Metatarsophalangeal Joint Synovitis Research Articles

Ultrasound findings of plantar plate tears of the lesser metatarsophalangeal joints.

Lesser metatarsophalangeal (MTP) joint plantar plate tears are a common and increasingly recognised cause of metatarsalgia, MTP joint instability and forefoot deformity. Increased interest in early accurate diagnosis of plantar plate tears follows recent surgical innovations allowing direct plantar plate repair. The purpose of this review is to describe the ultrasound features of normal lesser MTP joint plantar plates and to characterise and illustrate the direct and indirect ultrasound findings of plantar plate tears. Lesser MTP joint plantar plate tears are most commonly located at the 2nd MTP joint, involving the lateral distal plantar plate insertion with variable propagation medially and proximally. The most common ultrasound appearance of a plantar plate tear is a discrete partial or full thickness hypoechoic defect in the plate substance. Flattening and attenuation or non-visualisation of the plantar plate represent more extensive tears. Dynamic imaging with toe dorsiflexion improves visualisation of tears and augments MTP joint subluxation. A common indirect finding is pericapsular fibrosis along the MTP joint capsule adjacent to a plantar plate tear, which requires differentiation from Morton's neuroma, and key distinguishing features at ultrasound are described. Other indirect findings include the cartilage interface sign, flexor tendon subluxation onto the metatarsal head or medial to the midline, flexor tenosynovitis, proximal phalangeal enthesophytes or avulsion and MTP joint synovitis. Ultrasound offers several advantages over MR imaging but requires a meticulous ultrasound examination, and optimisation of scanning technique is described.

Differential diagnosis and treatment of Morton’s neuroma in ambulatory surgical practice

Introduction. Diagnosis of Mortoan neuroma in some cases does not cause much difficulty and is based on typical signs, but in some cases it presents certain difficulties. Therapeutic tactics for this disease involves the use of conservative or surgical treatment.Aim. Study of the results of differential diagnosis of Morton’s neuroma in the practice of an outpatient surgeon.Material and methods. A study of the results of diagnostics and differential diagnostics in 15 patients with chronic foot pain at the age of 28 to 46 years was conducted. Among them, there were 14 women and 1 man. Differential diagnostics for foot pain syndromes allowed us to distinguish three groups of patients. The first group included 7 patients with Morton’s neuroma. The second group included 4 patients with plantar fasciitis and the third group-4 patients with arthritis, synoviitis of the metatarsophalangeal joints. To conduct differential diagnostics, we used anamnesis, physical examination, and data from instrumental diagnostic methods.Results. Diagnosis of Morton’s neuroma was based on the use of standard research methods (anamnesis, data from a physical instrumental examination of the foot). It should be noted the importance of ultrasound examination of the soft tissues of the foot on the plantar surface for the diagnosis of Morton’s neuroma. This allows for differential diagnosis with foot diseases such as plantar fasciitis and metatarsophalangeal joint synovitis, which may show similar symptoms.Conclusion. Morton’s neuroma is not a rare disease of the foot, which in the initial stages of the disease has a blurred clinical picture, similar to other diseases of the foot. This can lead to diagnostic errors, but the use of modern diagnostic methods, including sonographic methods, allows in most cases to establish an accurate diagnosis and choose an appropriate treatment strategy.

AB0341 Visualisation of the fifth metatarsophalangeal joint in patients with rheumatoid arthritis: Comparative pilot study using ultrasonography and magnetic resonance imaging in detection of the synovitis and erosions

ObjectivesTo compare ultrasound (US) with magnetic resonance imaging (MRI), which was taken as a “gold standard” for detection of fifth metatarsophalangeal joint synovitis and erosions in patients diagnosed with RA...

