Operative Techniques in Sports Medicine
Volume 18, Issue 1 , Pages 34-45, March 2010

Management of Forefoot Injuries in the Athlete

Foot and Ankle Service, OrthoCarolina and the Carolinas Medical Center, Charlotte, NC

Article Outline

Athletes who participate in high-impact sports are at higher risk for acute and chronic forefoot injuries. We review the diagnosis and treatment techniques for the most common conditions that produce forefoot pain in the athlete: metatarsal stress fracture, hallux valgus, hallux rigidus, second metatarsophalangeal synovitis and instability, turf toe, and sesamoid pathologies. These conditions and their treatments are discussed in the context of forefoot anatomy and biomechanics. Both nonoperative and operative techniques are highlighted.

Keywords: turf toe, sesamoid, hallux, sports injuries, metatarsalgia

 

Athletes who participate in high-impact sports that include considerable running, jumping, or contact are at higher risk for acute and chronic forefoot injuries. Some athletes may be predisposed to certain forefoot injury because of training regimens, footwear, and pre-existing biomechanical pathologies (eg, cavus, ankle malalignment, or Achilles contracture). For the purposes of this review, we consider forefoot injuries to include those distal to the tarsometatarsal joint. The most common conditions that produce forefoot pain in the athlete are metatarsal stress fracture, hallux valgus, hallux rigidus, second metatarsophalangeal (MTP) synovitis and instability, turf toe, and sesamoid pathologies. We discuss the diagnosis and treatment of these common causes of forefoot pain in the athlete in the context of forefoot biomechanics.

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Anatomy and Biomechanics 

The forefoot includes 5 metatarsals, 14 phalanges, and 2 sesamoid bones. The tibial (medial) and fibular (lateral) sesamoids each articulate with the plantar aspect of the first metatarsal head. During the normal gait cycle, the forefoot experiences most of its stresses during the late stance phase while the foot is rigid. As gait progresses to heel rise and toe off, the hallux and lesser toes reach their maximum dorsiflexion. Normal motion of the lesser MTP joints is 90° extension to 50° flexion. Normal motion of the hallux MTP joint is 90° dorsiflexion and 30° plantarflexion.1 About 15° of hallux MTP dorsiflexion is required for normal gait.

The foot supports substantial loads during gait that increase as pace increases. Peak vertical forces reach 120% of body weight during walking, and are up to 220% of body weight during running.2 A 68 kg man absorbs more than 63 tons on each foot when walking 1 mile and 110 tons/ft while running the same mile.3 During the normal gait cycle, the center of pressure progresses along the plantar aspect of the foot from the heel at heel strike to the toes at toe off. The center of pressure is initially located in the central heel, then accelerates rapidly across the midfoot to reach the forefoot, where the center of pressure is located under the second metatarsal head. At toe off, the center of pressure is located under the hallux.4 Studies of plantar pressure distribution in runners have documented that most of the pressure is located in front of the shoe under the forefoot during running2 predominantly under the metatarsal heads.5

Most of the stability of the hallux MTP joint comes from the capsular ligamentous sesamoid complex. Fan-shaped medial and lateral collateral ligaments course between the proximal phalanx and the metatarsal. They are important for MTP joint stability in cutting activities. Each collateral ligament is made up of an MTP ligament and a metatarsosesamoid ligament. The plantar plate is a separate fibrous structure that courses from the proximal phalanx to the metatarsal head, through the joint capsule. The capsular ligamentous complex of the MTP joint is a confluence of structures that includes the collateral ligaments and plantar plate, abductor hallucis, adductor hallucis, and flexor hallucis brevis (FHB).

