateral, and oblique views. A plantar axial view may also be beneficial in evaluating the structure and position of the central metatarsal heads.Radiographs are evaluated for both soft tissue and osseous changes. Soft tissue is investigated for edema, foreign bodies, and other abnormalities. Joint dislocation, subluxation, or irregularities of the metatarsal head or phalangeal base may be seen. Alignment of the second, third, and fourth MPJs as well as any abnormalities of the metatarsal parabola are assessed on the AP radiograph (Fig. 2). The presence of degenerative and/or avascular changes may be indicated by erosions, joint space narrowing, subchondral cysts, osteophyte formation, sclerosis, and alteration in the normal contour of the metatarsal head. A metatarsal stress fracture may or may not be radiographically apparent. Indeed, the first radiographic evidence of a stress fracture may be reflected by healing bone callus several weeks after the fracture had occurred (Fig. 3).FIGURE 2Metatarsal deformities are often correlated with length relationships to each other on standard weightbearing radiographs. (A) Parabola have been described as well as (B) metatarsal tangents. Certainly, osseous relationships vary from patient to patient, but weightbearing radiographs have been used as an objective parameter to explain the forefoot pathologies discussed in this document. (Metatarsal tangents from ACFAS Scoring Scale, 2006.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)FIGURE 3Metatarsal stress fractures are common. This patient had (A) radiographs taken 2 weeks prior in the emergency room that were negative and now show complete fracture with displacement of the second metatarsal. (B) A follow-up radiograph 3 weeks later shows exuberant bone callus indicative of the unstable nature of the fracture.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Additional Diagnostic Imaging Studies (Pathway 3, Node 4)Evidence of pathology at the MPJ joint or metatarsal may be further substantiated with the use of magnetic resonance imaging (MRI), computed tomography (CT), diagnostic ultrasound, radionucleotide scanning, and arthrography. These more advanced imaging techniques may assist in determining the presence and extent of both soft tissue and osseous damage in this area of the foot.MRI, CT, and radionucleotide scanning are helpful in determining the presence of metatarsal stress fracture or articular pathology such as an arthritide, Freiberg's infraction, or plantar plate rupture not appreciated radiographically (7Mandell G.A. Harcke H.T. Scintigraphic manifestations of infraction of the second metatarsal (Freiberg's disease).J Nucl Med. 1987; 28: 249-251PubMed Google Scholar). Ultrasound may support clinical evidence of soft tissue trauma/edema and may offer an alternative diagnostic aid for suspected plantar plate ruptures (8Gregg J. Silverstein M. Schneider T. Marks P. Sonographic and MRI evaluation of the plantar plate: a prospective study.Eur Radiol. 2006; 16: 2661-2669Crossref PubMed Scopus (57) Google Scholar). The use of intra-articular radio-opaque dye is beneficial in documenting a plantar plate rupture if extravasation of the dye is found to be present (9Blitz N.M. Ford L.A. Christensen J.C. Second metatarsophalangeal joint arthrography: a cadaveric correlation study.J Foot Ankle Surg. 2004; 43: 231-240Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar). Plantar pressure studies may be helpful in identifying weightbearing anomalies of the forefoot.Diagnosis (#3; Node 5)Establishment of the correct diagnosis may be very challenging as quite a variety of pathologies may be etiologic of pain in this anatomic location. These include:—Capsulitis (mechanical, arthritic, or secondary to second MPJ instability)—Metatarsal abnormalities (dorsiflexed, elongated, plantarflexed, shortened, hypertrophic plantar condyles and first ray hypermobility)—Metatarsal stress fracture—Second MPJ Instability—Other (avascular necrosis, tumor, foreign body, infection)Capsulitis (Pathway 3, Node 6)Capsulitis of the central MPJs may be secondary to mechanical or arthritic etiologies (Fig 4). Mechanical causes include any condition that results in increased forces through the joint