The Physician and Sportsmedicine

ISSN: 0091-3847 (Print) 2326-3660 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsm20

Second MTP Joint Instability: Grading of the

Deformity and Description of Surgical Repair of
Capsular Insufficiency

Michael J. Coughlin MD, Daniel S. Baumfeld MD & Caio Nery MD

To cite this article: Michael J. Coughlin MD, Daniel S. Baumfeld MD & Caio Nery MD (2011)
Second MTP Joint Instability: Grading of the Deformity and Description of Surgical Repair of
Capsular Insufficiency, The Physician and Sportsmedicine, 39:3, 132-141

To link to this article: http://dx.doi.org/10.3810/psm.2011.09.1929

Published online: 13 Mar 2015.

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Second MTP Joint Instability: Grading of the
Deformity and Description of Surgical Repair
of Capsular Insufficiency
Michael J. Coughlin, MD 1
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Daniel S. Baumfeld, MD 2
Caio Nery, MD 3
1
Coughlin Clinic, Boise, ID; 2Felicio
Rocho Hospital, Foot and Ankle
Division, Belo Horizonte, Minas
Gerais, Brazil; 3Foot and Ankle Clinic,
Federal University of São Paulo,
São Paulo, Brazil
Correspondence: Michael J. Coughlin, MD,
Coughlin Clinic,
Fellowship Director of the Idaho Foot and
Ankle Fellowship,
901 N. Curtis Rd, Ste. 503,
Boise, ID 83706.
Tel: 208-367-3330
Fax: 208-367-3331
E-mail: footmd@aol.com
132
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CLINICAL FEATURES
DOI: 10.3810/psm.2011.09.1929
Abstract: A crossover second toe is a commonly seen forefoot problem, usually occurring in
women aged ⬎ 50 years, and often in association with a bunion deformity. The plantar plate is
the principal static stabilizer of the second metatarsophalangeal (MTP) joint. Different authors
have proposed classifications to define instability of the second MTP joint, but only describe
clinical progression of the deformity. Once a plantar plate tear has developed, conservative
treatment can eliminate the symptoms and prevent progression of the deformity but cannot
achieve correction or realignment of the deformity. The proposed clinical staging and anatomic
grading classification combines clinical findings and anatomic aspects of the plantar plate tears.
The surgical treatment described herein reconstructs the anatomic structures that lead to the
instability of the second MTP joint. A plantar plate tear repair and lateral soft tissue reefing can
restore the normal alignment of the joint with an anatomic repair.
Keywords: plantar plate; anatomy reconstruction; crossover second toe; instability lesser
metatarsophalangeal joints; hyperextension metatarsophalangeal joint
Introduction
Pain in the second toe at the metatarsophalangeal (MTP) joint is a common complaint
among patients.1,2 Several etiologies have been described for such symptoms and
include trauma, synovitis, and inflammatory conditions.3,4 In the chronic situation,
deterioration of the plantar plate and collateral ligaments may lead to instability of
the MTP joint (crossover toe), in which the second toe crosses either under or over
the hallux.5,6 This deformity can be associated with hallux valgus, hallux rigidus, a
hammertoe deformity, or a neuroma of the second intermetatarsal space.7–9
Coughlin10 introduced the term crossover toe in 1986, and subsequently character-
ized the deformity and outlined its treatment.1,7-9,11 Chronic subluxation can develop
in association with intrinsic inflammatory joint diseases such as rheumatoid arthritis
and other connective tissue disorders.5 Extrinsic pressure can also lead to MTP joint
instability. The high incidence of second MTP instability in the older female popu-
lation led Coughlin to hypothesize that the long-term use of high-fashion footwear
leads to chronic hyperextension forces on the MTP joint, causing elongation of the
plantar plate.7,8 Although there continues to be a significant number of predominantly
sedentary older women who develop second MTP instability, he observed a similar
instability to occur in the younger, more athletic male population.1,7
Recently, pathology in the plantar plate has been observed in cases of second MTP
joint instability.3,12–14 Most of these reports describe pathology near the distal attach-
ment of the plantar plate at the base of the proximal phalanx.13,15–17 In 1987, Thompson
© The Physician and Sportsmedicine, Volume 39, Issue 3, September 2011, ISSN – 0091-3847

