Capsulitis (cap-su-li-tis) is a common condition affecting the ball of the foot, the second metatarsophalangeal (meta-tar-so-fa-lan-ge-al) joint being the most commonly affected. This condition is often likened to walking around with a pebble in the shoe with the pain worsening when walking bare foot or when treading on the raised paving stones around traffic lights, going on tip toes or running. There are several different reasons as to why this problem occurs including overuse injuries, bunion deformities, long or prominent metatarsals and inflammatory conditions such as inflammatory arthritis i.e. rheumatoid arthritis.
The Plantar Plate
Initially the joint capsule and the fluid within becomes inflamed but as the condition progresses the joint capsule can become stretched or torn. The area of damage is related to a thickening of the capsule called the plantar plate. The plantar plate provides stability to the toe and prevents it from elevating and when damaged this restraining mechanism is lost and a hammer toe can develop. Often the condition is progressive and early management is essential to prevent worsening of the condition and the toe position.
Conservative and medical treatment includes:
- Alteration of activity
- Footwear modification
- Calf stretching (tightness in of the calf muscles can produce overload of the forefoot and increased pressure on the metatarsal heads and joint capsules)
- Steroid injections
Includes correcting any length abnormalities or prominence of the metatarsals and thereby reduce the force placed through the joint. This procedure is called a metatarsal osteotomy. Repair of the plantar plate. There are varying grades of plantar plate rupture and if the plate is not too damaged a repair may be possible. The video contains live surgery and shows the method of a plantar plate repair: Warning – Graphic Content
Tendon transfers are utilised if the plantar plate is beyond repair and the elevated position of the toe requires correction. The tendon transfer is performed at the base of the toe and involves relocating the tendon on the underside of the toe to the top so to pull the toe down into a corrected position. Correction of the hammer toe through either an arthoplasty or arthrodesis, to include any in or outward deviation of the toe.