Foot and Ankle Kinematics in Rheumatoid Arthritis: Influence of Foot and Ankle Joint and Leg Tendon Pathologies

From early onset of the disease, patients with rheumatoid arthritis (RA) experience walking impairments. Pathologic effects of RA on foot and ankle structures have been studied clinically, but little is known as to how they relate to kinematic changes during gait. The aim of this study was to explore the relationship between clinically observed pathologies of foot and ankle joints and leg tendons and the corresponding gait kinematics. The gait of 25 subjects with varying stages of RA was recorded and foot and ankle kinematics were assessed. Magnetic resonance imaging was performed for each subject: first metatarsophalangeal (MTP) joint, midfoot, and hindfoot synovitis, erosion scores, and leg tendon involvement were determined. The joint alignment and motion score represented daily clinical assessment. The 95% confidence intervals of the Spearman's correlation coefficient tests were used to explore the relationships between the clinical and kinematic parameters. Maximum first MTP joint dorsiflexion at preswing was related to reduced first MTP joint passive motion, first MTP joint synovitis and erosion, midfoot synovitis and erosion, and hindfoot erosion. Midfoot pronation range of motion during single stance was related to subtalar alignment and Achilles tendon involvement. Hindfoot eversion range of motion during single stance was related to subtalar alignment and peroneus longus tendon involvement. Involvement of the tibialis posterior tendon could not be identified as an independent factor influencing foot or ankle kinematics. Our findings suggest moderate to strong relationships between foot and ankle gait kinematics and structural pathologies.

Comparison of Clinical and Ultrasonographic Evaluations for Peripheral Synovitis in Juvenile Idiopathic Arthritis

The characteristics of synovitis in juvenile idiopathic arthritis (JIA) are important to evaluate, as they define several clinical categories. The metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints are frequently involved. Few studies have investigated peripheral joint evaluation using ultrasonography, a sensitive tool for detecting subclinical synovitis. Our objectives here were to compare clinical and ultrasound evaluations of MCP and MTP joint synovitis and to determine the prevalence of predefined ultrasound abnormalities in JIA patients and healthy controls. Standardized physical and ultrasound assessments of the same joints were done in 31 consecutive patients with JIA and 41 healthy volunteers. Joint pain, motion limitation, and swelling were recorded. Ultrasonography was performed on the same joints by 2 trained sonographers who recorded synovial fluid, synovial hypertrophy, erosion, and power Doppler signal. Intraobserver reproducibility of ultrasonography was assessed. Of 558 peripheral joints examined in JIA patients, 69 (12.5%) had ultrasonographic synovitis and 83 (15%) had abnormal physical findings. All the physical abnormalities were significantly associated with ultrasonographic synovitis (P < 0.0001) but agreement was low between ultrasonographic and physical findings. Ultrasonographic synovitis was most common at the feet (59.4%), where it was detected clinically in only 25% of cases. Ultrasonographic synovitis was associated with the presence of synovial fluid. Cartilage vascularization was found in 2 (4.2%) healthy controls. Ultrasonography is useful for monitoring synovitis in JIA. Subclinical involvement of the MTP joints is common. Clinicians should be aware of the specific ultrasonographic findings in children.

Clinical Tip: A New Clinical Sign Associated with Metatarsophalangeal Joint Synovitis of the Lesser Toes

Clinical Tip: A New Clinical Sign Associated with Metatarsophalangeal Joint Synovitis of the Lesser Toes

Ultrasound-guided Interdigital Neuroma Injections: Short-term Clinical Outcomes after a Single Percutaneous Injection—Preliminary Results

To describe the procedure of ultrasound-guided Morton's neuroma and recurrent stump neuroma injections and early clinical outcomes after a single injection. Retrospective review of 44 percutaneous ultrasound-guided neuroma injections in 24 patients who had completed clinical outcomes questionnaires. A 10-point pain scale [scale of 1 (no pain) to 10 (severe pain)] in a 7-day pain log format was distributed to patients at the time percutaneous neuroma injection was performed. Neuromas were clearly visualized with sonography as hypoechoic nodules and were distinguishable from other causes of forefoot pain, such as metatarsophalangeal joint synovitis and intermetatarsal bursae. The sizes of the neuromas injected ranged between 4 and 19 mm. Postinjection, all neuromas displayed increased echogenicity and/or the appearance of fluid surrounding it, confirming localization of the therapeutic mixture. We arbitrarily subdivided the pain ratings into symptomatic (greater than 4) and asymptomatic (less than or equal to 4) for statistical analysis. Average pain level pre injection was 5.2 and average pain level was 3.7 at 7 days post single injection, with 62% of the initially symptomatic patients asymptomatic on day 7 (p < 0.000001). Overall, 76% of the total number of neuromas injected once were asymptomatic on day 7. Ultrasound can be used to accurately target Morton's neuromas and, therefore, appropriately direct therapeutic interventions, with good short-term clinical results.

