The lesser metatarsophalangeal joints are stabilised by the plantar plate, collateral ligaments, and the deep transverse metatarsal ligament that ties all five metatarsal heads together. The plantar plate is the primary restraint against dorsal subluxation of the MTP joint. Its rupture from overloading or inflammatory arthritis produces the hammertoe and crossover toe deformities. Morton neuroma arises in the interdigital space between MTP joints from interdigital nerve compression.
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Plantar plate tears at the second MTP joint produce the crossover second toe deformity where the toe migrates dorsally and medially, confirmed by the drawer test (applying dorsal force to the proximal phalanx) and MRI. Surgical plantar plate repair is often done through a dorsal approach combined with a Weil osteotomy, which shortens the metatarsal and gives access to the joint. Second MTP joint overload, metatarsalgia, is the most common forefoot pain and reflects the excessive load the second metatarsal bears when the first metatarsal is elevated or shortened. Freiberg disease, osteonecrosis of the second (or third) metatarsal head, causes MTP pain in adolescents with flattening of the head on X-ray. Inflammatory arthritis often affects these joints early.
Second MTP joint plantar plate disruption producing crossover toe deformity and metatarsalgia confirmed by the MTP drawer test, managed with taping and orthotics before surgical plantar plate repair, often with a Weil osteotomy.
Interdigital nerve compression between MTP joints producing forefoot burning and web space numbness reproduced by the Mulder click test, managed with orthotics, injection, or neurectomy.
Osteonecrosis of the second or third metatarsal head, usually in adolescents, causing MTP joint pain and head flattening; managed with offloading, and debridement or osteotomy if it persists.