The hallux sesamoid bones are analogous in function to the patella in the knee and are of great functional importance during the push-off phase of gait. They ossify between the ages of 9 and 11. They lie within the FHB tendon which, as it courses distally, divides into a medial and lateral tendon which envelop the medial and lateral sesamoid, respectively. The medial sesamoid is larger and longer and tends to rest more distally. It is often situated more directly under the metatarsal head, and thus is subject to greater weight-bearing forces. The sesamoids help dissipate force at the MTP joint by elevating the metatarsal head. Their function is especially important in sports that involve jumping, sprinting, spring-board diving, ballet, and certain martial arts (ie, taekwondo). In cadaver studies, distal hemiresection or complete excision of the tibial sesamoid does not appreciably compromise the effective mechanical advantage of the FHB muscle and does not significantly reduce push off strength. However, this mechanical advantage is diminished by up to 30% after excision of both sesamoids.6

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Metatarsal Stress Fractures 

The metatarsals absorb substantial loads during running and jumping resulting in repetitive loads through the metatarsal shafts. The second and third metatarsals are the longest and most rigid and are therefore the most common locations of metatarsal stress fractures. The location of the fracture is usually in the neck or distal shaft although 2 notable exceptions include the proximal second metatarsal (dancers fracture) and the proximal fifth metatarsal metaphysis (Jones fracture). Risk factors for metatarsal stress fractures in athletes include limb length inequality, a cavo-varus foot, high weekly running mileage, and menstrual irregularities.7 Reduced bone mineral density, which is associated with menstrual, hormonal, and nutritional abnormalities, may also place athletes at risk for a metatarsal stress fracture.8

Presentation 

Athletes will generally present with chronic, dull, aching pain in the forefoot that limits their ability to run. Examination shows tenderness to palpation in the metatarsal region where the stress fracture is located. There may be erythema and swelling on the dorsum of the foot. It is important to evaluate for abnormalities of foot contour, such as cavovarus or pes planus, and for stiffness of the first ray.

Radiographic Studies 

Routine radiographs of the forefoot, including anteroposterior (AP), lateral, and oblique views are positive for stress fracture relatively late, after microdamage has accumulated to form a fracture line or the body has remodeled sufficiently to form a callus (Fig. 1). Technicium 99 three-phase bone scan may be positive as early as 1 week after injury and can be used as a screening tool, but has poor specificity.9 Magnetic resonance imaging (MRI) is the diagnostic test of choice as it can reveal the injury earlier than a bone scan, has high accuracy, and has prognostic value.10, 11

Nonoperative Treatment 

Initial treatment of a metatarsal stress fracture includes modification of the offending activity, which is usually a prolonged running program or a dramatic increase in the intensity or duration of the running program. If the athlete has significant pain and tenderness, a short-leg walking boot or cast can be used for 4 weeks. If at that point radiographs do not show any callus or sclerosis, gradual return to activity is appropriate. It is important to address shoe wear to support biomechanical abnormalities with modification and orthotic inserts as well as to stretch a tight Achilles tendon. Metatarsal stress fractures generally heal after 6-8 weeks. If the patient is slow to show clinical or radiographic healing after 4 weeks of immobilization, additional modalities, such as external bone stimulators can be implemented combined with continued immobilization. Nutritional and smoking cessation programs should be instituted as indicated.

Surgical Treatment 

Surgical treatment is reserved for displacement of fractures or nonunions. Both are rare in metatarsal stress fractures. Surgery consists of a longitudinal incision at the fracture site with opening of the fracture, curettage of the fracture edges which are usually fibrous, reaming of the canal with a small diameter drill or kirchner wire, and dorsal plate fixation with screws. Autogenous bone graft can be obtained from the calcaneus, tibial metaphysis, or iliac crest. We prefer iliac crest autograft. Return to running includes a graduated regimen that begins at radiographic and clinical healing, usually 8-12 weeks postopeartively. If symptoms allow, nonimpact exercises, such as elliptical, recumbent biking, and swimming may begin as early as 2 weeks after surgery to maintain strength, flexibility, and conditioning.

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Hallux Valgus 

Hallux valgus, commonly associated with a bunion deformity, is rarely problematic in athletes. The deformity usually consists of a medial deviation of the first metatarsal (metatarsus primus varus) combined with lateral deviation of the hallux on the first metatarsal. Likely causes include a genetic predisposition which may be exacerbated by improper shoe wear. With progressing lateral deviation of the hallux, the sesamoids may subluxate laterally resulting in pronation of the hallux, shifting weight bearing from the first metatarsal head to the second metatarsal. This may result in painful plantar keratosis under the lesser metatarsal heads and/or second toe cross-over deformity or hammertoe.