and Hamilton18 described the use of a drawer test or “positive
Lachman” test for the second MTP joint (Figure 1) to detect
dorsal/plantar capsular instability in situations without obvi-
ous clinical MTP malalignment. A positive drawer sign is
the first objective finding of early instability.8
Pathogenesis
While acute trauma to a lesser MTP joint can lead to joint
instability,4,19,20 more commonly, instability has an idiopathic
onset, with attritional changes to the plantar plate most likely
secondary to chronic inflammation. While the cause of this
inflammation is poorly understood, authors have proposed
that overloading of the second MTP joint can result from a
long second metatarsal, hypermobility of the first ray, hallux
valgus, pes planus, or genetic predisposition.7,8,21 Anatomic
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studies have revealed attenuated or even ruptured collat-
eral ligaments and plantar plate, with displacement of the
proximal phalanx dorsal or dorsomedially.13,22
Anatomy of the Second MTP Joint
The second MTP joint is stabilized by a combination of
static resistance provided by the plantar plate and collateral
ligaments and the dynamic pull of the intrinsic flexors.8,16
It is mainly the plantar plate, however, that provides this
major stabilizing force.23,24 The plantar plate is rectangular to
trapezoidal and originates on the metatarsal head via a thin
synovial attachment, just proximal to the articular surface
and inserts on the base of the proximal phalanx.12,25 It also
serves as an attachment for a number of important structures,
including the distal fibers of the plantar fascia, collateral liga-
ments, transverse metatarsal ligaments, interosseous tendons,
and the fibrous sheath of the flexor tendons.13 The thickness
of the plantar plate ranges from 2 to 5 mm, the length from
16 to 23 mm, and the width from 8 to 13 mm.25 The borders
are thicker than the central region.25 Biochemical analysis of
the plantar plate has revealed type 1 collagen to be the most
Figure 1. The dorsal plantar drawer test. The second toe is grasped between the
thumbs and index finger, and the second MTP joint is stressed in a vertical direction.
Instability of the joint is demonstrated with increased mobility of the second MTP joint.
Abbreviation: MTP, metatarsophalangeal.
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Second MTP Joint Instability
common collagen type at 75% of composition, while type 2
collagen is the next most common at 21%.25 The collagen
fibers of the plantar plate run in a longitudinal direction, with
oblique bundles interspersed at regular intervals.25 Biome-
chanically, the plantar plate functions to resist tensile loads
in the longitudinal direction (particularly in dorsiflexion) and
to cushion the joint and support weight bearing forces.12,13,25
The collateral ligaments are positioned medially and laterally
to the second MTP joint, and their function is to resist varus/
valgus stress at the second MTP joint.26 With the application
of long-term, chronic, hyperextension forces to the MTP
joint, the plantar plate and the capsule may stretch or become
attenuated, losing its stabilization of the MTP joint.8,10,27
Biomechanics of the Second
MTP Joint
During 40% of the stance phase of gait, the forefoot func-
tions in weight transfer.11,16 The toes are exposed to high
compressive and shear forces. The main function of the
toes is to increase the weight bearing area of the forefoot
so the metatarsal heads alone do not absorb all the forces
during toe-off. Normal toe position is a combination of
intrinsic and extrinsic muscle balance and competent static
joint restraints. The extensor digitorum longus functions
to dorsiflex the proximal phalanx by its attachment to a
fibroaponeurotic sling that suspends the phalanx. Flexion
of the MTP joint is primarily the function of the intrinsic
musculature.10,23
The flexor digitorum longus and brevis flex the proximal
interphalangeal joints and distal interphalangeal joints but
are weak flexors of the MTP joint. The intrinsic muscle
control of the second toe is unique in that it has 2 dorsal
interossei and no plantar interossei.23 The lumbrical tendon
insertion into the medial extensor hood adds an unopposed
adduction force to the second toe. This may become an
important deforming force and potentially lead to a cross-
over toe deformity when lateral restraints become lax or
torn.1 Both interossei, as well as the lumbrical tendon, pass
plantar to the axis of rotation of the MTP joint. With hyper-
extension of the proximal phalanx, the interossei subluxate
dorsal to the axis of the MTP joint and are no longer efficient
flexors of that joint.1,16,23 The lumbrical tendon is tethered
by the deep transverse metatarsal ligament and so remains
plantar to the axis of rotation, but is an inefficient flexor
due to the acute angular line of pull. Thus, as the proximal
phalanx hyperextends, there are no major muscular antago-
nists to further extension and progressive subluxation of
the MTP joint occurs.
133
 Coughlin et al

