A subungual exostosis is a bony prominence that can occur under the toenail. They generally are a result of some form of trauma to the toe that results in the formation of bony irregularity or prominence. When they are symptomatic, removal of the spur is the treatment of choice. Additionally other small tumors called osteochondromas andenchondroma can also form in the bone beneath the toenail as well as in other bones in the body.

An osteochondroma is a benign bone tumor that accounts for 50% of all benign bone tumors. They have a predilection for the long tubular bones of adolescents and young adults. Its peak incidence is in the second decade of life with a male to female ratio of approximately 2:1. They are generally painless or minimally painful unless they cause irritation to the surrounding tissue. When they are in the bone beneath the toenail they can deform the toenail and cause an ingrown toenail. The treatment of symptomatic osteochondromas is surgical excision. The final diagnosis is made after the bone tumor is removed and examined by a pathologist. Recurrence of the tumor is possible following their removal. Hereditary multiple exostosis (osteochondromatosis) have a prominent hereditary incidence which affects males more often then females. The disease is characterized by the presence of multiple exostosis, which are frequently bilateral and somewhat symmetrical and usually make their appearance during childhood or adolescence.

Enchondroma is a fairly common benign cartilaginous tumor, which is the most common bone tumor of the hands and feet. They affect patients in a wide age range with no sex predilection. When they occur within the small tubular bones the tumor can involve large portions of these bones, causing thinning of the cortex of the bone. This can weaken the bone and cause it to break spontaneously. When they occur in the small bone in the end of the toe they can cause pain that may mimic the pain of ingrown toenails. Ollier's disease, also known as enchondromatosis, shows a strong predilection for the small bones in the hands and toes (phalanges) and the long bones behind the phalanges called metatarsals. It is often shows an asymmetric involvement, tending to affect one side of the body more than the other and has a propensity to transform into a malignant sarcoma. Maffucci's syndrome is a very rare form of enchondromatosis associated with multiple soft tissue hemangiomas. This tumor has a greater predilection for the hands and feet, and has a greater toward malignant transformation than Ollier's disease.

A subungual exostosis is a bony prominence that can occur under the toenail. They generally are a result of some form of trauma to the toe that results in the formation of bony irregularity or prominence. When they are symptomatic, removal of the spur is the treatment of choice. Additionally other small tumors called osteochondromas and enchondroma can also form in the bone beneath the toenail as well as in other bones in the body.

An osteochondroma is a benign bone tumor that accounts for 50% of all benign bone tumors. They have a predilection for the long tubular bones of adolescents and young adults. Its peak incidence is in the second decade of life with a male to female ratio of approximately 2:1. They are generally painless or minimally painful unless they cause irritation to the surrounding tissue. When they are in the bone beneath the toenail they can deform the toenail and cause an ingrown toenail. The treatment of symptomatic osteochondromas is surgical excision. The final diagnosis is made after the bone tumor is removed and examined by a pathologist. Recurrence of the tumor is possible following their removal. Hereditary multiple exostosis (osteochondromatosis) have a prominent hereditary incidence which affects males more often then females. The disease is characterized by the presence of multiple exostosis, which are frequently bilateral and somewhat symmetrical and usually make their appearance during childhood or adolescence.

Enchondroma is a fairly common benign cartilaginous tumor, which is the most common bone tumor of the hands and feet. They affect patients in a wide age range with no sex predilection. When they occur within the small tubular bones the tumor can involve large portions of these bones, causing thinning of the cortex of the bone. This can weaken the bone and cause it to break spontaneously. When they occur in the small bone in the end of the toe they can cause pain that may mimic the pain of ingrown toenails. Ollier,s disease, also known as enchondromatosis, shows a strong predilection for the small bones in the hands and toes (phalanges) and the long bones behind the phalanges called metatarsals. It is often shows an asymmetric involvement, tending to affect one side of the body more than the other and has a propensity to transform into a malignant sarcoma. Maffucci's syndrome is a very rare form of enchondromatosis associated with multiple soft tissue hemangiomas. This tumor has a greater predilection for the hands and feet, and has a greater toward malignant transformation than Ollier,s disease.