Presentation 

The presence of an asymptomatic hallux valgus deformity in the athlete generally does not require treatment. However, in cases where the athlete experiences debilitating pain, a treatment protocol should be initiated. The athlete will usually present with a painful bump on the medial aspect of the first metatarsal head that is often red, enlarged, and tender. This is often associated with a clinical hallux valgus deformity that may cause compression between the first and second toes or second toe crossover. In more advanced cases where a second toe deformity is evident, a painful plantar keratosis may develop under the second metatarsal head.

Nonoperative Treatment 

Treatment of any degree of hallux valgus in an athlete should be initially conservative and remain conservative whenever possible. Modifying shoe wear to include a wider toe box will reduce pressure and irritation of the bunion. Custom arch supports may be used in patients when indicated by the alignment of their foot. Diligent Achilles stretching exercises should be encouraged, especially in cases of Achilles contracture. A simple toe spacer between the first and second toes may be helpful, but generally does not slow progression. Silicone bunion pads may be applied over the bunion to minimize direct pressure and irritation on the bump. In cases of pes planus associated with hallux valgus, a medial longitudinal arch support with Morton's extension under the first MTP joint may also alleviate symptoms. Most mild bunions with smaller hallux valgus angles can be managed effectively with nonoperative treatment.

Surgical Treatment 

For more severe bunions and those that cause debilitating symptoms despite conservative management, surgical intervention may be considered. We will typically use a simple distal chevron osteotomy (Fig. 2) with debulking and tightening of the medial capsule. We will add a closing wedge osteotomy of the proximal phalanx (Akin osteotomy12) if clinical and radiographic hallux valgus interphalangeus is present after the chevron osteotomy. This usually provides good correction and symptomatic relief.13 More extensive surgical procedures, such as proximal osteotomies, arthroplasty, or any joint fusion should be avoided as they are extensive procedures with prolonged recovery times and may alter the motion and function of the foot.

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  • Figure 2. 

    Illustration of bone cuts during distal chevron osteotomy. (A) After exposure, saw cuts are made forming a distal-based chevron cut. (B) The distal fragment is manipulated to slide laterally approximately 6-8 mm.

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Hallux Rigidus 

Hallux rigidus is a relatively common forefoot condition in athletes, particularly runners. It is characterized by pain and reduced dorsiflexion at the first MTP joint. Passive dorsiflexion is often painful because of impingement of dorsal osteophytes on the metatarsal head and the dorsal base of the proximal phalanx. Hallux rigidus is often associated with degenerative changes in the first MTP joint. The etiology is unknown, but theories include occult intra-articular fracture, compression of the articular surfaces (repetitive hyper dorsiflexion), or osteochondral lesion of the first metatarsal head.14 However, there are not yet good data to support these proposed causes, nor are there data associating activity levels with the development of hallux rigidus.15

Presentation 

The athlete may describe difficulty with walking or running, especially on an incline or stairs. Pain usually occurs during the toe-off phase of gait. Limited extension of the hallux MTP joint may result in the need to vault over the toe, causing external rotation of the foot to allow for toe clearance. A prominent osteophyte may cause an abrasion, ulceration, or numbness with tight shoe wear. Tenderness is present on palpation of the dorsal and lateral aspects of the joint. Radiographs will often demonstrate loss of first MTP joint space and dorsal and lateral osteophytes on the metatarsal head.

Nonoperative Treatment 

Conservative treatment includes assessment and modification of shoe wear, rest, and nonsteroidal anti-inflammatory medications. Shoes with an extra-depth toe box may help to decrease dorsal pressure on the first MTP joint. A rocker bottom sole will reduce extension of the hallux during normal gait. A cushioned custom orthotic with a Morton's extension can also be helpful in limiting toe dorsiflexion. A single corticosteroid injection into the hallux MTP joint can be therapeutic, but should generally be avoided if possible. Once the discomfort improves, physical therapy can be used to optimize MTP flexibility and slow return to play can be initiated.