Static restraints (capsule, collateral ligaments, and Figure 2. Progression of crossover second toe deformity beginning as mild instability
of the MTP joint and finally progressing to frank dislocation. A) mild; B) moderate;
plantar plate) also play a major role in maintaining joint C) severe (note the hammer toe deformity); D) severe crossover second toe with
stability.7,16,23 As chronic inflammation or acute trauma dislocated second MTP joint and with fixed hammertoe deformity.

occurs, the stabilizing structures of the second MTP joint

can become attenuated with time. Based on our surgical
and cadaveric findings, as well as the results of a few series
in the literature,3,14 we believe that the primary structure to
fail is the plantar plate. The collateral ligaments may also
fail in time, with both of these events leading to medial or
dorsomedial deviation of the second toe. The tendency with
weight bearing during normal gait is to displace the proximal
phalanx dorsally. The plantar plate, along with the intrinsic
flexors (interossei and lumbrical), resist this force and pull
the proximal phalanx back into a neutral position at the
MTP joint. Due to the anatomic characteristic of the intrinsic
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musculature, the end result of plantar plate attenuation is a

dorsal or dorsomedial subluxation of the proximal phalanx
on the metatarsal head.24,28

Clinical Presentation
A crossover second toe presents as pain and inflammation of
the second MTP joint. Symptoms can be acute, subacute, or
chronic. Focal pain at the plantar aspect of the forefoot at the
base of the second toe is the most common chief complaint.7
In general, pain is most noticeable during ambulation and
subsides during rest. Frequently, patients describe a feeling
of walking on a “marble in the ball of the foot,” which likely
represents swelling of the joint capsule and surrounding soft
tissues. With dorsal dislocation, the proximal phalanx lies
dorsal to the second metatarsal, causing the toe to strike
the top of the toe box, producing a painful callosity over
the proximal interphalangeal joint (Figure 2).2,7 The shoe,
in turn, forces the dislocated proximal phalanx downward
against the metatarsal head, which can lead to development
of a large, painful intractable plantar keratotic lesion. With
dislocation of the toe, the prominent dorsal base of the
proximal phalanx often is easily palpated. Patients may also
present with swelling at the base of the toe, more impressive
plantarly than dorsally. Some patients will have prodromal
symptoms of the toe subluxating for a period of weeks.24
In the earliest stage of crossover second toe, no defor-
mity is noted usually; however, swelling of the digit is
quite common. In later stages, severe pain may lead to an
antalgic gait, with the patient compensating by walking on
the lateral aspect of the foot. As the disease progresses,
the second toe crosses either under or, more often, over
the hallux.21 Barefoot weight bearing can be intolerable,
especially on hard surfaces.
Abbreviation: MTP, metatarsophalangeal.
Physical Examination
The primary restraint to MTP joint subluxation is the plan-
tar plate. Attenuation of this structure leads to MTP joint
instability,15,19,21 with the subsequent onset of pain and joint
deformity.8,13 While pain is the most prevalent complaint,7
various objective physical findings can be demonstrated,
including swelling, malalignment of the toe, neuritic
symptoms, and dysfunction in the normal biomechanics
of toe motion.8
Observation initially reveals swelling or thickening of
the MTP joint with no other deformities. As the disease pro-
gresses, dorsal or dorsomedial deviation of the second toe
toward the hallux occurs; a hammertoe may develop with
time. Tenderness on palpation can be localized to either the
medial or lateral aspect of the MTP joint or to the plantar
aspect of the joint, depending on the exact location of the
capsular disorder.28 Compression of the transverse meta-
tarsal arch typically does not elicit pain. Characteristically
absent is the radiation of pain into the toes or numbness of
the toes typically associated with interdigital neuroma.21
The drawer test is the first objective sign of MTP joint
instability (Figure 1; Table 1).18,21 It is a reproducible
physical examination to confirm pathologic findings. When
testing MTP joint stability, the involved toe should be
dorsiflexed 25° at the MTP joint before the vertical stress
test is performed. Comparison with the normal foot can be

