1 mtp joint capsulitis

by Antonio
(Rome, Italy)

hello,

male, 30 y.o. I was diagnosed with this condition last september and been suffering from it since April 2014 following a trauma on my big toe (no fractures). Took NSAIDs, did PT (ultrasound, laser), had a cortisone shot but the only thing that helped were orthotics. After the first 3 months (september - december 2014) the issue had almost resolved so I quit the orthotics but then things got worse again. So I kept wearing them up until this summer when I quit them again because the metatarsal pad had become quite uncomfortable. At the moment I've just started wearing them again.

An MRI scan I had last september detected a "mild capsulitis of the 1 mtp joint with minimal thickening of the plantar plate". No signs of neuromas or tendonitis.

What I would like to know is, basically, whether the MRI scan has the last word on the matter or there could be something else besides a "mild capsulitis".

The symptoms are the following:
- dull pain when I apply pressure to the area (for example when walking orthotics-free)
- no problem whatsoever in bending my big toe, though I feel it a tiny bit stiff
- the big toe deviates slightly towards the 2nd toe
- I have ligamentous laxity

These first points seem to be consistent with a capsulitis diagnosis, but what bugs me the most is this:

- I experience a somewhat mild burning sensation in the area caused by things that have nothing to do with the joint itself, for example when I press on my pelvic area (say, when I'm sitting on the toilet). Could some nerves or tendons be involved even if the MRI scan detected nothing? When I'm around the house I tend to walk on the outer part of my foot (avoiding contact with the affected area), could that have something to do with it?

Assuming that a "mild capsulitis" is the only problem at hand, it looks like the healing process have been going on really slowly, and I can't tell if that's normal with this condition, or if on the contrary I'm doing something wrong, apart from not having worn the orthotics steadily. What's the best thing to do in these cases? Absolutely avoid any contact with the area? Every now and then I nervously palpate the area to see if it's getting better, but maybe in doing so I keep stimulating the inflammation.

thank you for any help you are able to provide

Antonio

RESPONSE

Hi Antonio,

An MRI is only as good as the doctor reading it. You might want to consider having another doctor take a look at it for his or her opinion. As far as I am concerned, outside of a clinical presentation, an MRI would be the final source in determining an exact diagnosis.

Capsulitis of the great toe joint is also known as "turf toe" and as you have found out, this is an over-stretching of the ligament that attaches the big toe to the first metatarsal bone, in this case, on the bottom of the foot.

You might want someone to go over the MRI and see if there is any mention of problems with the sesamoid bones which are two small bones located just behind the capsular ligament and can be a constant source of pain as well and they are located in the same general area of the foot.

The fact that you have ligamentous laxity means your joints are hyper-mobile and it is easy to over stretch a joint and create a capsulitis.

The problem, of course, if getting the problem to improve. I must say this 10-15 times a week to my patients, but every time you take a step, you are essentially re-injuring an already injured area, and that is why foot problems can take so long to heal.

It is also within the realm of probability that you will need to wear an orthotic for a very extended period of time, as the orthotic helps limit motion of the capsular ligament and thus allows it to heal in spite of the fact that you continue to walk on the foot.

If the orthotic helped or if it no longer helps, it may have to be adjusted, but in either event you should wear them on a regular basis, even when you are home doing nothing. Walking barefoot at home will simply continue to inflame the ligament and negate all that you accomplish by wearing the orthotics outside.

One other option that you have to move this process along would be to consider having physical therapy, again, but making sure you are in your orthotics all the time. I happen to like ultrasound and cold laser, but you may also require massage in the area to help reduce the inflammation.

Marc Mitnick DPM
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