First metatarsophalangeal joint (MPJ) injuries can be both diagnostic and treatment challenges. From an anatomy standpoint, the number of structures that can be injured are numerous. Figuring out what structure(s) (see “A Brief Overview Of First MPJ Structures” at right) are injured can be difficult to assess via physical exam and X-rays, especially in cases in which there is no apparent fracture present. Even with a fracture, these injuries can have corresponding soft tissue injuries that complicate the diagnosis and treatment plan. More often than not, magnetic resonance imaging (MRI) is necessary to isolate specific structures.
First MPJ injuries are most commonly associated with either hyperflexion (plantarflexion) or hyperextension (dorsiflexion) type mechanisms of injury. One of the most common injuries is the “turf toe” injury associated with football but these injuries can virtually occur on any playing surface or in any sport. Additionally, we can see even greater soft tissue injuries when a transverse and/or frontal plane motion is present along with the typical injury pattern. We often see dislocations of the first interphalangeal joint (IPJ) or MPJ as a result. Often, the foot is planted on the ground while the body is moving in other directions.1,2
As with other sports, direct blows often lead to first MPJ injuries. For example, karate moves can result in injuries to the planted foot as well as the foot that is doing the kicking. Soccer is similar and more often involves kicking another player during a slide tackle. Stubbing the toe is a common injury but it can lead to both osseous and soft tissue injury.3
As we all know, the greater the force, the higher probability of not only developing a fracture but also developing bone bruising. That can not only result in an acute cartilage injury but also develop into a cartilage defect months later, which predisposes athletes to hallux limitus and post-traumatic arthritis. Therefore, understanding the mechanism and severity of injury is critical during the diagnostic phase.
All that matters to athletes is how quickly they return to play. Unlike non-athletic patients, athletes live for the moment and will often ignore the consequences of the future. Surgeons need to remind them that these injuries can be career ending.
Turf toe seems to be the classic sports injury involving the first MPJ. The injury became a household name in the 1970s as the National Football League and then colleges transitioned from natural grass to Astroturf. Many have blamed the harder surfaces, in conjunction with more flexible and lighter cleats, for these injuries. Turf toe has been classified as a hyperextension injury leading to significant sprain to the plantar ligaments and/or sesamoid apparatus. Thus, athletes are left with an inability to push off and cut.
Often, these injuries can take six to eight months to heal. Prior to the widespread use of MRI, trainers would simply tape up the joint and allow athletes to play week by week, leading to re-injury.4-9 Often, re-injury complicated the recovery. In comparison to a fracture, turf toe seemed minor so providers encouraged athletes to play and this ultimately set them up for re-injury or prolonged pain.
Acute treatment for turf toe injuries always entails ice and time off from the sport. The degree of edema and ecchymosis that develops will be the clue of a more significant injury. When the athlete has significant pain with first MPJ range of motion, then MRI is necessary. Further treatment will be based solely on the MRI findings. Simple strains may only require taping and stiffer shoes while tears will benefit from plantarflexed splinting of the first MPJ and four to six weeks on crutches.
Fractures of the hallux do not pose diagnostic challenges but there is significant debate on how to treat them. Fractures of the hallux may be either extra-articular or intra-articular. Obviously, intra-articular fractures of the first IPJ or first MPJ are far more concerning because of the risk of future post-traumatic arthritis.
Fractures may involve the distal phalanx or proximal phalanx. Anatomically, fractures can involve the head, base or shaft of the proximal phalanx, and the distal tuft and base of the distal phalanx. Other than shaft fractures, the majority are avulsion-type fractures. There are tendon, ligament and capsular structures that insert on the distal and proximal phalanx. We can see avulsion fractures at any one of those attachments. The larger the fracture piece, the greater the likelihood that surgical intervention will be necessary.3,10
Personally, I have been very aggressive in fixing intra-articular fractures of the hallux. Of course, any displaced fractures will automatically be dealt with surgically. Recovery often takes three to four months regardless of the treatment but one must caution athletes in regard to chronic hallux swelling. Ultimately, the chronic swelling associated with hallux fractures will always delay an athlete’s ability to wear shoes, let alone compete.
Sesamoid fractures are more often associated with hyperdorsiflexion injuries often leading to splitting of the sesamoid in either half, thirds or tiny avulsions. Crush injuries can occur but are not related to hyperflexion injuries. Sesamoid injuries can also lead to bipartite and tripartite disruptions, which can be just as devastating as a fracture. In my experience, fractures tend to heal better than fibrous disruptions. The position of the foot will determine which of the two sesamoids are injured. Every surgeon prays that the tibial sesamoid is the one injured simply because it is so much easier to deal with surgically if it fails to heal.11-12
Surgeons need to thoroughly understand the mechanism of injury because sesamoid fractures are often associated with significant soft tissue injury. Frequently, it is the soft tissue component that will determine the outcome. Do not forget to assess the soft tissue structures via MRI. Although treatment may remain the same, the recovery will always be longer for the soft tissue component of these injuries: six to eight months versus three to four months for a simple sesamoid fracture.