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Table 1. Clinical Staging System for Second MTP Joint Instability
Grade Alignment
0 MTP joint alignment; prodromal phase with pain but no
deformity
1 Mild malalignment at MTP joint; widening of web space,
medial deviation
2 Moderate malalignment; medial, lateral, dorsal, or
dorsomedial deformity, hyperextension of toe
3 Severe malalignment; dorsal or dorsomedial deformity;
second toe can overlap the hallux; may have flexible
hammertoe
4 Dorsomedial or dorsal dislocation; severe deformity
with dislocation, fixed hammertoe
Abbreviation: MTP, metatarsophalangeal.
helpful. A gap between the second and third toes, or medial
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deviation of the second toe, is another classic clinical sign of
instability and malalignment.1,7 Based on the clinical findings
of deformity and/or instability, the MTP joint condition is
staged on a 0-to-4 scale that defines the severity of the instabil-
ity and deformity. We have found that the staging assists us
in determining the magnitude of the surgical treatment and is
predictive as to whether a simple or complex capsular repair
may be necessary.
The strength of toe touch on the ground or digital purchase
was evaluated using the “paper pull-out test.”3 With the patient
standing, a narrow strip of paper (1 cm wide and 8 cm long)
is placed beneath the affected toe, and the patient is asked
to plantarflex the digit. If the patient is unable to prevent the
paper strip from being pulled out from beneath the digit, this
is considered a positive test (absence of digital purchase).3
Pain on the lateral aspect of the second MTP joint may be
accompanied by progressive deviation of the toe in a medial
direction, caused by degeneration of the lateral plantar plate
and collateral ligament complex. A hyperextension deformity
at the second MTP joint leads to plantar pain caused by attri-
tional changes or a tear of the plantar plate.10 In the early stance
phase of gait, symptoms might be absent, but the toe-off phase
is characteristically uncomfortable.29
Development of an interdigital neuroma in the second
intermetatarsal space also has been associated with second
toe instability.9 A comprehensive review21 of crossover toe
reported that a high percentage of patients had a hammertoe
deformity, and hallux valgus occurred in 49%, hallux rigidus
in 14%, and hallux varus in 7%. Intractable plantar keratosis
beneath the second metatarsal head, however, was not a
consistent finding (7%).21 The specific diagnosis of MTP joint
instability may be aided by local Xylocaine injections into the
symptomatic MTP joint. Differentiation of pain originating
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Second MTP Joint Instability
Physical Examination
MTP joint pain, thickening or swelling of the MTP joint, reduced toe
purchase, negative drawer
MTP joint pain, swelling of MTP joint, loss of toe purchase, mild
positive drawer (⬍ 50% subluxable)
MTP joint pain, reduced swelling, no toe purchase, moderate positive
drawer (⬎ 50% subluxable)
Joint and toe pain, little swelling, no toe purchase, very positive drawer
(dislocatable MTP joint), flexible hammertoe
Joint and toe pain, little or no swelling, no toe purchase, dislocated
MTP joint, fixed hammertoe
from a symptomatic interdigital neuroma or an unstable lesser
MTP joint can be difficult, and sequential injections may help
to differentiate the specific area of pain.7,16,21,29
Classification of Plantar Plate
Injuries
Instability of the second MTP joint has been categorized by
several authors into distinct grades.14,24,28,30 Mendicino et al28
and Yu et al24 both described a prodromal stage preceding
subluxation characterized by MTP joint pain and swelling,
while Haddad et al30 proposed a clinical description of sec-
ond MTP joint instability based on deformity. Until now, all
