From the Guidelines
The workup for metatarsophalangeal (MTP) joint pain should begin with conventional radiography (X-rays) of the foot, as it is usually the first imaging study in evaluating patients with chronic foot pain. This approach is supported by the American College of Radiology, which states that radiography can be useful to distinguish among different causes of chronic foot pain, with overall sensitivities ranging from 80% to 100% and specificities ranging from 97% to 98% for radiographs in the diagnosis of calcaneonavicular coalitions 1.
When evaluating MTP joint pain, it is essential to consider the potential causes, including stress fractures, sesamoid dislocation, osteoarthritis, and Morton’s neuroma. Radiographs are usually performed initially in the clinical setting of a suspected stress fracture, with sensitivities ranging from 12% to 56% and specificities ranging from 88% to 96% for radiographs in the detection of lower-extremity stress fractures 1.
For conditions such as sesamoid dislocation and osteoarthritis, radiographs may be useful to diagnose and distinguish between bipartite versus fractured sesamoid, although differentiation between these conditions remains difficult to assess with radiographs alone 1. Additionally, radiographs are insensitive to diagnose Morton’s neuroma but are useful to exclude other causes of webspace pain such as osteoarthritis, Freiberg’s infraction, and stress fractures 1.
In some cases, advanced imaging such as MRI, CT scan, or ultrasound may be necessary to evaluate soft tissue structures, cartilage damage, or subtle fractures. However, ultrasound is usually not indicated as the first imaging study in the evaluation of chronic foot pain, but may be performed when there is a high clinical suspicion of pathologic conditions of the Achilles tendon, plantar fascia, and other conditions such as tarsal tunnel syndrome, Morton’s neuroma, plantar plate tears, and intermetatarsal bursitis 1.
Key points to consider in the workup for MTP joint pain include:
- Conventional radiography (X-rays) as the initial imaging study
- Evaluation for stress fractures, sesamoid dislocation, osteoarthritis, and Morton’s neuroma
- Consideration of advanced imaging (MRI, CT scan, or ultrasound) for complex or persistent cases
- Ultrasound may be useful in specific cases with high clinical suspicion of certain pathologic conditions.
From the Research
Initial Evaluation
The workup for metatarsophalangeal (MTP) joint pain involves a thorough initial evaluation to identify the underlying cause of the pain. This includes:
- A detailed history to determine the onset, duration, and characteristics of the pain 2
- A physical examination to assess the joint and surrounding tissues 2
- Laboratory studies and diagnostic imaging to help evaluate the joint and rule out other conditions 2
Differential Diagnosis
The differential diagnosis for MTP joint pain is varied and includes:
- Acute conditions such as toe fractures, toe dislocations, and metatarsal head and neck fractures 3
- Chronic conditions such as metatarsalgia, Morton's neuroma, Freiberg infraction, brachymetatarsia, bunionettes, and lesser toe disorders 3
Treatment
Treatment of MTP joint pain consists of both pharmacologic and nonpharmacologic modalities. Pharmacologic therapies may include:
- Medications specific for pain, inflammation, and adjuncts specific to the diagnosis 2
- Nonsteroidal anti-inflammatory drugs (NSAIDs) such as meloxicam, which has been shown to be effective in reducing inflammation and pain 4 Nonpharmacologic therapies may include:
- Protection, rest, ice, compression, elevation, and simple office procedures 2
- Physical therapy and education to assist in the recovery process and prevent recurrence 2
Management of Chronic Conditions
The management of chronic conditions such as rheumatoid arthritis, which can cause MTP joint pain, involves a multifaceted approach including: