Méd. Chir.
Pied (2013) 29:7-13
DOI 10.1007/s10243-013-0352-9
ORIGINAL ARTICLE / ARTICLE ORIGINAL
Metatarsophangeal joint instability of the lesser toes
Instabilité des articulations métatarsophalangiennes latérales des petits orteils
J.F. Doty · M.J. Coughlin
© Springer-Verlag France 2013
Abstract Instability of the lesser metatarsophalangeal
(MTP) joint occurs with deterioration of the plantar plate
and/or collateral ligaments leading to pain and deformity.
Previously described, treatment techniques have utilized an
indirect repair of the instability (soft tissue balancing and
periarticular osteotomies) without addressing the plantar
plate deficiency. We describe a staging system of the clinical
examination, and a grading system of the surgical findings
which is helpful to clinicians to both classify and also treat
the primary pathologic findings. An improvement in imag-
ing techniques and the use of direct surgical repair techni-
ques have changed the treatment and possibly the results of
this troublesome condition.
Keywords Lesser metatarsophalangeal joint instability ·
Crossover second toe · Plantar plate tears
Résumé L’instabilité des articulations métatarsophalan-
giennes (MTP) latérales provient de la détérioration des liga-
ments latéraux et/ou de la plaque plantaire et engendre
douleur et difformité. Comme décrit précédemment, les
techniques de traitement utilisent une réparation indirecte
de l’instabilité (équilibrage des tissus mous et ostéotomies
péri-articulaires) sans s’occuper de la déficience de la plaque
plantaire. Nous décrivons un système de phases pour l’exa-
men clinique, et un système de classification des constata-
tions opératoires qui peut être utile aux cliniciens pour
classer mais aussi traiter les premières constatations patho-
logiques. Une amélioration dans les techniques d’imagerie et
l’usage de techniques de réparation chirurgicales directes ont
fait évoluer le traitement et éventuellement les résultats de
cette pénible condition.
J.F. Doty · M.J. Coughlin
St. Alphonsus Coughlin Foot and Ankle Clinic,
Boise, Idaho, États-Unis
M.J. Coughlin
Co-editor in chief “Médecine et Chirurgie
du Pied - Foot Medicine and Surgery”, IFFAS Past president
Mots clés Instabilité des articulations métatarso-
phalangiennes latérales · Chevauchement du deuxième
orteil · Déchirures de la plaque plantaire
Introduction
Lesser metatarsophangeal (MTP) joint instability is a common
finding and cause of metatarsalgia [1–3]. While the etiology of
instability can be attributed to inflammatory or traumatic
arthropathy [4–8], often the cause is undetermined and the
onset is quite chronic in nature. Deterioration of the plantar
plate and collateral ligaments may lead to the development
of sagittal and/or transverse plane instability of the lesser
MTP joints [8,9]. The term crossover toe was introduced by
Coughlin in 1987 to both characterize the clinical deformity
and also describe a method of treatment [2,6,7,10,11]. This
deformity has been associated with hallux valgus, hallux rigi-
dus, hammertoe deformity, or a neuroma of the second inter-
metatarsal space [6,7,10] The pathologic anatomy found at the
lesser MTP joint (degeneration of the plantar plate) has only
recently been described [12–20]. A new classification scheme
for plantar plate tears has been developed and surgical treat-
ments have been developed to directly repair plantar plate
tears surgically as a treatment of lesser MTP joint instability
[12,13,16–20].
Epidemiology and pathophysiology
Typically, those affected with this condition are sedentary
older women, although similar findings have been seen in
a younger athletic population [2,3,21]. While the second
MTP joint is most commonly affected, Nery et al. [18]
reported on a series of 28 patients (55 MTP joints) in
which the second MTP joint was affected in 64% of cases,
while the third and fourth MTP joints were affected in 32%
and 4% of cases, respectively.
While acute trauma can destabilize a lesser MTP joint
[5,22,23], more often it appears that an idiopathic onset
8 Méd. Chir. Pied (2013) 29:7-13
from attritional changes to the plantar plate is the cause.
