Management of Mild Medial Subluxation of First and Second Metatarsophalangeal Joints with Associated Bone Spurs
The most appropriate management for mild medial subluxation of the first and second metatarsophalangeal joints with bone spurs and vascular calcification includes conservative treatment with custom orthotic devices and appropriate footwear modifications as first-line therapy, reserving surgical intervention for cases that fail conservative management.
Clinical Assessment and Diagnosis
The radiographic findings present a complex foot condition with several components:
- Mild medial subluxation of first and second metatarsophalangeal (MTP) joints
- Bone spur at the medial aspect of the distal phalanx of the big toe
- Plantar calcaneus spur
- Vascular calcification surrounding the ankle joint
These findings suggest degenerative changes consistent with osteoarthritis of the MTP joints, which commonly affects the first MTP joint 1.
Conservative Management (First-Line Approach)
1. Offloading Interventions
- Custom orthotic devices: Provide metatarsal support and redistribute pressure away from the affected MTP joints
- Appropriate footwear modifications:
- Wide toe box to accommodate deformity
- Rocker-bottom soles to reduce pressure on MTP joints during gait
- Low heels to minimize forefoot pressure
2. Pain Management
- NSAIDs: For pain and inflammation control
- Topical analgesics: Applied locally to affected joints
- Intra-articular corticosteroid injections: For acute pain relief in inflamed MTP joints 2
3. Physical Therapy
- Toe and foot strengthening exercises
- Range of motion exercises to maintain joint mobility
- Gait training to optimize weight distribution
Surgical Management (For Failed Conservative Treatment)
If conservative measures fail after 3-6 months of consistent application, surgical options should be considered based on the specific pathology:
1. For First MTP Joint
- Metatarsal head (MTH) resection: Indicated when there is persistent pain, limited joint mobility, or evidence of osteomyelitis/infection 3
- Metatarsophalangeal joint arthroplasty: Particularly useful for hallux ulcers with limited range of motion of the first MTP joint 3
2. For Second MTP Joint
- Digital flexor tenotomy: Effective for flexible toe deformities affecting digits 2-5 3
- Metatarsal osteotomy: To realign the metatarsal and reduce pressure on the MTP joint
3. For Bone Spurs
- Surgical removal of bone spurs: When they cause persistent pain or interfere with joint function 4
Special Considerations
Vascular Calcification
- The presence of vascular calcification around the ankle suggests possible peripheral arterial disease
- Vascular assessment should be performed before any surgical intervention
- Wound healing may be compromised in the presence of significant vascular disease
Diabetic Considerations
- If the patient has diabetes, more aggressive preventive care is needed to avoid ulceration
- Regular foot examinations are essential
- Early intervention for any skin breakdown is critical 3
Treatment Algorithm
- Initial approach: Begin with conservative management for 3-6 months
- Reassessment: Evaluate response to conservative treatment
- Decision point:
- If improved: Continue conservative management
- If no improvement: Consider appropriate surgical intervention based on specific pathology
- Post-surgical care: Appropriate offloading devices during recovery
Common Pitfalls to Avoid
- Attributing symptoms solely to bone spurs when the subluxation may be the primary pain generator
- Pursuing arthroscopic debridement alone, which provides limited benefit in established osteoarthritis 5
- Neglecting to address vascular status before considering surgical intervention
- Failing to provide appropriate offloading devices post-surgically, which can lead to recurrence or new deformities
The management of MTP joint subluxation with bone spurs requires careful consideration of both the mechanical and inflammatory components of the condition, with conservative management as the cornerstone of initial treatment.