itself as well as overload to the plantar metatarsal head. This may be associated with tears of the plantar plate or ligament disruption. Arthritic conditions include any of the inflammatory arthritidies such as rheumatoid arthritis and many of the seronegative arthritidies. Laboratory testing often is indicated in the establishment of an arthritic process. In the case of a mechanical etiology of capsulitis, treatment includes offloading and management of any contributing biomechanical abnormality with padding and/or orthotic therapy. Oral anti-inflammatory medication as well as local injection of a corticosteroid also may be beneficial. If the patient fails to respond appropriately to these measures, surgical treatment may be necessary. This would include synovectomy along with correction of any contributing pathology (eg, metatarsal abnormality) and repair of any capsuloligamentous tears if present (see Node 9).FIGURE 4(A) Lesser metatarsalgia or localized inflammation of a lesser MPJ is a symptom that is commonly associated with hallux valgus deformities with involvement of the second MPJ. (B) Forefoot derangements frequently include hammertoe deformities with progressive contracture of lesser MTP joints that may lead to complete joint subluxation in the sagittal plane or (C) with a multiplanar deformity with “cross-over” toe. Inflamed or stiff MTP joints may represent (D) a feature of diabetic Charcot foot or (E) an inflammatory arthritis with involvement of the third MPJ with significant metatarsal head erosions.View Large Image Figure ViewerDownload Hi-res image Download (PPT)When arthritis of the MPJ is the cause of capsulitis, attempts should be made to establish an accurate diagnosis of the arthritic process involved. These attempts include the previously-mentioned laboratory testing, as well as joint aspiration and rheumatologic consultation/referral if indicated. Treatment for an inflammatory arthritic condition of the central MPJs includes all of the nonsurgical and surgical alternatives previously listed for mechanically-induced capsulitis. In addition, arthroplasty-type procedures may be necessary to remove painful ostephytes, remove loose bodies, perform other procedures such as chondroplasty or joint implantation. In some cases, metatarsal head resection may at times also be considered, but this usually is done only in the presence of significant deformity, such as in the performance of pan metatarsal head resection in the setting of rheumatoid arthritis (Fig 5).FIGURE 5(A) The MPJs are a target area for rheumatoid arthritis and this patient exhibits severe deformity (B) with dislocation of the first, second, and third MPJs. (C) This patient underwent forefoot arthroplasty with first MPJ fusion and panmetatarsal head resections. (D and E) Shown are the foot and a radiograph at 1 year postsurgery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Metatarsal Abnormality (Pathway 3, Node 7)Sagittal plane abnormalities of the central metatarsals may be the result of anatomical variations that are congenital, developmental, or acquired (perhaps from trauma or prior surgery). These abnormalities can manifest themselves as dorsiflexed (elevated), elongated, plantarflexed, and shortened metatarsals, or as hypertrophic plantar condyles. Hypermobility of the first ray may result in a lateral transfer of stress away from the first metatarsal, with resultant symptoms. Any of these conditions, either alone or in combination, can cause increased load or pressure around one or more of the central metatarsals, producing pain, bursal formation, and/or a hyperkeratotic lesion.Although an elevated (dorsiflexed) metatarsal may be congenital, more frequently it is a result of trauma or a surgical procedure. Consequently, the adjacent metatarsal heads bear more weight, which may result in pain or plantar hyperkeratotic lesions.An elongated central metatarsal extends beyond the “normal” metatarsal parabola. The developmental form may be a result of delayed closure of the growth center for that particular metatarsal. However, the elongation may be only relative if adjacent metatarsals have been shortened from either trauma or surgery. During the gait cycle, particularly at the