These degenerative changes have been associated with over-
loading of the symptomatic lesser MTP joint. A long second
metatarsal, hallux valgus, hallux rigidus, pes planus, and hal-
lux varus have all been implicated as causes of this instabil-
ity pattern [6,7,21,24]. The high incidence of second MTP
joint instability in the older female population led both
Coughlin and Nery to consider that the long-term use of
high fashion footwear may lead to chronic hyperextension
forces of the MTP joint. Chronic hyperextension may lead in
time to elongation of the plantar structures leading to sec-
ondary instability [6,7,18].
Longitudinal fibers of primarily collagen type 1 (75%) and
collagen type 2 (21%) create a dense fibrocartilagenous con-
nective tissue meshwork involved in weightbearing function
[14,25]. The plantar plate functions to resist tensile loads in
the longitudinal direction (dorsiflexion) via its direct attach-
ments to the metatarsal and phalanx while supporting the
windlass mechanism via an insertion of the distal plantar fas-
cia into the plantar plate [11]. The plantar plate also contri-
butes to medial and lateral stability by serving as an attach-
ment site for the intermetatarsal ligaments and collateral
ligaments. The medial and lateral collateral ligaments are
positioned such that they can resist varus and valgus strain
as well as dorsal instability of the MTP joint. With chronic
hyperextension forces to the MTP joint, the plantar plate and
capsular attachments may tear or become attenuated, losing
the cushioning and stabilization effects on the MTP joint
[1,6,12,26]. Based on our cadaveric and surgical findings as
well as the findings of other authors [4,12,13,18,19,27], we
believe that the primary structure to fail is the plantar plate.
The collateral ligaments may also fail with time and contrib-
ute to the transverse and sagittal plane malalignment of the toe
[12,27]. During weightbearing with normal gait, the toe-off
phase tends to displace the proximal phalanx dorsally. The
plantar plate along with the intrinsic flexors (interossei and
lumbricals) resists this force and pulls the proximal phalanx
back into a neutral position. With the loss of these stabilizing
forces of the plantar plate and intrinsic musculature, the prox-
imal phalanx subluxates in a dorsal or dorsomedial direction
with respect to the metatarsal as the plantar plate becomes
attenuated [12,13,28,29]. In a comprehensive review of cross-
over toe deformity, Kaz and Coughlin [21] reported that hal-
lux valgus occurred in 49%, hallux rigidus in 14%, and hallux
varus in 7%.
Clinical presentation
While plantar plate tears may present with acute or chronic
pain and inflammation of any of the lesser toe MTP joints,
the second MTP joint seems to be most commonly involved
[6,7,10,18,21]. Focal pain located at the plantar aspect of the
forefoot at the base of the second toe is the most common.
In the early stages of plantar plate attenuation, only swell-
ing with no deformity may be present. In a chronic situation,
a hammertoe deformity may develop [3,7]. Patients may
have significant plantar swelling at the base of the toe, and
the dorsal base of the proximal phalanx may be palpable if
the toe is dislocated dorsally. As the deformity progresses the
second toe may cross either under or, more often, up and
over the hallux [21].
Differentiating forefoot pain from MTP joint instability
from pain caused by an adjacent interdigital neuroma or
other diagnoses can be difficult [2,6,28] (Table 1). An inter-
digital neuroma is often associated with numbness and neu-
ritic pain that radiates into the toes. Reproduction of pain
with the transverse compression of the metatarsal arch can
produce a “Mulder’s click” [30,31]. MTP joint instability is
not frequently associated with either radicular pain or numb-
ness unless a concomitant neuroma is present. Coughlin et
al. [11] reported a 20% incidence of the cases in which an
interdigital neuroma was present with simultaneous instabil-
ity of the second MTP joint.
Physical examination
Attenuation of the plantar plate, capsule, or collateral liga-
ments leads to MTP joint instability [12,13,17,18,21,22].
With the development of pain and deformity [6,12,13,
15,18], other objective physical findings may be demon-
strated including swelling, neuritic symptoms, and MTP
joint malalignment [6]. Initially only plantar swelling of
the MTP joint may be present, but as the process progresses,
dorsal or dorsomedial deviation of the toe occurs. Tender-
ness on palpation can be localized to the plantar, or the
medial/lateral aspect of the lesser MTP joint depending
upon the development of plantar plate, or collateral ligament
degenerative tears. Pain at the lateral aspect of a lesser MTP
joint may be accompanied eventually by progressive trans-
verse plane deviation of the toe. Plantar pain, which is
Table 1 Differential diagnosis for forefoot pain.