A subungual exostosis is a bony prominence that can occur under the toenail. They generally are a result of some form of trauma to the toe that results in the formation of bony irregularity or prominence. When they are symptomatic, removal of the spur is the treatment of choice. Additionally other small tumors called osteochondromas and enchondroma can also form in the bone beneath the toenail as well as in other bones in the body.

An osteochondroma is a benign bone tumor that accounts for 50% of all benign bone tumors. They have a predilection for the long tubular bones of adolescents and young adults. Its peak incidence is in the second decade of life with a male to female ratio of approximately 2:1. They are generally painless or minimally painful unless they cause irritation to the surrounding tissue. When they are in the bone beneath the toenail they can deform the toenail and cause an ingrown toenail. The treatment of symptomatic osteochondromas is surgical excision. The final diagnosis is made after the bone tumor is removed and examined by a pathologist. Recurrence of the tumor is possible following their removal. Hereditary multiple exostosis (osteochondromatosis) have a prominent hereditary incidence which affects males more often then females. The disease is characterized by the presence of multiple exostosis, which are frequently bilateral and somewhat symmetrical and usually make their appearance during childhood or adolescence.

Enchondroma is a fairly common benign cartilaginous tumor, which is the most common bone tumor of the hands and feet. They affect patients in a wide age range with no sex predilection. When they occur within the small tubular bones the tumor can involve large portions of these bones, causing thinning of the cortex of the bone. This can weaken the bone and cause it to break spontaneously. When they occur in the small bone in the end of the toe they can cause pain that may mimic the pain of ingrown toenails. Ollier's disease, also known as enchondromatosis, shows a strong predilection for the small bones in the hands and toes (phalanges) and the long bones behind the phalanges called metatarsals. It is often shows an asymmetric involvement, tending to affect one side of the body more than the other and has a propensity to transform into a malignant sarcoma. Maffucci's syndrome is a very rare form of enchondromatosis associated with multiple soft tissue hemangiomas. This tumor has a greater predilection for the hands and feet, and has a greater toward malignant transformation than Ollier's disease.

A small nodular single mass that can form on the top of the toe is often times a Muco-Cutaneious Cyst. These occur most frequently at the joint just behind the toenail. These are caused by a weakening of the joint capsule, which allows a swelling to occur. They are firm and rubbery to the touch. Sometimes as the skin thins due to the stretching pressure of the mass it will appear translucent. When the mass is broken or punctured, a thick clear fluid will leak out. If the mass does break open, the area should be kept clean and free of infection. Once the skin heals the mass will reappear.

Treatment

Treatment consists of surgical excision. This can be performed in the doctor's office under a local anesthesia or in an out patient surgery center. The procedure is relatively simple but can pose a problem for the surgeon, as closure of the skin following removal of the mass can be difficult. Often the surgeon will have to create a skin flap to rotate over the hole where the mass was removed. This requires a bit more of an incision than most patients expect. The foot is bandaged in a dry sterile dressing and the sutures remain in place from 7 to 10 days. The area must be kept dry during this period of time and a limitation of activity is advised. Complications associated with the surgery are infection, delays in healing associated with difficulty in surgically closing the wound. Draining the mass as a form of treatment is not advised unless the patient is made aware of the likely recurrence. Picking the area open at home or attempting to drain it at home is discouraged. An infection in the area could cause permanent joint damage or bone infection.

What is 2nd MTP Joint Capsulitis?

Capsulitis is inflammation of a joint capsule. The second MTP joint is one of the capsules that most commonly experiences inflammation.  Each foot possesses five MTP joints that connect your toe bones, or phalanges, with your metatarsal bones—long, thin bones located in your mid-foot.