Surgical Treatment 

If conservative treatment fails to alleviate symptoms, surgical treatment is usually indicated. The most commonly implemented procedure is a dorsal first metatarsal cheilectomy to remove the osteophytes and improve toe dorsiflexion. We combine this with a plantar capsulotomy and release (Fig. 3). We also remove up to 25% of the joint with a chamfer cut to remove degenerative cartilage. This preserves healthy articular cartilage on the remaining metatarsal head and allows substantial improvement in motion. We are usually able to obtain 80-90 degrees of dorsiflexion intraoperatively with this procedure. With an accelerated rehabilitation program, most athletes have significant improvement in symptoms and motion, though they only recover a small portion of the motion gained intraoperatively.16

A dorsiflexion osteotomy of the proximal phalanx (Moberg procedure) may be used concurrently with a cheilectomy in selected patients to increase functional toe dorsiflexion.17 In athletes with a concurrent hallux valgus interphalangeus, we will often use a hybrid of an Akin-type lateral closing wedge osteotomy and a Moberg dorsal osteotomy (Mo-Akin; Figs. 4A–C). This oblique osteotomy allows improved dorsiflexion and correction of valgus. We use a cannulated screw for fixation (Fig. 4D).

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  • Figure 4. 

    The Mo-Akin procedure. (A) Dorso-medial starting point. (B) The saw cut is aimed slightly proximal and plantar. (C) After a thin wedge is removed, the osteotomy is reduced manually (D) Fixation is with a compression screw.

We do not recommend resection of the base of the proximal phalanx (ie, Keller arthroplasty), as it disrupts the plantar plate resulting in diminished push off strength. First MTP fusion offers good pain relief, but is poorly tolerated by athletes. We also do not recommend first MTP arthroplasty with a prosthetic implant for any patient.

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Second MTP Instability 

Metatarsalgia is a broad diagnosis that may be caused by any biomechanical intrinsic or extrinsic condition that increases stress on the metatarsal heads leading to painful plantar keratoses.18 A number of biomechanical factors have been associated with painful calluses under the second metatarsal head and second MTP instability. These include rigid cavus hind foot, feet with a relatively long second metatarsal, patients with abnormally flexible first tarsometatarsal joints, increased forefoot load in late stance phase due to a tight Achilles tendon, and the use of narrow toe box high-heeled shoes.

Second MTP synovitis is likely a result of plantar plate attrition due to a long second metatarsal or hypermobile first ray.19 With progressive attirition, subluxation and dislocation may lead to chronic MTP joint instability. A hammertoe or clawtoe deformity will often be found and a cross-over deformity may develop with destruction of the fibular collateral ligament of the MTP joint.

Presentation 

The athlete will initially present with pain ambulating and tenderness to palpation of the plantar and dorsal aspects of the MTP joint. Instability is detected by a digital Lachman's (or drawer) test: grasp the proximal phalanx and attempt to translate dorsally. This will produce pain and palpable dorsal translation of the phalangeal base.20 Patients complaining of diffuse swelling, pain, and stiffness of one or more MTP joints should be evaluated for inflammatory arthropathies like rheumatoid arthritis, seronegative spondyloarthropathy, or gouty arthritis.

Nonoperative Treatment 

Treatment generally starts with shoe wear modification, Non Steroidal Anti-inflammatory Drugs and orthotic inserts. We discourage the use of high-heeled or tight toe box shoes. We will prescribe a metatarsal pad placed proximal to the painful metatarsal heads or custom, molded, well-cushioned, full-length orthotics to accommodate biomechanical alignment, and reduce load on the first and second metatarsal heads and distribute load evenly across the forefoot. Achilles tendon stretching can be a useful adjunct during initial treatment. Plantar callosities can be pared down in the office. A one-time intra-articular corticosteroid injection combined with rocker-sole modification has shown good results.21

Surgical Treatment 

For athletes that do not respond to conservative treatment, there are a number of described surgical procedures.22 A simple joint debridement, synovectomy, and plantar condylectomy can help to resolve a discrete plantar keratosis.23 If the second metatarsal is noted to be long on radiographs, we will usually recommend a joint debridement and Weil osteotomy, which has shown good results in the literature.22, 24 The surgical technique involves a longitudinal incision over the second MTP joint, dissection, and retraction of the extensor tendon, and a longitudinal arthrotomy. The joint is debrided of synovitis and the metatarsal head is exposed and examined. The collateral ligaments are transected at their metatarsal insertion. A small, parallel wedge oblique osteotomy is made starting at the dorsal aspect of the articular surface with the saw blade almost parallel to the ground. The distal fragment is shortened the amount required to correct the metatarsal to an appropriate length. This is confirmed fluoroscopically. Fixation is achieved with a single snap-off screw (Fig. 5).