Forefoot Pain In A Cross Country Runner

HISTORY An 18-year-old college freshman cross country runner with about one month of plantar surface left great toe pain. Pain initially started in her medial longitudinal arch. Seen by a physical therapist who found decreased range of motion of the great toe and initiated a stretching program. Within a couple days, the arch pain resolved and she developed pain beneath her great toe. The pain consistently increased until it was constant, even while walking. At time of maximal pain, she was running about 50 miles per week. She began using a donut cutout and elastic tape to relieve pressure at the plantar first metatarsophalangeal (MTP) joint. The pain improved while running and occurred only with palpation and without taping. Denied previous history of this type of pain. Regular menses. Diet appropriate upon review. Denied history of eating disorder or disordered eating currently or in the past. PHYSICAL EXAMINATION Examination of the left foot about 1 month after onset of symptoms: Inspection revealed bilateral pes cavus and significant callus formation at plantar first MTP joint. No obvious swelling. No skin discoloration. Exquisite tenderness to palpation at the plantar first MTP joint. Active and passive extension of the great toe was decreased by about 15–20 degrees compared to the right great toe. Flexion was equal bilaterally. Strength was within normal limits. DIFFERENTIAL DIAGNOSIS Sesamoiditis Sesamoid stress reaction or fracture First metatarsal stress reaction or fracture First MTP joint synovitis Flexor hallucis longus tendonitis TEST AND RESULTS Left great toe anterior-posterior, lateral, oblique radiographs: two foci of calcification just plantar to tibia sesamoid beneath the first metatarsal head no sign of fracture of sesamoid or any other bone or soft tissue abnormality FINAL WORKING DIAGNOSIS Flexor hallucis longus calcific tendonitis TREATMENT AND OUTCOMES Modified training/cross training. Continued use of donut cutout and elastic taping. Iontophoresis to the affected area. Orthotics prescribed and obtained with special cutout below great toe. Able to run without difficulty and pain only present with direct palpation or when not wearing orthotics.

Nonsurgical treatment of monarticular nontraumatic synovitis of the second metatarsophalangeal joint.

Thirteen patients with second metatarsophalangeal joint synovitis in 14 feet were seen during 4.5 years for monarticular nontraumatic synovitis of the metatarsophalangeal joint. They were treated with a nonsurgical regimen of intra-articular corticosteroids, along with the modification of a regular laced shoe to provide a rockerbottom effect. Nine feet of 8 patients were available for follow-up at an average of 75 months. Seven feet were asymptomatic, with no recurrence. One patient with bilateral involvement continued with symptoms unchanged. There were no recurrences. The treatment was unsuccessful for one patient who underwent surgical synovectomy. The above regimen seems to satisfactorily resolve the symptoms in 70% of the patients treated.

Treatment of the Atypical Lesser Toe Deformity with Basal Hemiphalangectomy

Eighty-six lesser toe basal hemiphalangectomies were performed in 52 patients. The surgical technique included an oblique dorsal incision, resection of 8 mm of bone, and an extensor tenotomy. Minimum follow-up was 2 years (range 2-6/1/2 years). Sixty percent of the patients had total relief of pain. Twenty-nine percent stated that they would not have the surgery again, and we categorized these patients as dissatisfied. An extensor tenotomy increased the satisfaction rate and was found to decrease the radiographic sagittal angulation of the toe. The preoperative diagnosis was significant to the outcome of the surgery. Patients with metatarsophalangeal joint synovitis and rheumatoid toe deformities had high rates of satisfaction; those with transverse deviation, metatarsalgia, and hammertoes with metatarsophalangeal joint subluxation/dislocation had lower rates of satisfaction. Seventy percent of the dissatisfied patients were dissatisfied because of persistent flexion deformity of the PIP joint or pain under the metatarsal head. We now add a PIP fusion if any flexion deformity, even a mild deformity, is present at the PIP joint and a plantar metatarsal condylectomy for metatarsalgia.

Metatarsophalangeal Joint Synovitis in Athletes

Metatarsophalangeal joint synovitis is a clinical entity of the forefoot with distinct findings. From a survey of 46 patients, characteristics and clinical findings are presented. Differential diagnosis and methods of treatment are discussed.