classification schemes have used only clinical descriptions,
without considering the anatomic finding of the associated
plantar plate tear.
We developed a comprehensive clinical staging system
based upon physical examination, which incorporates many
of the clinical findings of previous rating systems.8,14,24,28,30
(Table 1). We subsequently have developed an anatomic grad-
ing scale (Table 2) to match the clinical staging system. This
anatomic scale has been developed from our investigation of
cadaveric specimens with crossover second toe deformities
with confirmed plantar plate tears. These staging and grading
systems address plantar plate dysfunction (Figure 3) and can
help with the surgical planning and management of plantar
plate ruptures.
Differential Diagnosis
The differential diagnosis of pain localized to the area of
the second MTP joint includes MTP joint synovitis, cap-
sule degeneration, Freiberg’s infraction, metatarsal stress
fracture, degenerative arthritis, systemic arthritis localized
to the second MTP joint, synovial cyst formation, and inter-
digital neuroma.7,8,10 Although a synovial cyst or interdigital
135
 Coughlin et al
Table 2. Anatomic Grading of Plantar Plate Tears
Grade Patterns of Injury
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)
4 Extensive tear with button hole (dislocation); combination
transverse and longitudinal plate tear
neuroma may be associated with pain and deviation of the
toe, intrinsic capsular instability more often is the cause of
malalignment of the second MTP joint.6,24 It can be difficult
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to differentiate pain from MTP joint capsule instability and
that from an adjacent interdigital neuroma.1,8,28 However, a
neuroma typically is associated with neuritic radicular pain
to the involved toes, as well as numbness, reproduction of
pain with the squeeze test (compression of the metatarsal
heads), and a Mulder click.31,32 MTP joint instability typi-
cally is not associated with neuritic symptoms or numbness,
unless simultaneously there is a concomitant interdigital
neuroma. Coughlin et al,9 however, reported that 20% of
the cases in which an interdigital neuroma was excised also
demonstrated instability of the second MTP joint.
Figure 3. Anatomic grading for plantar plate dysfunction. A) grade 1; B) grade 2; C) and D) grade 3; E) grade 4. Arrows mark tears.
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Imaging Studies
Radiographic evaluation of the MTP joint may be less helpful
than the clinical examination. Typically, the lateral inclination
of the lesser toes at the MTP joint averages approximately
12°. With progressive deviation of the MTP joint, this orien-
tation can increase or decrease. Anteroposterior and lateral
radiographs may be helpful in evaluating the magnitude of
the MTP joint angular deformity, assessing joint congruity,
ascertaining the presence of MTP joint arthritis, and deter-
mining the length of the second metatarsal.21
In a normal anteroposterior radiograph, the articular car-
tilage leaves a clear space of 2 to 3 mm.21 As hyperextension
of the MTP joint progresses, the clear space disappears, and
the base of the proximal phalanx subluxates dorsally over
the second metatarsal head. With frank dislocation, the base
of the proximal phalanx can lie dorsally over the metatarsal
head. This is best seen on a lateral radiograph. With progres-
sion of the deformity, the second toe deviates medially or
dorsomedially and gradually comes to rest above the hallux.
A hallux valgus deformity may be identified on examination
in association with a crossover toe.
Upon reviewing an anteroposterior radiographic series of
17 patients (22 toes), Coughlin7 suggested that a long second
metatarsal placed the second MTP joint at risk for increased
pressure and subluxation. Kaz and Coughlin,21 in reviewing
the radiographs of these same 17 patients in addition to a

