Metarsalgia post op bunionectomy

by Ann
(Charlotte, NC)

I recently posted a question about pain after bunion surgery and wanted to follow up with the 2nd opinion. Thank you so much for your response.

I had a right bunionectomy in March 2017. I started having pain on the bottom of my foot at the 2nd and 3rd metarsal heads approximately 5-6 months post op. I also experience pain in my entire 2nd toe, especially if I bend it towards the floor. I complained about this pain 6 weeks post op but my doctor said the ligament may still be a little tight. He did a chevron cut and placed a screw in my big toe as well as removing a bone spur. I apologize that I don't know exactly what he did that has caused the ligament to be tight.

I was fitted with orthotics and wore them from November 2017- April 2018 but felt I was having pain in other parts of my foot and big toe and the pain on the ball of my foot at the 2nd and 3rd metatarsals never resolved. My doctor decided on an injection to reduce inflammation but I didn't get any relief. I went back 1 month later and he did another injection. I had relief for 1 -1 1/2 month.
He wants to perform another surgery to shorten the bones in the 2nd and 3rd toes in order to relieve the pain.

I decided to see another doctor who doesn't feel I should rush into surgery. His feels the 1st doctor may have slightly over corrected and this is causing my pain because my 2nd toe is slightly being pulled toward my big toe (one of the PAs that I saw when my 1st doctor couldn't fit me in made a similar comment about my toe being pulled towards the big toe).
The course of action from the 2nd opinion: oral anti inflammatory (Vimovo). Compound cream with anti inflammatory ingredients and 6 treatments of MLS Laser treatments.
He also mentioned capsulitis since I can feel a hardness on the top of my foot between the big toe and 2nd toe.
He is also concerned I could develop a hammer toe in the future. He is having me fitted for another orthotic with more arch support. He didn't feel the original custom orthotics were going to help. With my original custom orthotics there was a slight elevation or raised at my big toe which made my big toe hurt and some pain at the ball of my foot by the big toe.

I've always been very active, exercising 5-6 times per week but I have difficulty walking more than a mile and cannot run. When working out, I've avoided anything high impact to avoid further injury. I've learned to try different forms of exercise but have become very frustrated on how limited I've become to something as simple as walking....even with sneakers.
I'm in sales/training and required to dress business casual. I'm unable to wear sneakers to work and have never worn heels greater than 2 inches. It has been very difficult to find shoes especially one that fits an orthotic. I've tried other metarsal pads but feel that the padding may be too prominent as I still experience pain throughout the day.

Are you familiar with the MLS laser? With everything I've read, the metarsal pads helped others but since I haven't had much relief, I'm concerned there may be other issues causing the problem. Can a doctor actually "over correct" when doing a bunionectomy and this cause pain? Even after wearing the pads and orthotics all day, I couldn't walk barefooted at all at the end if the day. I
Do those with metarsalgia experience pain in the 2nd toe? I feel that is where all my pain is originating from. I have good mobility in my toes...I had PT after surgery. Would complete rest with no weight on my foot be beneficial or would the pain return once I start walking again?

Thank you so much for your help.

RESPONSE

Hi Ann,

There is such a thing as over correction of bunions, but that is where the big toe ends up in the complete opposite direction, which is not your case. Because you had a Chevron osteotomy on the first metatarsal, he may have shortened the first metatarsal which happens with this type of cut and if the first metatarsal was already short to begin with, you were destined to end up with this issue. That is why he wants to cut the second and third metatarsal, to try and create a better alignment.

Not sure I would have the same surgeon do the second surgery if you opt to go forward. I would suggest an MRI of the second and third metatarsal phalangeal joints, to see if the ligaments attaching the metatarsal bones to the base of the toes is torn. If your insurance will not cover an MRI, then have an ultrasound.

If torn and you want to try and avoid further surgery, then you would have to go into a boot for a period of time.

If the ligaments are not torn, then you need an orthotic with a metatarsal pad built in to lift the metatarsal heads and reduce the stretching of the ligaments. If this is a custom orthotic, your doctor can experiment around a little bit; if the metatarsal pad is not comfortable, then it can be replaced with a softer, flatter one.

Marc Mitnick DPM
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