12/18/2013    Don Peacock, DPM

Neuritis of The Plantar Digital Nerve

Neuroma or neuritis of the first interspace is
highly unlikely following a bunionectomy with
osteotomy. The etiology of your pain is most
likely related to placing the fibular sesamoid
from a deviated position to a more rectus
position.

As the fibular sesamoid begins to laterally
deviate, the cristae erodes. During the Austin, we
transposition the metatarsal head laterally
placing the sesamoid into what is essentially
arthritic cristae under the first metatarsal.
This is not usually an issue but can be.

The way to determine this etiology is to use
ultrasound. If there is edema around the fibular
sesamoid, the issue is related to placing an
arthritic sesamoid back under the an arthritic
cristae. The only solution will be to remove the
the fibular sesamoid. If in fact you do have a 1st
intermetatarsal neuroma this can also be
visualized utilizing ultrasound.

In addition, your x-ray shows shortening of the
first metatarsal on the AP view and some
dorsiflexion present in the lateral view. It is
hard to tell, because we cannot see the talus
incline in your lateral view.

Most likely this patient has a rigid or stable
rear foot and a relatively flexible forefoot.
Fabricating an orthotic to get the heel to
neutral position and thereby allowing mechanical
advantage to the peroneal longus could reduce
pressure in the 1st interspace.

It is likely that your pain is either directly
related to the fibular sesamoid position or is an
extension of pain under the second
metatarsophalangeal joint area due to shortening
of the 1st ray and/or the foot type
characteristics expected following bunionectomy
with osteotomy and predictable increase pressure
in the 2nd MPJ/1st interspace.

Don Peacock, DPM, Whiteville, NC
peacockdpm@gmail.com

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