larger series of 169 patients, concluded that the supposed
increased length of the second metatarsal was largely due to
the method of measurement; in cases of hallux valgus, the
increased intermetatarsal angle can lead one to conclude that
the first metatarsal is shorter than the second while, in fact,
the length is virtually the same.
A lateral radiograph can demonstrate dislocation or
hyperextension of the MTP joint. The magnitude of the defor-
mity appears to be related to chronicity.21,24 Arthrography of
the second MTP joint was described by several authors,14,28
and may be helpful in assessing capsule deterioration or
instability of the MTP joint. Dissemination of contrast into
the tendon sheath can indicate a plantar plate rupture. Yao
et al17 have reported that magnetic resonance imaging (MRI)
is useful and reliable in the diagnosis of plantar plate abnor-
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malities and may enhance the specificity of a thorough history
and clinical examination. Magnetic resonance imaging is a
noninvasive alternative to arthrography and may help differ-
entiate between other articular and nonarticular diagnoses.17
In most cases, the diagnosis can be made clinically.8,10
Conservative Treatment
Nonsurgical treatment of an unstable second MTP joint defor-
mity is generally unsuccessful. Coughlin10,11 reported that 3
patients with mild-to-moderate crossover deformity treated
with taping had no progression of the deformity, but they
continued to have symptoms on the lateral aspect of the toe.
Taping
The goal of taping is to secure the toe into a neutral position
and provide stability. As inflammation decreases, symptoms
tend to diminish (Figure 4A–B). Stability may be achieved
with eventual capsular scar tissue formation; however, this
can require several months of taping. Whether successful
healing of a plantar plate tear occurs remains controversial.25
Prolonged taping does not correct the digital deformity and
may lead to chronic edema or ulceration of the toe.
Metatarsal Pad
Padding to relieve metatarsal head pressure can alleviate
plantar discomfort by redistribution of weight on the plantar
surface of the foot. The pad should be placed just proximal
to a symptomatic metatarsal head (Figure 4C).
Anti-inflammatory Medications
The use of nonsteroidal anti-inflammatory drugs (NSAIDs)
can decrease discomfort from inflammation at a symp-
tomatic lesser MTP joint. Intra-articular corticosteroid
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Second MTP Joint Instability
Figure 4. Conservative treatment of second metatarsophalangeal joint instability.
A) and B) dorsal and plantar views of taping the second toe; C) metatarsal pad;
D) carbon fiber footplate insole.
Abbreviation: MTP, metatarsophalangeal
injections may also be considered, but should not be used
repetitively. Pain and swelling relief can be dramatic and
almost immediate.29 The potential disadvantage of corti-
costeroid injections, however, is the risk of further plantar
plate attenuation with subsequent dislocation.11,24
Orthotics
Stiffening the area under the metatarsal head with a carbon
fiber footplate (Figure 4D) can relieve the dorsiflexion
stress across the second MTP joint. A rocker-bottom sole
may improve the gait and relieve dorsiflexion stress to
the forefoot.29
Surgical Intervention
Until recently, the surgical treatment of second MTP joint
subluxation was characterized by indirect repair of the
MTP joint malalignment. The most frequent options were
synovectomy,6 soft tissue release,1,10,11,16,19,21,30 tendon trans-
fers,1,3,9,10,16,21,24,28,30 and bony decompression.8,24,28 Results
improved with the advent of distal metatarsal osteoto-
mies8,11,24,28 for decompression or realignment of the involved
joint, but this did not directly address the plantar plate tear.
In fact, none of the methods mentioned above directly
reconstruct the plantar plate tear or the collateral ligament
attenuation.
The plantar plate, in conjunction with the collateral
ligaments, provides the main stability to the second MTP
joint.8,10,23 Recently, direct plantar plate repair has been
proposed, although reports remain scant.3,14,15,25 Using a
plantar approach, Powless and Elze14 and Bouche and Heit3
have reported a total of 78 plantar plate repairs in 2 series
137
 Coughlin et al