Differential diagnoses of forefoot pain
Instability of the lesser MTP joints
Freiberg’s infraction
Degenerative arthritis of lesser MTP joints
Systemic arthritis with involvement of lesser MTP joints
MTP joint synovitis
Metatarsal stress fracture
Interdigital neuroma
Synovial cyst formation
Méd. Chir. Pied (2013) 29:7-13
attributed to attritional changes in the plantar plate, often
leads to a hyperextension deformity of the MTP joint.
Compression of the transverse metatarsal arch in the pres-
ence of joint instability typically does not illicit numbness or
pain radiating into the toes, which is typically present with an
interdigital neuroma [21]. Differentiating the pain from a symp-
tomatic interdigital neuroma or an unstable lesser MTP joint
can be difficult, especially in early stages. When this presents
a problem in diagnosis, the use of sequential injections to dif-
ferentiate the specific area of pain can be helpful [7,21,32,33].
The drawer test is one of the first objective signs of MTP
joint instability and is reproducible on physical examination
to confirm pathologic findings [18,21,34]. The drawer test is
correctly performed by holding the proximal phalanx in a
neutral position at the MTP joint and then applying vertical
stress in a dorsal direction (Fig. 1). Medial deviation of the
toe or an asymmetrical gap between the lesser toes is also a
clinical sign of instability of a lesser MTP joint [2,7,12]. The
clinical examination, and magnitude of the drawer test help
to stage the deformity on a 0-4 stage that helps to define the
severity of the deformity (Table 2). Pre-operative staging is
helpful in anticipating surgical findings and predicting the
magnitude of surgical treatment necessary. The paper pull-
Fig. 1 Drawer test to test stability of lesser toe. (A) The toe is
grasped between the thumb and index finger. (B) A dorsal force
is applied and increased translation and pain denote instability or
a tear of the plantar plate
Table 2 Clinical staging of the exam for second MTP joint instability.
Clinical staging of exam for second MTP joint instability
Grade Alignment
0 No MTP joint malalignment; prodromal phase with pain
but no deformity
1 Mild malalignment of MTP joint; widening of the webspace,
medial deviation
2 Moderate malalignment; medial, lateral, dorsal,
or dorsomedial deformity, hyperextension of the MTP joint
3 Severe malalignment; dorsal or dorsomedial deformity;
the second toe can overlap the hallux; may have flexible
hammertoe
MTP: metatarsophalangeal.
9
out test is a method to evaluate the plantar flexion strength of
the digit on the ground [4]. A narrow strip of paper (1cm x
8cm) is placed beneath the affected toe. The patient grasps
the paper by plantar flexing the affected digit while the
examiner attempts to pull the paper out from underneath
the toe (Fig. 2). A positive test and the absence of digital
purchase is seen when the patient is unable to resist this
pull. Correlating all of the findings of the physical exam
can be highly reliable means of diagnosing plantar plate
tears. Sung et al. [35] reported on a series of patients and
reported that clinical exam accuracy was 91% which was
then confirmed by both imaging and surgical findings.
Imaging studies
Standard anteroposterior and lateral radiographs may be
helpful in evaluating the magnitude of the angular deformity,
assessing joint congruity and arthritic changes, and evaluat-
ing the length of the second metatarsal [21]. Several authors
Fig. 2 Paper pull-out test. To test for plantar flexion strength,
the toe pushes down on a strip of paper (A) and if the paper tears
without being pulled out, this denotes adequate toe strength
Physical examination
MTP joint pain, thickening or swelling of the MTP joint,
diminished toe purchase, negative drawer
MTP joint pain, swelling of MTP joint, reduced toe
purchase, mildly positive drawer (< 50% subluxable)
MTP joint pain, reduced swelling, no toe purchase,
moderately positive drawer (> 50% subluxable)
Joint and toe pain, little swelling, no toe purchase
(dislocatable MTP joint), flexible hammertoe
10
have described the use of lesser MTP joint arthrography to
evaluate chronic metatarsophalangeal joint pain [19,28,36].