Causes

Often this occurs after wearing a pair of shoes that don't have as much support as typical with increased walking. Sometimes runners we'll experience this after they've increased training, or if shoes have worn out and have not been replaced. Other times there is no distinct cause as to why this has started. Many of the problems and the feet are mechanical, and this particular problem is no exception. From a mechanical standpoint approximately 50% of the forefoot weight bearing load is carried by the great toe and the bones behind it including the first metatarsal. The remaining 50% is distributed amongst the second third fourth and fifth metatarsals and the corresponding metatarsophalangeal joints (where the toes meet the forefoot) this entire area (MTP joints #1-#5) is also described as "the ball of the foot". A very common problem occurs when the first metatarsal does not carry its appropriate weight bearing load and therefore an increased load gets shifted to the remaining second third fourth and fifth metatarsals.

Typically the second metatarsal is next in line and receives the brunt of this "stress overload". Over time this increased stress can cause problems including inflammation and pain and eventually damaging the second MTP joint capsule itself. When this damage occurs, often there is resultant misalignment of the second toe whether it starts to drift toward the great toe or starts to contract into what is described as a hammertoe. It is even possible over time for this capsule to completely breakdown and for the second toe to dislocate from the metatarsal head. This is also seen in some other conditions such as with rheumatoid arthritis.

Additional common mechanical causes of stress overload to the second MTP joint include an elevated first metatarsal, a hypermobile first metatarsal, a short first metatarsal, where a long second metatarsal. In addition, hammertoe contracture can cause a retrograde buckling of the joint and abnormal pressure on the capsule and related structures.

Symptoms

Pain associated with capsulitis of the second metatarsal phalangeal joint, or the second MTP joint, is felt in the ball of the foot especially near the base of the second and sometimes third or fourth toes. Sometimes there is even swelling in the knuckle behind the second toe. Pain in the second MTP joint is often diagnosed as second MTP joint capsulitis. This is a bit of a catch all term but in general is like inflammation of the ligaments around this joint because of a stress overload and increase weight bearing and a disproportionate manner to this joint.

Treatments

After the initial physical examination of your foot and ankle, we typically will need an x-ray to evaluate the foot structure. We evaluate potential causes of pain in the second MTP joint area and rule out other potential differential diagnosis considerations such as a stress fracture or arthritis. Looking at the foot in a weight bearing position and gait evaluation can also be very helpful. Diagnostic ultrasound imaging can provide an excellent image of the associated structures including the capsule. But in some of the more difficult cases, we will need MRI evaluation to get a definitive picture and/or assessment of a tear of the capsule. A further sub-category of the capsule is the plantar plate. This can be torn and is also well visualized MRI evaluation.

Because this is a mechanical problem, change in the mechanics of foot function and the way the foot interfaces with the ground is a good approach. This includes both shoes and prescription orthotics. There are some over-the-counter inserts they can provide temporary relief and support. Prescription orthotics can have specific modifications unique to the particular foot and the related pathology. The whole goal is to get the first metatarsal to bear more weight and the second metatarsal less weight. In addition to shift some of the weight bearing phase of gait off of the forefoot and allow a longer time frame with the heel strike phase of gait. Some of this can be quite complicated including both the orthotics and related shoe recommendations. But it is quite impressive what can be done by changing the mechanics here. Other simple things that can help include avoiding going barefoot at home, aggressive calf stretches, and a night splint.

Finally, some of our patients as such pronounced underlying structural problems that these have to be corrected in order for the problem to resolve. Many of these patients end up requiring surgery. Once the normal mechanical function has been reestablished, we are able to resolve the second MTP joint pain in the ball of the foot

This condition is often confused with a Morton’s Neuroma because the pain is felt in the same general region, however not in the exact same region. Many patients will complain of pain in this general area and a web diagnosis may lead them to an incorrect self-diagnosis. Properly identifying the cause of pain is the first step to properly treating the condition.

