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The response to the question below was authored by Marc Mitnick DPM

New diagnosis, same pain 2nd and 3rd metatarsal post bunionectomy

by Katherine
(Richmond, VA)

It's now been 14 months since the bunionectomy. I've seen 3 Podiatrists with 3 different diagnosis. Luckily, 2 started talking with each other and have agreed that I have Freiberg's Infarction. I was told either too much bone was taken off during the osteotomy and/or the surgeon didn't place a pin for stability. Either way, this caused a "forefoot imbalance" resulting in a lot of stress on the 2nd and 3rd Metatarsals. Is a pin customarily used with a Bunionectomy? The heads of the joints have flattened. I've had 2 MRI's. The bones are not dead. Right now, my doctor is trying conservative treatments. High doses of Vitamin D (my levels are low), a bone stimulator and an orthotic (which i'm really having a hard time using) If this doesn't work, she says I will need a joint replacement.

I also have a small nodule on the forefoot under the 2nd Metatarsal. It can move if touched and causes a lot of pain too. The MRI shows no neuromas. I was told it could possibly be a ganglion cyst. What I have read, it might also be bone fragments??
Any input would be appreciated again. Thank you.

RESPONSE

Hi Katherine,

Freiberg's disease is a fairly easy diagnosis to make based on an x-ray and a history of localized pain in the area.
If you had a bunionectomy that required an osteotomy where the metatarsal bone was surgically broken and reset, whether a pin or any other type of fixation was used or not, what happens is that the first metatarsal bone shortens slightly and this then creates excessive pressure on the second metatarsal bone and sometime even the third metatarsal bone. This excess pressure could be enough to cause Freiberg's disease.
As far as the movable growth underneath the foot, the MRI should be able to make a distinction between a bone spur and a ganglion cyst. From a purely clinical standpoint I find it impossible to believe a bone spur could be large enough to be felt and movable. My guess is that it is a cyst. If it hurts enough, you might consider a cortisone injection to see if that will relieve it.
A major component of treating Freiberg's disease is to rest the joint, so the process can calm down. My opinion is that an orthotic is probably not the best best and either a surgical shoe or even crutches and non-weightbearing might be a better option. You should speak to your doctor about that possibility.

Marc Mitnick DPM
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Colorado

Wonderful advice

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