Freiberg's Disease 

Radiographs can rule out Freiberg's disease, which is avascular necrosis (AVN) of the second metatarsal head leading to pathologic collapse. While it is doubtful that athletic activity or injury is a primary cause of Freiburg's disease, the process can be exacerbated by repetitive trauma.25 Radiographs will demonstrate subsidence of the subchondral bone at the metatarsal head and eventual flattening and collapse of the dorsal metatarsal head. If conservative treatment fails, many surgical treatments have been described. These include debridement of the joint, removal of loose bodies, and removal of metatarsal head osteophytes with head reshaping.26 A dorsal closing wedge osteotomy of the second metatarsal head has also been described as a method of rotating healthy plantar cartilage into articulation with the proximal phalanx while shortening and unloading the metatarsal head.27

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Turf Toe 

Turf toe is defined as a sprain or tear of the capsular ligamentous structure of the first MTP joint. It was originally described in 1976 by Bowers and Martin28 who found an average of 5.4 turf toe injuries per football season in football players at the University of West Virginia. Turf toe injuries classically occur in football players participating on artificial surfaces. This theory was supported in 1990 by Rodeo et al29 who surveyed 80 active National Football League players. Their findings were that 45% had experienced a turf toe injury and 83% of these had occurred on artificial turf. Turf toe injuries, however, can occur in any field sport, on any surface.

The mechanism of turf toe injuries is typically an axial load to a foot fixed in equinus. This load drives the hallux MTP joint into hyperextension, attenuating, or disrupting the plantar joint complex. The spectrum of injuries ranges from a sprain of the plantar structures to frank dorsal dislocation of the toe. Other variations exist and are based on the position of the hallux at the time of the force of injury30, 31

Presentation 

The history and physical examination is critical to proper diagnosis and clinical grading of the turf toe injury (Table 1), allowing for more efficient management and prognosis of return to play. It is important to understand the mechanism of injury and timing surrounding the event. This not only helps in appreciating the magnitude of force at the time of injury, but also helps guide the clinical examination by suggesting potential areas of injury. The hallux MTP joint should be observed for ecchymosis and swelling. The capsular ligamentous structures should then be palpated systematically with the toe tested through range of motion maneuvers to determine instability. Varus and valgus stress can be placed on the joint to determine the integrity of the collateral ligaments. Decreased resistance to dorsiflexion suggests a plantar plate injury, and a Dorso-plantar drawer test (similar to a Lachman test at the knee) may show further instability. Active flexion and extension of the MTP joint will help determine if there is injury to the flexor or extensor tendons. Grading the strength of active flexion at the hallux MTP joint can be helpful in determining the extent of injury, as normal strength suggests a less severe structural damage.

Table 1. Clinical Classification System for Turf Toe Injury
Reprinted with permission from Anderson RB, Shawen SB. Great-toe disorders. In: Porter DA, Schon LC, eds. Baxter's The Foot and Ankle in Sport, 2nd ed. Philadelphia, PA: Elsevier Health Sciences, 2007, pp: 411-433. (Adapted with permission from Adelaar RS [ed]: Disorders of the Great Toe. Rosement, IL, American Academy of Orthopaedic Surgeons, 1997)
GradeObjective FindingsActivity LevelTreatment
1Localized plantar or medial tendernessContinued athletic participationSymptomatic
Minimal swelling
No ecchymosis
2More diffuse and intense tendernessLoss of playing time for 3-14 dWalking boot and crutches as needed
Mild to moderate swelling
Mild to moderate ecchymosis
3Severe and diffuse tendernessLoss of playing time for at least 4-6 wkLong-term immobilization in boot or cast vs surgical repair
Marked swelling
Moderate to severe ecchymosis
Painful and limited range of motion

Radiographs 

Radiographic evaluation is mandatory for all hyperextension injuries. AP and lateral views of the foot and a sesamoid axial view should be obtained. Radiographs are usually negative, but a small avulsion fracture from the plantar aspect of the proximal phalanx or the distal aspect of a sesamoid may be seen, suggesting capsular avulsion. Comparison radiographs to the contralateral foot are highly recommended (Fig. 6A), as patients with complete rupture of the plantar plate often have proximal migration of the sesamoids.32

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  • Figure 6. 