The Lis Fran's joint is a combination of joints in the middle of the foot. At the point where the long bones behind the toes, called metatarsals, connect with a grouping of small cube shaped bones, called cuniform bones, there are several joints the move together in an interlocking fashion. This grouping of interlocking joints is referred to as the Lis Franc's joint. The Lis Franc’s joint are bound together by a series of transverse ligaments on the top and bottom of the joint, as well as an intermetatarsal ligament. This grouping of joints is clinically called the tarsometatarsal joints. Fracture-dislocations of the tarsometatarsal joint are named for Lis Franc who was a field surgeon in the Napoleonic army. Fracture-dislocations of the tarsometatarsal joint (Lis Franc’s) is extremely significant in that it is a commonly missed diagnoses with a great potential for long term disability.

Lis Franc’s fracture-dislocations can occur in many different ways. It can be caused by both a direct crushing type injury or a force applied to the metatarsal heads (ball of the foot) which both can result in displacement of the Lis Franc’s joint or fractures that in involve the joint. Common causes are motor vehicle accidents, falls from heights, severe foot and ankle sprains, crushing force to the top of the foot. These injuries can occur during strenuous and competitive athletic activities. The athlete who complains of sudden onset of pain, in the middle of the foot during the course of an athletic event should be carefully evaluated for a possible Lis Franc's injury.

Diagnosis

Diagnosis is extremely important following the injury. Early diagnosis and treatment can prevent long-term chronic pain and other sequalae. Diagnosis is made by both clinical and X-ray modalities. On physical examination there is marked tenderness across the tarsometatarsal joint usually with pinpoint tenderness at the articulation of the second metatarsal base and the medial and intermediate cuneiforms. Global forefoot and midfoot swelling is commonly seen from several minutes to several hours following injury. In severe dislocations it is very easy to visualize a change in shape of the foot as compared to the other foot. X-rays may reveal either a partial or total dislocation at the tarsometatarsal joint. The difficult cases to diagnosis are those when the joint dislocates and then relocates on it’s own. When this occurs there may be little evidence of the injury on an x-ray. If there are no X-ray changes and clinical diagnosis makes the doctor suspicious of injury they may order stress X-ray, bone scan or MRI. In all acute injuries circulation must be monitored to assess the possibility of compartment syndrome (increase in pressures within the foot which can shut off circulation). This could result in loss of oxygen to the tissues, which might result in loss of the foot.

Treatment

Closed reduction should always be attempted in an acute fracture-dislocation. Treatment involves general anesthesia to relax the patient and an attempted reduction of the second metatarsal base into its anatomic position is attempted. If the second metatarsal can be reduced then metatarsals two through five may reduce without much manipulation. If closed reduction is successful then reduction of the first metatarsal cuneiform joint is performed and pins are inserted to allow for stability during healing. If closed reduction fails it is usually due to one of the foot tendons, which may be caught in the dislocated joint. If closed reduction fails in an acute injury or the injury is old then open reduction must be performed to reduce long-term problems. If vascular compromise is evident this also constitutes a need for immediate surgery. There are usually two to three incisions placed on the top of the foot to allow for adequate visualization and manipulation of the bones. Once the foot has been placed back into anatomic position the tarsometatarsal joint is stabilized with either pins or screws to allow for stability during the healing process. If pins are used they are usually removed in six to eight weeks. Whether pins or screws are used doesn’t really matter as the patient is non-weight bearing for six weeks and is usually casted for at least eight to twelve weeks. Following bony healing and return to ambulation the patient will need a good functional foot orthotic to provide support and relieve stress from the tarsometatarsal joints and assist in pain free ambulation. Long-term prognosis for this injury is guarded. When any injury involves a joint the likelihood of an on-going arthritic process is likely. In sever cases fusion of the joints may be necessary. In the athlete this injury can be devastating. Rehabilitation to return to the same level of performance can takes several months or longer.