ranging from 20 to 50 cases (follow-up ranging from Figure 5. Graphic demonstration of Weil osteotomy. A) sagittal saw to perform
the cut; B) small pusher to retract the metatarsal head; C) resection of a small area
6–100 months). An anatomic study of the surgical exposure dorsal to the second metatarsal; D) Weil osteotomy fixation with 2 small screws.
of the lesser MTP joints from a dorsal approach utilizing
a Weil osteotomy has demonstrated that a dorsal approach
does offer adequate exposure to the MTP joint.27 Gregg
et al15 published a series on a dorsal approach combined with
a Weil osteotomy. In this report, 35 plantar plate repairs
were performed with a mean follow-up of 26 months. A high
rate of good and excellent results was reported. Recently,
Weil et al33 reported 15 cases in which a similar technique
was used, and at an average follow-up of 22 months, 77%
of patients achieved good and excellent results. In neither
analysis were the type or magnitude of the plantar plate
tear reported.
In a cadaveric dissection, Deland and Sung13 observed a
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rupture of the lateral collateral ligament, and an attenuation

but incomplete rupture of the plantar plate insertion at the
base of the proximal phalanx both laterally and centrally.
Deland et al12 reported previously their analysis of the plan-
tar plate in 5 normal feet and discerned that the plate was
composed mainly of type 1 collagen. Johntson et al25 also
reported type 1 collagen in 75% and type 2 in 21% of plantar
plate biochemical analysis. This collagenous composition
may be a factor that affects the healing capability of the
plantar plate tear.34 The same healing problem occurs in the
meniscus of the knee, in which there is also a high level of
type 1 collagen. Below, we describe a surgical technique
that we have used to directly repair the plantar plate tear.
Surgical Technique
The patient is placed supine on the operating room table;
the surgery is performed under tourniquet control.
1. A dorsal longitudinal incision is centered over the
second web space. A longitudinal capsulotomy is
performed just inferior to the tendons of the extensor
digitorum longus and brevis to expose the affected
second MTP joint.
2. A partial collateral ligament release off of the
proximal phalanx of the MTP joint improves
visualization.27
3. A Weil osteotomy, using a sagittal saw, is performed
(Figure 5). The saw cut is made parallel to the plan-
tar aspect of the foot, starting at a point 2 to 3 mm
below the top of the metatarsal articular surface. The
capital fragment is pushed proximally about 10 mm
and fixed with a temporary vertical Kirschner wire,
to hold it in a retracted position.
4. A second vertical Kirschner wire is then placed in
the base of the proximal phalanx. A special miniature
joint distractor (Arthrex, Inc., Naples, FL) is placed
over the vertical wires and spread to expose the
plantar plate (Figure 6).
5. The plantar plate tear is evaluated and graded. Lon-
gitudinal tears in the plate (grade 3) are repaired
with a side-to-side interrupted nonabsorbable suture
(0-FiberWire®; Arthrex, Inc., Naples, FL). Distal
transverse tears (grades 1 and 2) are repaired by
placing the same nonabsorbable suture in the distal
plantar plate. The distal plantar edge of the proximal
phalanx is roughened with a burr or curette to prepare
a surface for reimplantation of the plantar plate. The
distal plantar plate is transfixed just proximal to the
transverse tear using a small curved needle or a special
curved Micro SutureLasso™ (Arthrex, Inc.; Naples,
FL), or suture punch (Mini Scorpion™; Arthrex, Inc.;
Naples, FL) to pass the suture within the restricted
MTP joint surgical area of exposure.
6. Using a 1.6-mm drill, 2 parallel drill holes are created
medially and laterally on the proximal phalanx,
directed from the dorsal cortex of the proximal phalanx