push-off phase, the elongated metatarsal tends to bear more weight for a longer period of time, resulting in symptoms of increased stress under the involved metatarsal head.A structurally plantarflexed metatarsal results in a more plantar location of its respective metatarsal head in comparison to the adjacent metatarsals. Congenital plantarflexed metatarsal is rare, but if present it is commonly associated with an anterior cavus foot deformity. The condition of an isolated plantarflexed metatarsal most often exists as a result of trauma or prior surgery. A clinical plantar prominence of the metatarsal head may also be the result of increased retrograde force from an associated digital deformity with dorsal contraction of the MPJ. This results in increased weightbearing stress, which may result in pain or a hyperkeratotic lesion beneath the metatarsal.A shortened metatarsal may be associated with a congenital or acquired syndromic condition (10Schimizzi A. Brage M. Brachymetatarsia.Foot Ankle Clin. 2004; 9 (ix.): 555-570Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar) or iatrogenically induced secondary to a surgical procedure. In addition to the decreased length of the metatarsal, relative elevation to the adjacent metatarsals results due to the inherent declination of the metatarsals. This shortening may increase the load or pressure to the adjacent metatarsal heads as they bear more weight, at times producing pain and/or hyperkeratotic lesions. Congenital shortening of a metatarsal (brachymetatarsia) usually becomes clinically evident between the ages of 4 and 15 years. Brachymetatarsia is relatively rare, with a reported incidence of 0.022% or 1 in 4586, and affects females more commonly than males in an approximate 25:1 ratio (11Davidison R.S. Metatarsal lengthening.Foot Ankle Clin. 2001; 6: 499-518Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 12Urano Y. Kobayashi A. Bone-lengthening for shortness of the fourth toe.J Bone Joint Surg Am. 1978; 60: 91-93PubMed Google Scholar). Several retrospective studies report the fourth ray being the most commonly affected (10Schimizzi A. Brage M. Brachymetatarsia.Foot Ankle Clin. 2004; 9 (ix.): 555-570Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar). A congenitally short metatarsal may also result in metatarsalgia secondary to increased weightbearing forces around the adjacent metatarsal(s). An elevated toe can cause footwear difficulties and painful hyperkeratotic lesions. Physeal abnormalities and other changes may indicate associated syndromic conditions. Complaints from patients seeking treatment for a congenitally short fourth metatarsal may be only for cosmetic concerns.Congenital hypertrophy of the plantar condyles of the metatarsal heads is rare. The condition is most commonly the result of exostosis formation secondary to an arthritic condition or a degenerative process. Inflammatory joint disease with or without bursitis may also be a significant contributing factor. Patients with atrophy or anterior displacement of the plantar fat pad will appear to have this condition and may increase weightbearing stress under the involved metatarsal head(s). The lateral plantar condyle is most commonly involved.Hypermobility of the first ray has been reported to result in overload of the second metatarsal head with resultant pathology in this area. Treatment of associated first ray hypermobility may be necessary in the treatment of central metatarsalgia.Each of these conditions creates similar symptomatology in the area of the metatarsal with the deformity or in the area of adjacent metatarsals. Elongated or plantarflexed metatarsals as well as metatarsals adjacent to an elevated metatarsal sustain increased weightbearing forces. In addition, metatarsals with hypertrophy of the plantar condyles show a similar pattern of increased forces and possible focal keratoses at the level of the condyles.Nonsurgical treatment involves medications, offloading the painful joint or metatarsal head, and treating any associated biomechanical pathology. Treatment includes padding, orthoses, and rocker-bottom shoe modifications. Nonsteroidal anti-inflammatory drugs and corticosteroid injections may also be used (13Co A.Y. Ruch