Description

Another common digital deformity is contracture of the toes in the formation of hammertoes and mallet toes. Hammertoes are described in depth in another article. Mallet toes are a result of contracture of the last joint in the toe. In the pediatric population it is often flexible and not painful. Over time the deformity becomes rigid and a callus may form on the skin overlying the joint at the end of the toe. Additionally the toenail may become thickened and deformed form the repetitive jamming of the toe while walking. The deformity usually involves one or two toes, with the second toe most commonly affected. Mallet toes have several etiologies. Longer toes that are forced against a short toe box in the shoe will, over time, develop a contracture of the last joint in the toe causing a mallet toe.

Treatment

Conservative treatment consists of padding and strapping the toes into a corrected position. This treatment may alleviate the symptoms but will not correct the deformity. Diabetic patients often develop ulcerations on the ends of their toes secondary to mallet toe deformity and the pressure that results from the toe jamming into the shoe. When standing, the toe will demonstrate a contracture, with the tip of the toe facing downward into the floor. If the deformity is flexible a simple release of the tendon in the bottom of the toe will allow straightening of the toe. Following the procedure the patient must avoid shoes that cause jamming of the toe or the deformity can reoccur. When the deformity is rigid surgical correction requires the removal of a small section of bone in the last joint of the toe. On occasion fusion of the last two bones in the toe may be necessary. This requires removing the cartilage from the last joint in the toe and pinning the bones together. When the bone heals it forms a single bone and the toe remains in a straightened position. Healing time is dependent upon the procedure selected. If a tendon release is performed the patient my return to a roomy shoe within a week. If the toe is straightened by removing a section of the bone in the toe it make ten days to three weeks for a patient to return to normal shoes. If a fusion is performed to straighten the toe, the patient may not return to normal shoes for 6 to 8 weeks. Time off from work will depend upon the type of shoe gear that must be worn and the level of activity necessary to perform the job. A minimum of three to four days off from work is generally recommended and longer if the job responsibilities can not be modified to accommodate the normal healing time for the surgery.

Maffucci's syndrome is a very rare form of enchondromatosis associated with multiple soft tissue hemangiomas.

A subungual exostosis is a bony prominence that can occur under the toenail. They generally are a result of some form of trauma to the toe that results in the formation of bony irregularity or prominence. When they are symptomatic, removal of the spur is the treatment of choice. Additionally other small tumors called osteochondromas and enchondroma can also form in the bone beneath the toenail as well as in other bones in the body.

An osteochondroma is a benign bone tumor that accounts for 50% of all benign bone tumors. They have a predilection for the long tubular bones of adolescents and young adults. Its peak incidence is in the second decade of life with a male to female ratio of approximately 2:1. They are generally painless or minimally painful unless they cause irritation to the surrounding tissue. When they are in the bone beneath the toenail they can deform the toenail and cause an ingrown toenail. The treatment of symptomatic osteochondromas is surgical excision. The final diagnosis is made after the bone tumor is removed and examined by a pathologist. Recurrence of the tumor is possible following their removal. Hereditary multiple exostosis (osteochondromatosis) have a prominent hereditary incidence which affects males more often then females. The disease is characterized by the presence of multiple exostosis, which are frequently bilateral and somewhat symmetrical and usually make their appearance during childhood or adolescence.

Enchondroma is a fairly common benign cartilaginous tumor, which is the most common bone tumor of the hands and feet. They affect patients in a wide age range with no sex predilection. When they occur within the small tubular bones the tumor can involve large portions of these bones, causing thinning of the cortex of the bone. This can weaken the bone and cause it to break spontaneously. When they occur in the small bone in the end of the toe they can cause pain that may mimic the pain of ingrown toenails. Ollier's disease, also known as enchondromatosis, shows a strong predilection for the small bones in the hands and toes (phalanges) and the long bones behind the phalanges called metatarsals. It is often shows an asymmetric involvement, tending to affect one side of the body more than the other and has a propensity to transform into a malignant sarcoma. Maffucci's syndrome is a very rare form of enchondromatosis associated with multiple soft tissue hemangiomas. This tumor has a greater predilection for the hands and feet, and has a greater toward malignant transformation than Ollier's disease.

