Acorn December 1999

Starting The Millennium On The Right (And Left) Foot

Michael Zapf, D.P.M.

"Doc, what is that swelling under the ball of my left foot?" was how Peter answered my query on how I could help him. Peter was an executive who had to wear dress shoes, golf cleats on weekends and he was planning on wearing fancy dress shoes on New Year's Eve.

With his shoes removed I saw that he did, indeed, have a swelling on the ball of his left foot, just behind the 2^nd toe (the one next to the big toe). After asking a few questions, I squeezed the foot at just the right point. "Yeoww" was how he answered my next question, "Does it hurt right here?" I apologized for my little experiment but I needed to know the exact location of his pain. I could also see that he was secretly pleased that I understood where his pain was located. Peter thinks his pain must be quite uncommon, but I am seeing one like it almost every week.

I squeezed the base of his second toe on the underneath side where the toe meets the rest of the foot. In Peter's case this little spot was so inflamed that there was visible swelling. The condition has a couple of names. Usually it is put in the catchall category of metatarsalgia. At a recent seminar in Chicago a lecturer gave it the name 2^nd metatarsal pre-dislocation syndrome. I know this is an ungainly name and I will try to translate.

At a joint two bones come together. The end of each bone is covered with cartilage -- the rather slippery tissue that allows bones to move against each other. The cartilage is, in turn. covered with a thick, oily lubricant called synovial fluid. To keep the lubricating fluid from wandering off, the joint is surrounded by a connective tissue called a capsule. The cells on the inside of the capsule produce the synovial lubricating fluid and are called synovial cells. Peter was experiencing an acute swelling of the capsule, called a capsulitis, and a swelling of the synovial cells called synovitis.

Why, Peter wanted to know, would a heretofore normal joint decide to develop a synovitis and a capsulitis (actually he just called it a swelling, but I am trying to be a little scientific). The answer is overuse. He is bearing more weight on the second joint that it was mechanically designed to handle. In his case he has a small bunion. It was just big enough that the first joint (behind the big toe) was bearing less weight than it was designed for. It is a side effect of bunions and a few other conditions. The joint capsule responded by blowing up like a little water balloon. In this case a painful water balloon that hurts from the inside.

At the seminar the lecturer showed a series of slides showing what happens over the years to an untreated second toe capsulitis/synovitis. Slowly the joint looses its integrity and the toe seems to lift as if it is floating. It's actually called a floating toe syndrome where the second toe does not touch the ground when you are standing. If a bunion develops, the big toe either pushes the second toe toward the smaller three toes or the second toe actually lifts over the big toe. (I have pictures of these conditions in my bunion monograph - free for the asking).

My seminar helped me understand that 2^nd toe capsulitis is not a benign condition and needs to be treated. Pain means inflammation and inflammation means eventual problems. If it hurts - it should be treated.

For Peter, I injected his joint with a bit of cortisone that immediately shrank the joint and got him back on the golf course. Cortisone, like anti-inflammatory pills are, of course, just a temporary solution. Long-term solutions include softer shoes, gentler floor surfaces and custom shoe inserts, called orthotics, designed to shift the weight bearing from the second toe to the neighboring toes.

Peter did not know what he was getting into when he came to my office. He now understands that this is the potential tip of an iceberg. With the injection he is ready to kick off a great New Millennium. With his new orthotic shoe inserts he will be looking forward to the 2000s as well.

Dr. Michael Zapf is a podiatrist in private practice with offices in Agoura Hills and Thousand Oaks. For more information or a copy of his monograph "What Every Patient With A Bunion Needs To Know" Please call his office at (818) 707-3668 or (805) 497-6979. Dr. Zapf also thanks everyone who has read this column over the last 14 years and wishes everyone a Happy New Millennium.