J.A. Malay D.S. Radiographic analysis of transverse plane digital alignment after surgical repair of the second metatarsophalangeal joint.J Foot Ankle Surg. 2006; 45: 380-399Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar).Surgical treatment is indicated for those patients who fail to respond to nonsurgical care or for patients in whom nonsurgical care would not be considered beneficial.Dorsiflexed (elevated) metatarsals are surgically treated by an osteotomy at either the proximal or distal aspect of the metatarsal to plantarflex the metatarsal with the goal of reestablishing the normal weight bearing pattern of the forefoot. Care must be taken to avoid over- or under-correction of the deformity.Structurally plantarflexed metatarsals are surgically treated by an elevating osteotomy at either the proximal or the distal aspect of the metatarsal to re-establish the sagittal plane alignment of the bone and a normal metatarsal parabola (14Feibel J.B. Tisdel C.L. Donley B.G. Lesser metatarsal osteotomies A biomechanical approach to metatarsalgia.Foot Ankle Clin. 2001; 6: 473-489Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar) (Fig 6). Care must be taken to prevent common complications of excessive elevation or shortening resulting in transfer lesions or metatarsalgia. Painful dorsal exostosis or prominence secondary to excessive elevation and floating toe/lack of toe purchase may also occur (15Migues A. Slullitel G. Bilbao F. Carrasco M. Solari G. Floating-toe deformity as a complication of the Weil osteotomy.Foot Ankle Int. 2004; 25: 609-613PubMed Google Scholar).FIGURE 6(A) Management of metatarsalgia associated with an elongated third metatarsal and a discrete keratotic lesion. (B). This patient underwent a shortening third metatarsal osteotomy to reduce localized pressures and a discrete sub-third metatarsal head lesion.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Surgical procedures for a shortened metatarsal include acute or gradual lengthening of the metatarsal, soft tissue release, correction of associated digital deformity, and in some cases syndactyly. Specific techniques used for metatarsal lengthening include metatarsal osteotomy, bone grafting, and distraction osteogenesis, (Fig. 7). Potential complications include under- or over-correction, decreased joint motion, delayed union, nonunion, malunion, or graft failure. Amputation at the MTP joint should be avoided because of the risk of subsequent adjacent toe deformity (16Ferrandez L. Yubero J. Usabiaga J. Ramos L. Congenital brachymetatarsia: three cases.Foot Ankle. 1993; 14: 529-533Crossref PubMed Scopus (26) Google Scholar).FIGURE 7(A) Brachymetatarsia most often involves the fourth metatarsal. This patient was surgically treated with distraction osteogenesis. (B) Fixator is in place. (C) Radiography at 1-year postsurgery shows very nice reconstitution of metatarsal length and morphology. (Courtesy Alan Banks, DPM, Atlanta, GA)View Large Image Figure ViewerDownload Hi-res image Download (PPT)Surgical treatment of enlarged plantar condyles is performed when the symptoms of metatarsalgia are due to the prominence and resultant increased pressure or load caused by this abnormality. Surgical treatment of enlarged plantar condyles involves remodeling or resection (condylectomy) of the involved metatarsal condyles. If other etiologic factors such as those described previously are determined to exist, consideration should be given to other procedures to treat the coexisting deformity.Operative treatment of first ray hypermobility may be necessary in some instances. This is usually done via medial column arthrodesis.Metatarsal Stress Fracture (Pathway 3, Node 8)Stress fractures of the central metatarsals develop when the bone is subjected repetitively to sub-failure loads (17Milgrom C. Finestone A. Sharkey N. Hamel A. Mandes V. Burr D. et al.Metatarsal strains are sufficient to cause fatigue fracture during cyclic overloading.Foot Ankle Int. 2002; 23: 230-235PubMed Google Scholar, 18Brukner P. Bradshaw C. Khan K.M. White S. Crossley K. Stress fractures: a review of 180 cases.Clin J Sport Med. 1996; 6: 85-89Crossref PubMed Scopus (230) Google Scholar, 19Arnd A. Ekenman I. Westblad P. Lundberg A. Effects of fatigue and load variation on metatarsal deformation measured in vivo during barefoot walking.J Biomech. 