There are several different causes of lumps and bumps on the top of the toes and foot. Working from the toes back these are:

1. Muco-Cutaneious Cyst

Small nodular single mass that can form on the top of the toe is called the Muco-Cutaneious Cyst. These occur most frequently at the joint just behind the toenail. These are caused by a weakening of the joint capsule, which allows a swelling to occur. They are firm and rubbery to the touch. Sometimes as the skin thins due to the stretching pressure of the mass it will appear translucent. When the mass is broken or punctured, a thick clear fluid will leak out. If the mass does break open, the area should be kept clean and free of infection. Once the skin heals the mass will reappear.

2. Treatment of Muco-Cutaneious Cysts

Treatment consists of surgical excision. This can be performed in the doctor's office under a local anesthesia or in an out patient surgery center. The procedure is relatively simple but can pose a problem for the surgeon, as closure of the skin following removal of the mass can be difficult. Often the surgeon will have to create a skin flap to rotate over the hole where the mass was removed. This requires a bit more of an incision than most patients expect. The foot is bandaged in a dry sterile dressing and the sutures remain in place from 7 to 10 days. The area must be kept dry during this period of time and a limitation of activity is advised. Complications associated with the surgery are infection, delays in healing associated with difficulty in surgically closing the wound or excessive activity which can lead to swelling and recurrence of the mass. Draining the mass as a form of treatment is not advised unless the patient is made aware of the likely recurrence. Picking the area open at home or attempting to drain it at home is discouraged. An infection in the area could cause permanent joint damage or bone infection.

3. Hammertoe Deformity

Another prominence on the top of the toes is caused by hammertoe deformity. As the hammertoe forms, the toe cocks up and the joint in the middle of the toe becomes prominent. As the toe rubs on the top of the shoe a callus will form. Treatment consists of padding to reduce pressure or surgical straightening of the toe (See surgical correction of hammertoe).

4. Hallux Limitus

A lump can be found just behind the toe at the joint where the toe attaches to the foot. This is due to a prominence of the head of the metatarsal bone. It indicates that there is an alignment problem with the bones in the ball of the foot. The area may or may not cause a problem. If the lump is behind the big toe joint, it is a sign of a progressive arthritis of the joint. The condition is called Hallux limitus or degenerative arthritis. Treatment consists of orthotics to improve the function of the joint and/or surgical correction. (See surgical correction of hallux limitus).

5. Metatarsal-Cuniform Exostosis, Ganglion

Further up on top of the foot a bony prominence can form. This occurs near the middle of the foot and is due to the formation of bone spurs in the area. Jamming of two bones can over time, cause the spurring. The condition is named after the bones involved and is termed metatarsal –cuniform exostosis. On occasion, as the spurring forms, a weakening of the joint capsule occurs and a ganglion will form. A ganglion is a soft, rubbery mass, which slowly enlarges. Often the ganglion will form without a spur forming first. Treatment consists of padding the area to reduce the pressure from shoes or surgical removal of the bone spur and ganglion if present (See surgical correction of Metatarsal-cuniform exostosis).

6. Other

Yet another area that can demonstrate a lump or bump on the top of the foot is an area just below the ankle on the outside of the foot. Normally there is a small fleshy area. This is the only muscle on the top of the foot called the Extensor digatorum brevis muscle. Some people have a larger muscle than others and the area may appear enlarged. The area may also enlarge if a lipoma or ganglion forms in this area. A MRI is a useful test to determine if a lipoma or ganglion is present. No treatment is recommended if there is no pain associated with the area.