Yao et al. [37] was the first to describe the use of MRI for
plantar plate evaluation in patients with plantar plate tears.
Sung et al. [35] more recently evaluated the use of MRI
performed for suspected plantar plate tears and reported a
95% sensitivity and a 100% specificity. Their findings con-
firmed that MRI is an accurate and valid test for diagnosing
injuries of the plantar plate. In our experience, a three tesla
MRI has provided us an excellent imaging tool without the
need for arthrography to make an accurate diagnosis (Fig. 3).
Classification
Distinct grading of second MTP joint instability has been
described by several authors [19,28,29,38]. Coughlin et al.
developed a comprehensive clinical staging system founded
on physical examination which incorporated many of the
ideas of previous rating systems [6,18,19,28,29,38]. The
authors, subsequently, performed cadaveric dissections on
specimens with confirmed plantar plate tears and developed
an anatomic grading scale to match the clinical staging sys-
tem. These scales address plantar plate dysfunction and can
be helpful in characterizing as well as planning surgical
management of plantar plate ruptures. Nery et al. [18]
reported in their series of 55 plantar plate tears, evaluated
arthroscopically prior to possible surgical repair, that the
Grade 3 tear was the most common accounting for almost
50% of all tears. They used the same grading system to eval-
uate these patients (Table 3) (Figs 4A–D).
Treatment
Often, there is a substantial delay between the onset of clini-
cal symptoms and the initiation of treatment for plantar plate
Fig. 3 MRI of a plantar plate tear. A sagittal view demonstrates
a complete tear of the plantar plate attachment to the base
of the proximal phalanx (tear with defect between arrows)
Méd. Chir. Pied (2013) 29:7-13
Table 3 Surgical grading of plantar plate tears.
Surgical grading of plantar plate tears
Grade Patterns of tears
0 Plantar plate or capsular attenuation,
and/or discoloration.
1 Transverse distal tear [adjacent to insertion into
proximal phalanx (< 50%); medial/lateral/central
area] and/or midsubstance tear (< 50%).
2 Transverse distal tear (> 50%); medial/lateral/
central area and/or midsubstance tear (< 50%).
3 Transverse and/or longitudinal extensive tear (may
involve collateral ligaments). Frequently a distal
transverse tear is also present.
4 Extensive tear with button hole (dislocation);
a combination of transverse and longitudinal tears,
with an extensive tear, little plantar plate to repair.
Fig. 4 Various patterns of plantar plate tears (Dotted line marks
the metatarsal head which has been removed for these diagrams).
(A) Grade 1 tear. (B) Grade 2 tear. (C) Grade 3 tear. (D) Grade
4 tear (Arrow marks tear(s); with increasing grade there is increas-
ing deformity of the digit)
tears. Many patients may not seek treatment for mild defor-
mity because they experience minimal or mild pain. While
occasionally the onset of pain may be acute, the patient ini-
tially observes no obvious anatomic abnormality. Often,
patients only become concerned after a fixed hammertoe
deformity develops in more chronic situations [7]. If medial
deviation of the lesser toe is recognized in early stages,
Méd. Chir. Pied (2013) 29:7-13
conservative measures may relieve pain but may not alter the
progression of the deformity. Some patients may be recep-
tive to altering footwear to a shoe with a low heel and roomy
toe box to eliminate pressure on the involved toe.
Padding the tip of the contracted toe or placing a padded
sleeve over a sensitive callous may relieve discomfort of a
painful hammertoe. A carbon fiber footplate and a rocker
bottom soled shoe may help to reduce dorsiflexion stresses
to the plantar plate region [12,33] (Fig. 5). While nonsurgi-
cal treatment of an unstable lesser MTP joint may temporar-
ily relieve pain, it will not correct the deformity [7,10,26].
