Metatarsophalangeal Hyperextension Movement Pattern Related to Diabetic Forefoot Deformity

Phys Ther. 2016 Aug;96(8):1143-51. doi: 10.2522/ptj.20150361. Epub 2016 Feb 25.


Background: Metatarsophalangeal joint (MTPJ) hyperextension deformity is common in people with diabetic neuropathy and a known risk factor for ulceration and amputation. An MTPJ hyperextension movement pattern may contribute to the development of this acquired deformity.

Objective: The purpose of this study was to determine, in people with diabetes mellitus and peripheral neuropathy (DM+PN), the ankle and MTPJ ranges of motion that characterize an MTPJ hyperextension movement pattern and its relationship to MTPJ deformity severity. It was hypothesized that severity of MTPJ deformity would be related to limitations in maximum ankle dorsiflexion and increased MTPJ extension during active ankle dorsiflexion movement tasks.

Design: A cross-sectional study design was used that included 34 people with DM+PN (mean age=59 years, SD=9).

Methods: Computed tomography and 3-dimensional motion capture analysis were used to measure resting MTPJ angle and intersegmental foot motion during the tasks of ankle dorsiflexion and plantar flexion with the knee extended and flexed to 90 degrees, walking, and sit-to/from-stand.

Results: The MTPJ extension movement pattern during all tasks was directly correlated with severity of MTPJ deformity: maximum ankle dorsiflexion with knee extended (r=.35; 95% confidence interval [CI]=.02, .62), with knee flexed (r=.35; 95% CI=0.01, 0.61), during the swing phase of gait (r=.47; 95% CI=0.16, 0.70), during standing up (r=.48; 95% CI=0.17, 0.71), and during sitting down (r=.38; 95% CI=0.05, 0.64). All correlations were statistically significant.

Limitations: This study was cross-sectional, and causal relationships cannot be made.

Conclusions: A hyperextension MTPJ movement pattern associated with limited ankle dorsiflexion has been characterized in people with diabetic neuropathy. Increased MTPJ extension during movement and functional tasks was correlated with severity of resting MTPJ alignment. Repetition of this movement pattern could be an important factor in the etiology of MTPJ deformity and future risk of ulceration.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Aged
  • Ankle Joint / diagnostic imaging
  • Ankle Joint / physiopathology
  • Cross-Sectional Studies
  • Diabetic Foot / etiology
  • Diabetic Foot / physiopathology*
  • Diabetic Nephropathies / complications
  • Diabetic Nephropathies / physiopathology*
  • Female
  • Foot Deformities, Acquired / diagnostic imaging
  • Foot Deformities, Acquired / etiology
  • Foot Deformities, Acquired / physiopathology*
  • Gait / physiology
  • Humans
  • Knee Joint / physiology
  • Male
  • Metatarsophalangeal Joint / diagnostic imaging
  • Metatarsophalangeal Joint / physiopathology*
  • Middle Aged
  • Range of Motion, Articular*
  • Tomography, X-Ray Computed