2002; 35: 621-628Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar). Stress fractures make up as much as 20% of all sports-related injuries (20Fredericson M. Jennings F. Beaulieu C. Matheson G.O. Stress fractures in athletes.Top Magn Reson Imaging. 2006; 17: 309-325Crossref PubMed Scopus (202) Google Scholar). A greater incidence of these injuries among females has been reported (21Kaye R.A. Insufficiency stress fractures of the foot and ankle in postmenopausal women.Foot Ankle Int. 1988; 19: 221-224Crossref Scopus (26) Google Scholar). Patients with chronic inflammatory arthropathies, severe osteoporosis, marked joint deformity, or receive chronic corticosteroid therapy are at high risk of developing stress fractures (22Maenpaa H. Lehto M.U. Belt E.A. Stress fractures of the ankle and forefoot in patients with inflammatory arthritides.Foot Ankle Int. 2002; 23: 833-837PubMed Google Scholar). Stress fractures of the second metatarsal base are most commonly seen in dancers (23Hardaker Jr, W.T. Foot and ankle injuries in classical ballet dancers.Orthop Clin North Am. 1989; 20: 621-627PubMed Google Scholar, 24Sarimo J. Orava S. Alanen J. Operative treatment of stress fractures of the proximal second metatarsal.Scand J Med Sci Sports. 2007; 17: 383-386Crossref PubMed Scopus (12) Google Scholar, 25Micheli L.J. Sohn R.S. Solomon R. Stress fractures of the second metatarsal involving Lisfranc's joint in ballet dancers:a new overuse injury of the foot.J Bone Joint Surg Am. 1985; 67: 1372-1375PubMed Google Scholar, 26O'Malley M.J. Hamilton W.G. Munyak J. DeFranco M.J. Stress fractures at the base of the second metatarsal in ballet dancers.Foot Ankle Int. 1996; 17: 89-94Crossref PubMed Scopus (65) Google Scholar). Although the length of the first metatarsal has been implicated as a risk factor for weight transference, equivalent rates of fracture in short, average, and long first metatarsal conditions have been reported (27Drez Jr, D. Young J.C. Johnston R.D. Parker W.D. Metatarsal stress fractures.Am J Sports Med. 1980; 8: 123-125Crossref PubMed Scopus (43) Google Scholar). Numerous studies have shown that abnormal mechanics of the first ray may transfer weight to the adjacent metatarsals and lead to stress transference and fracture of the adjacent metatarsal (28Kitaoka H.B. Cracchiolo III, A. Stress fracture of the lateral metatarsals following double-stem silicone implant arthroplasty of the hallux metatarsophalangeal joint.Clin Orthop Relat Res. 1989; 239: 211-216PubMed Google Scholar, 29Friend G. Sequential metatarsal stress fractures after Keller arthroplasty with implant.J Foot Surg. 1981; 20: 227-231PubMed Google Scholar, 30Zechman J.S. Stress fracture of the second metatarsal after Keller bunionectomy.J Foot Surg. 1984; 23: 63-65PubMed Google Scholar).The majority of metatarsal stress fractures occur in the second and third metatarsals. Radiographic examination may be normal for several weeks after the onset of symptoms. In cases of uncertain diagnosis or in cases where more aggressive treatment might be indicated (ie, high performance athletes), a technetium bone scan, MRI, or CT scan may assist in the early detection of a stress fracture (31Santi M. Sartoris D.J. Resnick D. Diagnostic imaging of tarsal and metatarsal stress fractures Part II.Orthop Rev. 1989; 18: 305-310PubMed Google Scholar).The primary treatment of a central metatarsal stress fracture is immobilization and offloading with the use of a walking boot or surgical shoe along with activity modification (32Gehrmann R.M. Renard R.L. Current concepts review: stress fractures of the foot.Foot Ankle Int. 2006; 27: 750-757PubMed Google Scholar, 33Fetzer G.B. Wright R.W. Metatarsal shaft fractures and fractures of the proximal fifth metatarsal.Clin Sports Med. 2006; 25 (x.): 139-150Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar). Proper shoes and orthoses are used to control abnormal biomechanical influences and may relieve symptoms. Failure to address pre-existing biomechanical abnormalities that result in metatarsal stress fractures can lead to complete fracture or possible recurrence (34Kaeding C.C. Yu J.R. Wright R. Amendola A. Spindler K.P. Management and return to play of stress fractures.Clin J Sport Med. 2005; 15: 442-447Crossref PubMed Scopus (96) Google Scholar, 35Heaslet M.W. Kanda-Mehtani S.L. Return-to-activity levels in 96 athletes with stress fractures of the foot, ankle, and leg: a retrospective analysis.J Am Podiatr Med Assoc. 