Site Search:

Question for Physiotherapists

CASE HISTORY | A 50 year old man who is a runner (30km/week on roads) presents with pain and swelling in his right forefoot. The pain was initially activity related but now occurs at rest. He has had to stop running. He has noticed swelling in the forefoot but no redness or numbness. He is otherwise in extremely good health and gives no history of diabetes or gout. He is a non-smoker. He does not suffer from psoriasis, eye infections and has had no history of sexually transmitted diseases.

On examination:
His toes are in slightly abnormal alignment, his second toe is subtly deviated towards his great toe (Figures 3 and 4). He has swelling in the forefoot but no redness. He walks comfortably on heels but is unable to walk on his toes.

He has normal peripheral circulation and sensation. He is maximally tender at the second MTP joint, particularly on the plantar surface. He has a satisfactory range of movement in the second MTP joint. He has no stigmata of psoriasis.

Investigations: He brings with him a plain x-ray of the forefoot which is normal.  

Differential Diagnosis:
  • Stress fracture 
  • Arthropathy seronegative or gout 
  • Neuroma 
  • Plantar plate tear 

What are the clues??

Fracture: the cardinal clinical sign of fracture is “point tenderness over bone”……x-ray was invented in 1895 but fractures have been diagnosed for millennia by this simple readily elicited clinical sign. Is the patient tender over the distal shaft of the second metatarsal or the metatarsal head?

An arthropathy: will often present with redness and heat with swelling either in the joint or on occasion the whole toe…..the so called “sausage digit” or dactylitis is pathognomic of an arthropathy. The finding of psoriasis clinches a diagnosis of psoriatic arthritis.(Figures 1 and 2)
A neuroma: with a mechanically inflamed interdigital bursa will present with pain at the interspace rather than on the bone. Look for altered sensation at the adjacent borders of the second and third toes. 

Plantar plate tears: are being increasingly recognised as a cause of forefoot pain in this situation. As per the image below, the second toe is deviated towards the great toe and no longer touches the ground. The patient complains of a “walking on a stone” sensation. The patient may also complain of numbness or paraesthesia in the second toe. This is a traction effect on the nerve and is a cause of confusion with neuroma.

On examination: The pain is at the base of the proximal phalanx on the plantar surface. The patient will frequently have a positive toe anterior drawer sign which reproduces their pain.

Further investigations: In medicine if you ask the wrong question you get the wrong answer!  As plantar plate tears/stress fractures/arthropathies and neuroma/bursas are the likely diagnoses then an MRI with a surface coil and an experienced radiologist is the test likely to be most helpful.  

Treatment: (Depends on the diagnosis) 
  • Plantar plate tear: Tape the toe and metatarsal dome with rest from impact sport. 
  • Stress fracture: Rest in a walking boot. 
  • Acute neuroma/bursa: Ultrasound guided steroid injection. 
  • Arthropathy/Gout:  Anti-inflammatory medication and rheumatological referral.
 Figure 1: Dactyitis of second toe    Figure 2: Psoriasis in the scalp
Figures 3 & 4: Typical findings in plantar plate tear - dorsal and medial deviation of the second toe

Dr John Negrine

If you are a physiotherapist and wish to be sent the Question for Physiotherapists or you would like to submit a Question please email including your name and practice. 

Previous Question for Physiotherapists:

