Second MTP synovitis

No matter how much you think you know about Second MTP Synovitis, it might surprise you to learn that it’s very treatable without surgery and almost completely preventable.

It might sound like a mouthful for those us not used to the term.

Don’t bother relying on what you find on certain sites you may normally turn to, for example Mayo or WebMD…And on other websites you might find through a Google search, the information available is not entirely complete or accurate. Misdiagnosis and misdirected treatment abounds, I am sorry to say.

Second MTP synovitis (also called capsulitis) is quite common, in fact the most common problem I see. There is definitely a lack of accurate literature and resources available for people, even doctors, on the subject.

The diagnosis of second MTP synovitis can be easily confirmed with a bit of patient history unveiling a pain felt on the ball of the foot followed by a simple exam. If you have (or have ever had) forefoot pain, then you will certainly want to continue reading.

I often talk to my orthopaedic residents about the “55 year old female” who represents the median and most common age presenting with second MTP synovitis. That’s not to stereotype or over-generalize the profile of people with second MTP synovitis, but I bring that up because of how common this forefoot problem is for people, particularly women, near this age. Of course I also see it between 30 and 80 years of age as well.

For many of these patients, there is swelling, and that swelling is often seen on the bottom, but sometimes on the top of the foot. Second MTP synovitis produces a painful lump commonly described as a “rock” on the bottom of the foot. It’s typically worse when people are barefoot on hard floors, and better in shoes.

Morton’s Neuroma, commonly misdiagnosed for second MTP synovitis, is really nothing like second MTP synovitis. Morton’s neuroma is generally better barefoot on a hard floor and worse in shoes. Second MTP synovitis has a fairly rapid onset—from a few hours, at most days to weeks. Morton’s neuroma almost always has an insidious onset from months to even years and never exhibits swelling of any type.

When left untreated, second MTP synovitis especially associated with swelling, often goes on to form a hammertoe and can eventually lead to a second MTP dislocation. In fact I will say right here that second MTP synovitis is the primary cause of the very common second hammertoe.

Given that second MTP synovitis is so prevalent, wouldn’t it be helpful to know what causes it?

The underlying source of the problem for second MTP synovitis is–surprise, surprise–a mechanical cause: the isolated gastrocnemius contracture.

In 30 years of practice, I have had a personal mantra that has served me very well, a concept I make very clear to my patients and my orthopaedic residents: most foot and ankle problems are mechanical first, and then, and only then, is there inflammation and the associated pain.

Unfortunately, that “end result” is what most patients and doctors end up focusing on. Inflammation may be the result we see/experience, but treating the symptoms isn’t going to solve the problem. Of course people may feel better in the short-term—which is no doubt a good thing for a temporary source of relief—but it does nothing to solve the underlying cause.

As described in this paper: “Gastrosoleal [calf] stretching is an important treatment modality that can lead to a higher success rate of conservative treatment. It can decrease the need for foot surgery, and significantly reduce the number of failed or serial surgical procedures.” 1

As humans, our calves get tighter as we get older.2

This is a gradual process, usually silent—that is, until one day when they are “too short.” As the leading cause of plantar fasciitis (the only cause in my opinion), it might not shock you to hear that tight calves are also the leading cause of second MTP synovitis.

To simplify the explanation of how this can happen, consider how overly tight calves will cause increased forefoot pressure or load on the front of the foot.3,4

Consider the anatomy of the normal human foot. The second metatarsal happens to be the longest, as well as the stiffest of all the metatarsals. If you’re going to put more weight on the front of your foot, it’s going to be focused on the second metatarsal head. In other words, and to make this critical point clear, this equates to increased pressure, step after step, distributed over a much smaller area. Something’s got to give.

A common urban myth is that the second metatarsal has somehow magically grown longer or dropped. I’m sorry, but this is just not true. Your second metatarsal is the exact same length it’s always been.

What has changed to cause this to happen now?

As you walk, something you have always done, there is increased, leveraged pressure transferred to the front of your foot, focused on the second metatarsal. Because of this recent mechanical change, it causes a bruising in the joint resulting in swelling and pain. It isn’t how much you walk, it isn’t magic, or bad luck, it isn’t trauma or injury, and it is not your shoes…it’s due to leverage in your foot that stems from an overly tight (shortened) calf.

A Leverage Causing Damage or Bruising of the Second MTP Joint

In simple terms, it’s “just” a physical pushing on the joint from the ground reaction, hitting the metatarsal head within your foot.

The new hot thing in our medical circles is the plantar plate rupture, and as one might surmise there’s an app surgery for that. Said another way, the damage is already done. The ship has sailed. The horse is out of the barn. Well, you get it. Who wouldn’t want to know this before it happens—or that in most cases it is still not too late to treat second MTP synovitis non-operatively?

So why then, or when do, people end up needing surgery?

The first and likely only reason is that you will be told surgical correction is the only treatment remaining to solve your problem. And I will say this time and again, your underlying equinus problem will not be addressed, let alone mentioned. I respectfully disagree with the surgical approach, except in the most advanced cases or those that have failed the only conservative therapy needed, calf stretching.

I want to educate people to treat the cause of the problem—before this happens, and before it’s “too late” and may require surgery.

The Good News: We Can Prevent Our Calves From Getting Too Tight

The calves being too tight, AKA equinus, are the number one mechanical problem producer I see each day, leading to adult foot and ankle problems including not just second MTP synovitis, but plantar fasciitis, non-traumatic midfoot osteoarthritis, insertional Achilles tendinosis, posterior tibialis tendon dysfunction, and Achilles tendinitis. (See a longer list here.) Dedicated, daily calf stretching eliminates the problem over time, but it also can prevent your calves from getting too tight in the first place. The biomechanics tell us our calves have the natural tendency to slowly tighten over time—so we must work against the inertia of this “uniquely human problem.”

Read more about the One Stretch, the optimal device for calf stretching, including its breakthrough and patented design.


1. Hill, R.S. (1995). Ankle equinus. Prevalence and linkage to common foot pathology. J Am Podiatr Med Assoc 85, 295–300.

2. Amis, J. (2014). The Gastrocnemius: A New Paradigm for the Human Foot and Ankle. Foot Ankle Clin 19, 637–647.

3. Aronow, M.S., Diaz-Doran, V., Sullivan, R.J., and Adams, D.J. (2006). The Effect of Triceps Surae Contracture Force on Plantar Foot Pressure Distribution. Foot & Ankle International 27, 43–52.

4. Macklin, K., Healy, A., and Chockalingam, N. (2012). The effect of calf muscle stretching exercises on ankle joint dorsiflexion and dynamic foot pressures, force and related temporal parameters. Foot (Edinb) 22, 10–17.