2007; 97: 81-84Crossref PubMed Scopus (10) Google Scholar). Return to regular activity or sport is allowed once adequate fracture healing has been accomplished. In the event of malunion, the metatarsal may become elevated, plantar-flexed, and/or shortened and this may increase the load to adjacent metatarsals. Surgical treatment of a metatarsal stress fracture is rarely necessary. However, surgery may be required in cases of complete fracture, failure to heal with usual nonsurgical measures, or in cases of malunion (24Sarimo J. Orava S. Alanen J. Operative treatment of stress fractures of the proximal second metatarsal.Scand J Med Sci Sports. 2007; 17: 383-386Crossref PubMed Scopus (12) Google Scholar).Other (Pathway 3, Node 9)Other causes of central metatarsalgia-related symptoms also exist. These include second MTP joint instability, avascular necrosis, tumor, foreign body, and infection.Second MPJ InstabilityThe second MPJ is most frequently implicated in MPJ instability. Second MPJ instability with or without inflammation of the articular and peri-articular structures can lead to multiplanar malalignment. Second MPJ instability has been described as predislocation syndrome (36Yu G.V. Judge M.S. Hudson J.R. Seidelmann F.E. Predislocation syndrome Progressive subluxation/dislocation of the lesser metatarsophalangeal joint.J Am Podiatr Med Assoc. 2002; 92: 182-199Crossref PubMed Scopus (98) Google Scholar), plantar plate dysfunction (37Blitz N.M. Ford L.A. Christensen J.C. Plantar plate repair of the second metatarsophalangeal joint: technique and tips.J Foot Ankle Surg. 2004; 43: 266-270Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar), mono-articular non-traumatic synovitis, MPJ capsulitis and synovitis, metatarsalgia, and" @default.
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• W2067909077 title "Diagnosis and Treatment of Forefoot Disorders. Section 2. Central Metatarsalgia" @default.
• W2067909077 cites W1469171564 @default.
• W2067909077 cites W1521265226 @default.
• W2067909077 cites W178410707 @default.
• W2067909077 cites W1903212275 @default.
• W2067909077 cites W1944741848 @default.
• W2067909077 cites W1954196596 @default.
• W2067909077 cites W1965376323 @default.
• W2067909077 cites W1966084953 @default.
• W2067909077 cites W1966772396 @default.
• W2067909077 cites W1970798409 @default.
• W2067909077 cites W1973052352 @default.
• W2067909077 cites W1973065154 @default.
• W2067909077 cites W1979944926 @default.
• W2067909077 cites W1985623559 @default.
• W2067909077 cites W1992524699 @default.
• W2067909077 cites W1993495194 @default.
• W2067909077 cites W199580283 @default.
• W2067909077 cites W2008083252 @default.
• W2067909077 cites W2011595760 @default.
• W2067909077 cites W201817228 @default.
• W2067909077 cites W2025218331 @default.
• W2067909077 cites W2029609664 @default.
• W2067909077 cites W2033465901 @default.
• W2067909077 cites W204752848 @default.
• W2067909077 cites W2052475953 @default.
• W2067909077 cites W2076970254 @default.
• W2067909077 cites W2082602479 @default.
• W2067909077 cites W2090315114 @default.
• W2067909077 cites W2094993167 @default.
• W2067909077 cites W2099570418 @default.
• W2067909077 cites W2105363501 @default.
• W2067909077 cites W2128422261 @default.
• W2067909077 cites W2140801896 @default.
• W2067909077 cites W2150239055 @default.
• W2067909077 cites W2159203497 @default.
• W2067909077 cites W2171582664 @default.
• W2067909077 cites W2255893141 @default.
• W2067909077 cites W2324366435 @default.
• W2067909077 cites W2331492247 @default.
• W2067909077 cites W2399925191 @default.
• W2067909077 cites W2417185475 @default.
• W2067909077 cites W2419256578 @default.
• W2067909077 cites W2471013537 @default.
• W2067909077 cites W4239438235 @default.
• W2067909077 cites W4240073263 @default.
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