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Figure 6. Intraoperative demonstration of a joint distraction and plantar plate tear
grade 1. Arrows mark tear, distractor, and proximal phalanx of the second MTP joint.
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Abbreviation: MTP, metatarsophalangeal
to the plantar rim of the proximal phalanx. This per-
mits us to pass a suture, plantar to dorsal, to fix the
plantar plate to its insertion point at the plantar base
of the phalanx (Figures 7–8).
7. The Weil osteotomy is then reduced (only shortening
it 1–2 mm). It is fixed in optimal position with 1 or
2 small compression screws.
8. Finally, the toe is held reduced on the metatarsal
articular surface, in 15° of plantar flexion, and with
tension on the sutures (having been pulled through the
holes in the proximal phalanx). They are tied over the
dorsal phalangeal cortex, thus advancing the plantar
plate onto the base of the proximal phalanx.
9. A lateral soft tissue reefing to repair the lateral col-
lateral ligamentous release is performed with 2-0
nonabsorbable sutures.
10. A routine interrupted wound closure is performed. The
foot is placed in a gauze and tape compression dressing
with the digit held in 10° to 15° of plantar flexion.
11. The dressings are changed at 1 and 2 weeks after sur-
gery. Postoperative dressings are then discontinued,
and the foot is placed in a compression wrap with a
dynamic toe exercise strap (Bio Skin® midfoot com-
pression wrap with Weil osteotomy strap, Cropper
Medical, Inc., Ashland, OR).
12. Postoperatively, the patient is allowed to ambulate
in a postoperative shoe with weight bearing only on
the heel. Dressings are discontinued and comfortable
shoes are permitted at 6 weeks postoperatively.
13. Passive and active range of motion exercises are
commenced at 2 weeks following surgery to recondi-
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Second MTP Joint Instability
Figure 7. Graphic demonstration of plantar plate suture with a small suture passer.
Left circle, transversal suture through plantar plate tear; central circle, dorsal view
demonstration of suture passed through proximal phalanx; right circle, lateral view of
suture engaging plantar plate (1 or 2 sutures may be used to secure the plantar plate
and are used to advance the plate to the base of the proximal phalanx). Two sutures
may be passed through each vertical hole.
tion the short and long flexors and extensors of the
lesser toes. A physical therapist is often included in
the postoperative regimen. One specific beneficial
exercise is the use of a Thera-Band® (The Hygenic
Corporation, Akron, OH) sling placed over the hal-
lux. With the ankle at neutral dorsiflexion, the hallux
(and lesser toes) are flexed aggressively against the
Thera-Band® sling. Ten-minute periods of exercise
3 times a day complement the exercise program of
walking and isometrics for the lower extremity.
Discussion
A crossover second toe is a commonly seen forefoot prob-
lem, usually in women aged ⬎ 50 years, and often in associ-
ation with a bunion.21 The clinical symptoms of the patients
can be minimal in the early stages and incapacitating with
chronic disease. Observation of clinical signs and physical
examination findings provide a specific diagnosis.1,7–9,11,21
The use of sequential Xylocaine injections help to differ-
entiate other pathologies.8,9,21 Our classification combines
clinical staging and anatomic grading of the findings of the
plantar plate tears.
Conservative treatment24,29 with NSAIDs, rest, padding,
taping, or injections may eliminate the symptoms and
prevent progression of the deformity, but do not achieve
correction or realignment of the toe deformity. If conserva-
tive treatment fails, surgical management may be indicated.
The surgical treatment that we describe reconstructs the
anatomic structures that lead to the instability of the sec-
139
 Coughlin et al

Figure 8. Surgical technique. A) intraoperative demonstration of second metatarsophalangeal joint distraction with a type 1 plantar plate tear (second metatarsal head is
inferior); B) a suture passer transfixing the plate (just proximal to the tear) and helping to pull the nonabsorbable suture through the plantar plate; C) 4 sutures positioned
at the distal aspect of the plantar plate (not yet passed through the phalanx); D) passing the nonabsorbable suture through the dorsal to plantar drill hole; E) fixation of Weil
osteotomy before tying the sutures; F) tying the sutures with the toe in plantar flexion.
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ond MTP joint. A plantar plate repair and lateral soft tissue
reefing can restore the normal alignment of the joint with
anatomic repair.
Currently, we are prospectively evaluating our patients
with second MTP joint instability in a long-term follow-up
study of the anatomic repair of the plantar plate, and we will
report these results based upon their preoperative clinical
staging and intraoperative anatomic grading when sufficient
follow-up is available.
Conflict of Interest Statement
Michael J. Coughlin, MD is a consultant for Arthrex, Inc.
Daniel S. Baumfeld, MD and Caio Nery, MD disclose no
conflicts of interest.
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