The Lis Franc,s joint is a combination of joints in the middle of the foot. At the point where the long bones behind the toes, called metatarsals, connect with a grouping of small cube shaped bones, called cuniform bones, there are several joints the move together in an interlocking fashion. This grouping of interlocking joints is referred to as the Lis Franc's joint. The Lis Franc’s joint are bound together by a series of transverse ligaments on the top and bottom of the joint, as well as an intermetatarsal ligament. This grouping of joints is clinically called the tarsometatarsal joints. Fracture-dislocations of the tarsometatarsal joint are named for Lis Franc who was a field surgeon in the Napoleonic army. Fracture-dislocations of the tarsometatarsal joint (Lis Franc's) is extremely significant in that it is a commonly missed diagnoses with a great potential for long term disability.

Lis Franc's fracture-dislocations can occur in many different ways. It can be caused by both a direct crushing type injury or a force applied to the metatarsal heads (ball of the foot) which both can result in displacement of the Lis Franc's joint or fractures that in involve the joint. Common causes are motor vehicle accidents, falls from heights, severe foot and ankle sprains, crushing force to the top of the foot. These injuries can occur during strenuous and competitive athletic activities. The athlete who complains of sudden onset of pain, in the middle of the foot during the course of an athletic event should be carefully evaluated for a possible Lis Franc's injury.

Diagnosis

Diagnosis is extremely important following the injury. Early diagnosis and treatment can prevent long-term chronic pain and other sequalae. Diagnosis is made by both clinical and X-ray modalities. On physical examination there is marked tenderness across the tarsometatarsal joint usually with pinpoint tenderness at the articulation of the second metatarsal base and the medial and intermediate cuneiforms. Global forefoot and midfoot swelling is commonly seen from several minutes to several hours following injury. In severe dislocations it is very easy to visualize a change in shape of the foot as compared to the other foot. X-rays may reveal either a partial or total dislocation at the tarsometatarsal joint. The difficult cases to diagnosis are those when the joint dislocates and then relocates on it’s own. When this occurs there may be little evidence of the injury on an x-ray. If there are no X-ray changes and clinical diagnosis makes the doctor suspicious of injury they may order stress X-ray, bone scan, CT scan or MRI. In all acute injuries circulation must be monitored to assess the possibility of compartment syndrome (increase in pressures within the foot which can shut off circulation). This could result in loss of oxygen to the tissues, which might result in loss of the foot.

Treatment

Closed reduction should always be attempted in an acute fracture-dislocation. Treatment involves general anesthesia to relax the patient and an attempted reduction of the second metatarsal base into its anatomic position is attempted. If the second metatarsal can be reduced then metatarsals two through five may reduce without much manipulation. If closed reduction is successful then reduction of the first metatarsal cuneiform joint is performed and pins are inserted to allow for stability during healing. If closed reduction fails it is usually due to one of the foot tendons, which may be caught in the dislocated joint. If closed reduction fails in an acute injury or the injury is old then open reduction must be performed to reduce long-term problems. If vascular compromise is evident this also constitutes a need for immediate surgery. There are usually two to three incisions placed on the top of the foot to allow for adequate visualization and manipulation of the bones. Once the foot has been placed back into anatomic position the tarsometatarsal joint is stabilized with either pins or screws to allow for stability during the healing process. If pins are used they are usually removed in six to eight weeks. Whether pins or screws are used doesn’t really matter as the patient is non-weight bearing for six weeks and is usually casted for at least eight to twelve weeks. Following bony healing and return to ambulation the patient will need a good functional foot orthotic to provide support and relieve stress from the tarsometatarsal joints and assist in pain free ambulation. Long-term prognosis for this injury is guarded. When any injury involves a joint the likelihood of an on-going arthritic process is likely. In sever cases fusion of the joints may be necessary. In the athlete this injury can be devastating. Rehabilitation to return to the same level of performance can takes several months or longer.