The Calamity of the 1st MTP fusion…


MTP = MetaTarsoPhalangeal, the joint at the ball of your foot where your toe joins…also the joint where patients develop bunions.


I’m not even sure where to start with this blog, my heart breaks every time I see a patient with a 1st MTP fusion…usually they are fused bilaterally. It is a biomechanical disaster that should essentially never happen.

Why do patients have this debilitating procedure?

  • They have 1st MTP joint pain.
  • They have radiographic evidence of 1st MTP degeneration (osteoarthritis).
  • Failed conservative management (arch supports, physical therapy, and medications).

Surgeons motivated to help the patient with their only real tool: surgery and NOT understanding the consequences of fusing this MOST critical joint in ambulation.

What leads to 1st MTP degeneration? Unless you are a ballerina, you have earned a degenerative 1st MTP through bad biomechanics and physics. The most common cause I see for 1st MTP pain and degeneration is a collapse of the Metatarsal or Transverse Arch which is also frequently a victim of further biomechanical issues.

Treatment of 1st MTP pain?

  1. Fix the biomechanics…this usually entails an Orthotic…NOT AN ARCH SUPPORT. (See my post on the difference between a biomechanical orthotic and a “custom” arch support)
  2. Get the 1st MTP joint moving.
    1. Treat the soft tissue on the medial (inside) and plantar (bottom) of the joint.
    2. Mobilize the joint (1st MTP extension in sagittal alignment).
    3. If the 1st MTP has been dysfunction for a long time, there is likely restriction of the plantar fascia and that will need to be treated too.
    4. This is NOT a problem that can be fixed with patient stretching exercises, however use of a “Prostretch” device can be a helpful addition to manual therapy intervention.
  3. NEVER consider surgical fusion of this joint!!! 5 degrees of motion is a whole lot better than zero. It may make the 1st MTP joint feel better to be fused, but it doesn’t fix the problem that caused it to fail in the first place and it forces further compensations up the lower extremity chain of joints where the patient will likely begin to manifest other symptoms (hip/back most common).




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