soreness bottom of 2nd toe

by Ann
(Simsbury CT USA)

I have quite a bit of pain upon walking at the base of the second toe on my left foot. It started while walking, gradually getting worse each time I walked last October. I am a teacher and on my feet all day so by the time I got home I did not want to go for a walk for exercise.I didn't really want to walk at all. I am 64 and about 15 lbs overweight according to the doctor. If I wear Chaco sandals the area does not feel sore for most of the day( a normal day at home- not a teaching day) but If I were to walk long distances the soreness returns even with those. I wear very supportive shoes with orthotics. The shoes have a wide toe area- no pointed toe shoes. I got the orthotics last summer when I had what the doctor thought was another foot problem but turned out to be a compressed nerve in my back. I have tried Hap pads ( metatarsal pads) but they haven't helped. The doctor did an ultra sound last spring and found fluid in the joint. The x ray report:no evidence of fracture or dislocation. minimal subarticular reaction large toe MTP, minimal hallus valgus. otherwise normal bones, joints and soft tissue.MRI report:Everything was normal. No morton's neuroma

Although it is summer and I haven't been on my feet as much there is still some soreness and I am concerned about returning to school in 2 weeks and the possibility of increased soreness and pain. I would like to know what the possible treatment would be for this so that I can prevent it and what the problem is. Thanks.

RESPONSE

Hi Ann,

The good news is that there are very few things that can cause pain under the second toe at the level of the metatarsal-phalangeal joint.

You do not mention if you have had any cortisone injections or even oral anti-inflammatory medication. Sounds like you have had just orthotic therapy, which raises another question. Is there a metatarsal pad built into the orthotic? The metatarsal pads you tried, were they attached to the orthotic or just "pasted" on to the foot?

Based on your narrative, the two things that come to mind are either capsulitis which is an inflammation of the ligament on the bottom of the toe that attaches into the metatarsal bone or its evil twin, a plantar plate tear, where this structure actually tears.

Fluid in the joint as evidenced by ultrasound would be suggestive of either of these conditions, BUT, generally an MRI will pick up a plantar plate tear. (there is always the possibility the tear was missed and perhaps you should have the MRI read by someone else).

In any event, if you have capsulitis, it should respond to a properly placed metatarsal pad along with either a cortisone injection or oral anti-inflammatory medication. A plantar plate tear on the other hand may feel better with this type of treatment but probably will not heal itself.

Do you have hammertoes, particularly rigid hammertoes which stay bent all the time and are hard to straighten with your hands? It is usually hammertoes that exacerbate both of these problems making it difficult for the problem to "just go away".

Do you find the problem worse if you walk barefoot on a hard floor like tile? Does it feel better on carpeting or in a good pair of sneakers?

If you are answering yes to all these questions than more than likely you have either capsulitis or a plantar plate tear.

Another test that you could perform to see if this is your problem, is to walk around in a surgical shoe. This type of shoe keeps the forefoot rigid and does not allow the toes to bend. If the pain subsides with this type of shoe, once again I would lean towards the diagnosis I have discussed.

In order to tell you how to prevent it going forward, you first have to remedy it, which you have not yet done. Secondly, I would have to actually see your foot and a sampling of the shoes that you wear in order to give you guidance going forward, however, I would think any qualified podiatrist should be able to do the same.

Marc Mitnick DPM
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