Coughlin reported on patients with crossover deformity and
found that taping of the digit slowed progression of the
deformity but the patients continued to have joint pain. The
Fig. 5 Conservative treatment of the plantar plate tear. (A) Graph-
ite insole, soft insole above with: (B) Metatarsal pad. (C) Padding
of digit. (D) and (E) Taping technique of lesser toe
11
goal of taping is to secure the toe and provide stability. This
stability may be achieved early on in the disease process
with the goal being eventual capsular contracture and scar-
ring; however, this technique is unreliable and may require
several months of taping with only transitory relief of pain
and later surgical correction may still be necessary. Taping is
routinely unsuccessful once the capsule is completely dis-
rupted and the toe is moderately malaligned or dislocated
[7]. Chronic taping may indeed lead to ulceration of the toe
or chronic edema [10]. A metatarsal pad, placed just proxi-
mal to the symptomatic metatarsal head, may alleviate plan-
tar discomfort by redistributing weight on the plantar surface
[10,12]. The use of non-steroidal anti-inflammatory drugs
(NSAIDS) may give relief from discomfort and inflamma-
tion at a symptomatic lesser MTP joint. Intra-articular corti-
costeroid injections have been reported to be effective with
immediate and dramatic pain relief, but should be used judi-
ciously and certainly should not be used on a repetitive basis
[12,33]. Corticosteroid injections have potential disadvan-
tages as well, including further capsular and plantar plate
attenuation with subsequent dislocation [10,12,39].
The plantar plate and meniscus of the knee consist of
largely Type 1 collagen, and thus, it is reasonable to expect
that injury sustained to the plantar plate is unlikely to heal
with the passage of time [14,19,25]. Thus, surgical repair
should be considered with increasing pain and deformity
associated with capsular instability and plantar plate tears.
Current surgical technique of plantar plate
repair
The surgical technique utilizes a dorsal approach to expose
the plantar plate. A 3–4 cm webspace incision is made and
the subcutaneous tissue is dissected to expose the extensor
tendons. A capsulotomy is performed in the interval
between the extensor digitorum longus and brevis tendons.
A capsular release off the base of the phalanx medially and
laterally allows preservation of capsular attachments and
circulation to the metatarsal head. A Weil metatarsal osteot-
omy is performed and the metatarsal head is translated
proximally 8–10mm and temporarily fixed with a vertical
Kirschner wire. A small amount of the dorsal metatarsal
flare is removed (2–3 mm) to improve visualization.
Another Kirschner wire is placed centrally in the metaphy-
sis of the proximal phalanx and a distractor is attached and
opened to visualize the plantar plate. The plantar plate tear
is repaired using a “mini-scorpion”® (Arthrex, Inc., Naples,
Fl) or a suture-passer to pass sutures through the plantar
plate (Fig. 6). Once the sutures have been passed, drill
holes are placed in the base of the proximal phalanx and
the sutures are then passed dorsally through the phalanx
and tied over a bone bridge. The Weil osteotomy is
12
Fig. 6 Surgical repair of the plantar plate tear. Suture technique
of the plantar plate tear; the sutures are pulled through drill holes
in the proximal phalanx and tied over a bone bridge
positioned with 1–3 mm of shortening and fixed with small
screws. A gauze and tape compression dressing is applied.
Strengthening exercises are commenced 10 days after sur-
gery, and protected weight bearing in a post-operative shoe
is continued for 6 weeks after surgery.
Surgical outcomes
In the past, the surgical repair of an unstable lesser MTP joint
subluxation has been characterized by indirect repair of the
MTP joint. The most frequent reported regimens include
synovectomy [9], soft tissue release [2,10,21,22,26,32,38],
tendon transfers [2,4,11,21,26,28,29,32,38], osseous decom-
pression [6,28,29], and even amputation [40]. Improved
results have been reported with the Weil distal metatarsal
osteotomy which decompresses and realigns the involved
joint [6,10,28,29]. Unfortunately, all of these different
surgical methods have circumvented the true pathology by
not addressing the plantar plate degeneration or tear. The plan-
tar plate in conjunction with the two collateral ligaments
is the main stabilizing force of the lesser MTP joints
[6,12,13,18,26,27,39]. Only recently, reports have noted the
development of new surgical techniques to directly treat the
primary plantar plate deficiencies by repairing tears of the
plantar plate [4,12,17–19,25]. Ford et al. [16] in a cadaveric
study compared different repair techniques including: a
primary plantar plate repair, a flexor tendon transfer, and a
combined primary plantar plate repair, and concluded that a
primary repair of the plantar plate was a viable alternative to
flexor tendon transfer in correcting lesser MTP joint instabil-
ity. Bouche and Heit [4] and Powless and Elze [19], using a
plantar approach, reported good results of a primary plantar
plate repair. Cooper and Couglin [1] demonstrated that ade-
Méd. Chir. Pied (2013) 29:7-13
quate exposure of the MTP joint could be obtained utilizing a
dorsal approach combined with a Weil osteotomy. Gregg et al.