Aug-2017 Wrist Ganglion
Dr Kwan Yeoh 
Jul-2017 Anterolateral Ligament Reconstruction  Dr Doron Sher 
Jun-2017  Scapholunate ligament Dr Kwan Yeoh 
Apr-2017  Knee Brace - ACL Reconstruction Dr Doron Sher 
Mar-2017 Sesamoid fractures  Dr Kwan Yeoh 
Feb-2017  Plantar Fasciitis
Dr Todd Gothelf
Nov-2016  Sternoclavicular Joint Dr Doron Sher 
Oct-2016  Proximal Humerus Fractures Dr David Lieu 
Sep-2016 Wrist Fractures  Dr Kwan Yeoh 
Aug-2016  Patella Instability Dr Doron Sher 
Jul-2016 Snowboarders ankle
Dr Todd Gothelf
May-2016  Cortisone Injections Dr Paul Annett 
Apr-2016 Shoulder Instability_1  Dr Ivan Popoff 
Mar-2016 Exercise after TKR  Dr Doron Sher 
Dec-2015 Scaphoid OA Dr Kwan Yeoh 
Nov-2015  Greater Tuberosity Fractures Dr Doron Sher
Oct-2015 Stress Fractures  Dr Paul Annett
Boxers Fractures
Dr Kwan Yeoh
Aug 2015
Resistance Training  Dr John Best
July 2015 LARS Ligament
Dr Ivan Popoff
Distal Biceps  Dr Doron Sher
May-2015 Latarjet procedure
Dr Jerome Goldberg
Apr-2015 TFCC Questions  Dr Kwan Yeoh 
Mar-2015  Acute Ankle Sprains
Dr Todd Gothelf
Nov-2014  PRPP Dr Paul Annett
Oct-2014 Driving After Surgery
Dr Doron Sher
Sep-2014  Distal Biceps Rupture Dr Doron Sher
Aug-2014 Ankle Sprain
Dr Todd Gothelf
Jun-2014  Patella Dislocation Dr Doron Sher
May-2014  Shoulder Instability Dr Todd Gothelf
Apr-2014  De Quervains Dr Kwan Yeoh
Acromio-clavicular joint injuries
Dr Todd Gothelf
Feb-2014 Chronic Knee Pain
Dr Paul Annett
Dec-2013 Foot and Ankle Questions  Dr John Negrine
Oct-2013 Rotator Cuff Repair  Dr Todd Gothelf
Sep-2013  ACL Reconstruction
Dr Doron Sher
Jul-2013 Slipped Upper femoral epiphysis  Dr Rod Pattinson
May-2013 Skiers thumb Dr Kwan Yeoh
Apr-2013  Bakers_Cyst
Dr Ivan Popoff


 Tibial Osteotomy vs UKR

Dr Doron Sher 

 ALIF success rate

Dr Andreas Loefler


 Lisfranc Injuries

Dr Todd Gothelf 

 Anterior Spinal Fusions

Dr Andreas Loefler 

 MCL Injuries

Dr Doron Sher 

Compartment Syndrome

Dr Paul Annett 

 Carpal tunnel

Dr Kwan Yeoh 

 Anterior Process Calcaneus Fx

Dr Todd Gothelf 

 Tenodesis vs Tenotomy

Dr Jerome Goldberg 


 Osteoarthritis in the young active patient Dr Doron Sher 

 Syndesmosis Sprain

Dr Todd Gothelf 


 Triangular Fibrocartilage Injuries

Dr Kwan Yeoh 

 Shoulder Replacement Older Population

Dr Jerome Goldberg



 Wrist Fracture

Dr Kwan Yeoh 



 Adductor Tendon Tear

Dr Paul Annett 

 Navicular Pain 

Dr Todd Gothelf 

 OCD Lesion

Dr Doron Sher 

 Metal on Metal Hip Replacements

Dr Andreas Loefler 

 Femoral Neck Stress Fract (Pt 2)

Dr John Best 


 Femoral Neck Stress Fractures

Dr John Best 

 PCL Injury Part 2

Dr Doron Sher 

 PCL Injury Part 1

Dr Doron Sher 

 Prolotherapy Autologous Blood Injections

Dr Paul Annett 

 Shoulder Impingement

Dr Todd Gothelf 

 Does Chondral Grafting Work

Dr Doron Sher 

 Shoulder Immobilisation-Dislocation

Dr Jerome Goldberg

SLAP Lesions Stable Shoulder

Dr Todd Gothelf 

 Ankle Sprains

 Dr Todd Gothelf


 Dislocation After THR

 Dr Peter Walker


 Acupuncture Muscle Strength Programmes

 Dr Paul Annett


 Full Thickness Rotator Cuff Tears

Dr Jerome Goldberg


 Skiing after TKR

 Prof Warwick Bruce


 Fractures of the Clavicle

 Dr John Trantalis


 Osteoarthritis of the Knee

 Dr Doron Sher


 Fifrth Metatarsal Fractures

 Dr Todd Gothelf


Partial Rotator Cuff Tears

Dr Todd Gothelf

Copyright © 2009 Orthosports
Heel Pain - Colles Fracture - Shoulder Rehabilitation

Orthopaedic Surgeon - Knee Reconstruction - ACL tear - Osteotomy
Orthopaedic Surgeon

Enter your email address:
CONCORD 02 9744 2666 | HURSTVILLE 02 9580 6066 | PENRITH 02 4721 7799 | RANDWICK 02 9399 5333 | BELLA VISTA 02 9744 2666
Copyright © 2009 Orthosports