More importantly, how do we deal with sesamoid fractures acutely? There are several reports of open reduction internal fixation (ORIF) for sesamoid fractures and there are numerous reports of how to fixate a sesamoid.13,14 I think the jury is still out on the success of sesamoid ORIFs. During my career, I have seen over 300 sesamoid fractures and I have not needed to fixate one acutely.
How should we treat sesamoid fractures non-surgically? The only method I have had success with is splinting the first MPJ into a plantarflexed position and casting for six weeks. Additionally, I do not clear patients to run for four to six months.
When the sesamoid remains painful, we end up performing sesamoidectomies six to 10 months after the injury. I prefer to keep athletes non-weightbearing for a minimum of six weeks with subsequent protection in a controlled ankle motion (CAM) walker for another six weeks. The rationale is simple: reduce the tension on the sesamoid fragments and plantar soft tissue attachments. Typically, many sesamoid fractures will either develop a nonunion, post-traumatic fibrosis and/or eventual arthrosis.
Unfortunately, the majority of us do not see sesamoid fractures acutely. We tend to see them months later. Either we see significant fracture gapping with chronic pain or we see them develop avascular necrosis. More often than not, we are forced to do a sesamoidectomy but in some patients who have developed arthrosis, we may be forced into a first MPJ fusion. So as with any injury, early diagnosis and treatment are keys to our success.
Sesamoid apparatus injuries are even harder to diagnose and treat. These are purely soft tissue in nature. When they are associated with first MPJ dislocation, these injuries are easy to predict. However, dislocations are infrequent. So we are left with injuries that seem minor but are debilitating to an athlete. They can be diagnostic challenges. It is critical to obtain a MRI to assess the collateral ligaments, flexor hallucis brevis (FHB), adductor, abductor, muscle and tendon attachments, and first IPJ and MPJ capsules. There are surgeons who have described soft tissue repairs of these structures but the effectiveness is questionable.
For most of us, determining the extent of the injury is more critical for determining how long we rest the athlete. Do we simply tape the toe? Restrict the motion? Stiffen up the shoe? Do we immobilize the foot completely? For many of us, seeing what athletes can do functionally will determine which approach to take. If athletes can not perform a single leg raise, we know they cannot return to the playing field.
Jahss was the first to classify first MPJ dislocations.15 As with any joint dislocation, we often see a myriad of injured structures. We may see a combination of soft tissue injury and fractures. Often, first MPJ dislocations can have sesamoid fractures, which often complicate the injury. We may see open dislocations less often. However, when we do see these, we will see significant soft tissue injury with either sesamoid or metatarsal fractures.16 All of this can lead to long-term sequelae.
Far too often, first IPJ and MPJ dislocations are reduced on the playing field or physicians reduce them in an emergency room setting. Failure to refer these athletes for further evaluation can lead to a premature return to play but what is more concerning is the development of joint instability or re-dislocation.
Many years ago, I had a soldier who dislocated his first IPJ. I performed an open reduction. I let him start running sooner than I probably should have. As a result, he proceeded to re-dislocate on two more occasions while playing basketball. He got to the point that he could dislocate his toe by simply adducting his hallux. He ended up needing a first IPJ fusion.
Orendurff and colleagues studied the foot pressures exerted during cutting, running and jumping.17 The hallux and first MPJ structures have to be stable to withstand push-off. The authors found the forces exerted on the joint are higher than once thought so it is no wonder athletes have so much difficulty getting back to competitive play and are prone to re-injury.
Cartilage injuries to the first MPJ can be difficult to diagnose acutely and may not become evident on X-rays for eight to 10 months. Bone bruising can be visible on MRI acutely or not at all.
All of this can be frustrating to the athlete and surgeon. Despite having essentially a normal exam, normal X-rays and often normal MRIs, the athlete is unable to perform. The minute athletes bear weight, they are in extreme pain. They cannot tolerate any pressure on the hallux. Athletes will often grow desperate and frustrated because we cannot provide them with immediate answers. We need to prove that the joint is the source of their pain.
One option to consider is performing a diagnostic injection. If that relieves pain, a diagnostic arthroscopy of the first MPJ can be beneficial. Many times, I have found a full thickness cartilage flap to be helpful. More often, these isolated cartilage flaps, tears or full thickness defects can go unnoticed diagnostically until we see subchondral damage on X-ray. All the while, the athlete is playing in pain. Over time, these injuries will predispose the athlete to arthritis.
Metatarsophalangeal joint injuries can become very debilitating for athletes. Although the mechanism of injury may seem minor, the extent of the injury may not be apparent. The use of MRI has helped to better define these injuries but ultimately treatment has remained the same: rest and immobilization. No matter the injury, these athletes can often have long-term symptoms and be predisposed to post-traumatic arthritis.
Dr. Spitalny is a staff podiatrist at General Leonard Wood Army Community Hospital at Ft. Leonard Wood, Mo. He is a Fellow of the American College of Foot and Ankle Surgeons.
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For further reading, see “How To Treat Turf Toe Injuries” in the September 2008 issue of Podiatry Today. To access the archives, visit www.podiatrytoday.com.