[17] and Weil et al. [20] have both reported on series in which
a dorsal approach was used and achieved excellent results and
good pain relief at final follow-up. In the first prospective
evaluation of direct plantar plate repair, Nery et al. [18] and
Coughlin [7] reported on 22 patients (40 MTP joints) at an
average follow-up of 1.5 years after primary repair. Excellent
pain relief and deformity correction was noted.
Conclusion
Over the past two decades, there has been an evolution in the
evaluation and treatment of instability of lesser MTP joint.
With staging of the deformity founded on clinical evaluation
and with grading of the deformity founded upon surgical
findings, the magnitude of the deformity and severity of
the plantar plate tear can now be defined. Likewise, the treat-
ment now encompasses a direct repair in which the plantar
plate tear is visualized and then sutured primarily. Excellent
early results have been reported with this surgical technique.
References
1. Barg A, Courville XF, Nickisch F, et al (2012) Role of collateral
ligaments in metatarsophalangeal stability: a cadaver study. Foot
Ankle Int 33:877–82
2. Blitz NM, Ford LA, Christensen JC (2004) Second metatarsopha-
langeal joint arthrography: a cadaveric correlation study. J Foot
Ankle Surg 43:231–40
3. Bouche RT, Heit EJ (2008) Combined plantar plate and hammer-
toe repair with flexor digitorum longus tendon transfer for
chronic, severe sagittal plane instability of the lesser metatarso-
phalangeal joints: preliminary observations. J Foot Ankle Surg
47:125–37
4. Brunet JA, Tubin S (1997) Traumatic dislocations of the lesser
toes. Foot Ankle Int 18:406–11
5. Cooper MT, Coughlin MJ (2011) Sequential dissection for expo-
sure of the second metatarsophalangeal joint. Foot Ankle Int
32:294–9
6. Coughlin MJ (1988) Crossover second toe deformity. Foot Ankle
Int 8:29–39
7. Coughlin MJ (2007) Lesser toe deformities. In: Coughlin MJ,
Mann CL, Saltzman CL (eds) Surgery of the foot and ankle.
Mosby Elsevier Inc., Philadelphia, pp 363–464
8. Coughlin MJ (1993) Second metatarsophalangeal joint instability
in the athlete. Foot Ankle Int 14:309–19
9. Coughlin MJ (1989) Subluxation and dislocation of the second
metatarsophalangeal joint. Orthop Clin North Am 20:535–51
10. Coughlin MJ (1987) When to suspect crossover second toe defor-
mity. J Musculoskeletal Medicine 39–48
11. Coughlin MJ, Baumfeld DS, Nery C (2011) Second MTP joint
instability: grading of the deformity and description of surgical
repair of capsular insufficiency. Phys Sportsmed 39:132–41
12. Coughlin MJ, Pinsonneault T (2001) Operative treatment of inter-
digital neuroma: a long-term follow-up study. J Bone Joint Surg
Am 83-A:1321–8
Méd. Chir. Pied (2013) 29:7-13
13. Coughlin MJ, Schenck RC Jr, Shurnas PS, Bloome DM (2002)
Concurrent interdigital neuroma and MTP joint instability: long-
term results of treatment. Foot Ankle Int 23:1018–25
14. Coughlin MJ, Schutt SA, Hirose CB, et al (2012) Metatarsopha-
langeal joint pathology in crossover second toe deformity: a
cadaveric study. Foot Ankle Int 33:133–40
15. Deland JT, Lee KT, Sobel M, DiCarlo EF (1995) Anatomy of the
plantar plate and its attachments in the lesser metatarsal phalan-
geal joint. Foot Ankle Int 16:480–6
16. Deland JT, Sung IH (2000) The medial crosssover toe: a cadav-
eric dissection. Foot Ankle Int 21:375–8
17. DuVries, HL (1956) Dislocation of the toe. JAMA 160:728
18. Ford LA, Collins KB, Christensen JC (1998) Stabilization of the
subluxed second metatarsophalangeal joint: flexor tendon transfer
versus primary repair of the plantar plate. J Foot Ankle Surg
37:217–22
19. Gallentine JW, DeOrio JK (2005) Removal of the second toe for
severe hammertoe deformity in elderly patients. Foot Ankle Int
26:353–8
20. Gregg J, Silberstein M, Clark C, Schneider T (2007) Plantar plate
repair and Weil osteotomy for metatarsophalangeal joint instabil-
ity. J Foot Ankle Surg 13:116–21
21. Haddad SL, Sabbagh RC, Resch S, et al (1999) Results of flexor-
to-extensor and extensor brevis tendon transfer for correction of
the crossover second toe deformity. Foot Ankle Int 20:781–8
22. Johnston RB, Smith J, Daniels T (1994) The plantar plate of the
lesser toes: an anatomical study in human cadavers. Foot Ankle
Int 15:276–82
23. Kaz AJ, Coughlin MJ (2007) Crossover second toe: demo-
graphics, etiology, and radiographic assessment. Foot Ankle Int
28:1223–37
24. Mann RA, Coughlin MJ (1979) The rheumatoid foot: review of
literature and method of treatment. Orthop Rev 8:105–12
25. Mann RA, Mizel MS (1985) Monarticular nontraumatic synovitis
of the metatarsophalangeal joint: a new diagnosis? Foot Ankle Int
6:18–21
26. Mendicino RW, Statler TK, Saltrick KR, Catanzariti AR (2001)
Predislocation syndrome: a review and retrospective analysis of
eight patients. J Foot Ankle Surg 40:214–24
13
27. Morton DJ (1927) Metatarsus atavicus: the identification of a dis-
tinctive type of foot disorder. J Bone Joint Surg 9:531–44
28. Mulder JD (1951) The causative mechanism in morton’s metatar-
salgia. J Bone Joint Surg Br 33-B:94–95
29. Murphy JL (1980) Isolated dorsal dislocation of the second meta-
tarsophalangeal joint. Foot Ankle Int 1:30–2
30. Myerson MS, Jung HG (2005) The role of toe flexor-to-extensor
transfer in correcting metatarsophalangeal joint instability of the
second toe. Foot Ankle Int 26:675–9
31. Nery C, Coughlin MJ, Baumfeld D, Mann TS (2012) Lesser
metatarsophalangeal joint instability: prospective evaluation and
repair of plantar plate and capsular insufficiency. Foot Ankle Int
33:301–11
32. Powless SH, Elze ME (2001) Metatarsophalangeal joint capsule
tears: an analysis by arthrography, a new classification system
and surgical management. J Foot Ankle Surg 40:374–89
33. Rao JP, Banzon MT (1979) Irreducible dislocation of the meta-
tarsophalangeal joints of the foot. Clin Orthop Relat Res
145:224–6
34. Sarrafian SK, Topouzian LK (1969) Anatomy and physiology
of the extensor apparatus of the toes. J Bone Joint Surg Am
51:669–79
35. Sung W, Weil L Jr, Weil LS Sr, Rolfes RJ (2012) Diagnosis of
plantar plate injury by magnetic resonance imaging with refer-
ence to intraoperative findings. J Foot Ankle Surg 51:570–4
36. Thompson FM, Hamilton WG (1987) Problems of the second
metatarsophalangeal joint. Orthopedics 10:83–9
37. Trepman E, Yeo SJ (1995) Nonoperative treatment of metatarso-
phalangeal joint synovitis. Foot Ankle Int 16:771–7
38. Weil L Jr, Sung W, Weil LS Sr, Malinoski K (2011) Anatomic
plantar plate repair using the Weil metatarsal osteotomy
approach. Foot Ankle Spec 4:145–50
39. Yao L, Cracchiolo A, Farahani K, Seeger LL (1996) Magnetic res-
onance imaging of plantar plate rupture. Foot Ankle Int 17:33–6
40. Yu GV, Judge MS, Hudson JR, Seidelmann FE (2002) Predisloca-
tion syndrome. Progressive subluxation/dislocation of the lesser
metatarsophalangeal joint. J Am Podiatr Med Assoc 92:182–99