    (A) Radiographic images of sesamoid retraction (L) compared with normal sesamoid position (R). (B) Spectral Presaturation Inversion Recovery sagittal MRI of the great toe. Arrow demonstrates rupture of the capsular ligamentous complex just distal to the medial sesamoid bone.

If there is clinical suspicion of a plantar plate injury, a forced dorsiflexion lateral radiograph, described by Rodeo et al,29 can be obtained. With passive hyperextension of the hallux MTP, the sesamoids should migrate distally. The forced dorsiflexion lateral helps evaluate the motion of the sesamoids and delineate diastasis of a fractured or bipartite sesamoid from MTP joint subluxation or proximal migration of the sesamoid in more serious plantar plate injuries. When possible, fluoroscopic imaging is helpful to show real-time motion of the MTP joint and sesamoid complex. Dynamic motion of the injured toe is compared with that of the uninjured side, with lack of distal sesamoid excursion suggesting a plantar soft tissue disruption. Live fluoroscopy is both diagnostic and educational for the patient and has become a standard part of our diagnostic algorithm.

MRI has become more common in turf toe evaluation. T2 weighted images obtained in coronal, axial, and sagittal planes provide excellent anatomic detail and can identify subtle bone or soft tissue injuries.33 To help formulate a treatment plan, MRI should be obtained whenever partial or complete tear of the plantar capsular ligamentous complex is suspected (Fig. 6B).

Nonoperative Treatment 

The early stages of all grades of turf toe injury can be treated similarly with rest, ice, compression, and elevation. This along with an anti-inflammatory medication can help reduce initial swelling and pain. Taping is not advised acutely as it may compromise circulation. Athletes may benefit from the use of a walking boot or short leg cast with toe spica extension in slight plantarflexion to protect the motion at the MTP joint. With this protection in place, the patient can weight bear as tolerated. If symptoms permit, gentle range of motion can begin at 3-5 days after the injury. Cortisone or anesthetic injections are not advised.

Grade 1 injuries may return to play with little or no loss of playing time. The toe can be taped in slight plantarflexion to provide compression and limit movement. Additionally, the athlete should modify their shoe wear to a stiff sole shoe that includes a turf-toe plate or Morton's extension to limit hallux MTP extension. Grade 2 injuries can be treated similarly, and will generally result in loss of about 2 weeks playing time. Return to play is dictated by the athlete's symptoms as well as their ability to reach near preinjury level of performance.

A grade 3 injury, or complete rupture of the plantar ligamentous complex, may require up to 8-week recovery. A longer period of immobilization is appropriate before returning to play. Ideally, the hallux MTP joint will have 50-60 degrees of painless passive dorsiflexion. Ultimately, return will be dictated by symptoms and ability to perform. It should be made clear to the athlete that up to 6 months of recovery time can be expected before symptoms completely resolve to the point that taping or shoe wear modifications are no longer necessary.

Surgical Treatment 

Operative treatment of turf toe injuries is seldom necessary. Indications for surgery include a large capsular avulsion, diastasis of a bipartite sesamoid, retraction of the sesamoids, and asymmetric hallux valgus (Table 2). Additionally, if a patient fails conservative management and remains dysfunctional, operative intervention must be considered.

Table 2. Indications for Surgical Repair of Turf Toe Injury
Indications for Surgical Repair of Turf Toe Injury

1.Large capsular avulsion with unstable joint

2.Diastasis of bipartite sesamoid

3.Diastasis of sesamoid fracture

4.Retraction of sesamoid(s)

5.Traumatic hallux valgus deformity

6.Vertical instability (positive Lachman's test)

7.Loose body

8.Chondral injury

9.Failed conservative treatment

Classically, acute reconstruction of the turf toe injury has been performed through a medial “J” incision, where the medial incision extends horizontally across the hallux MTP flexion crease. Recently, we have been using a 2 incision technique to improve access to the lateral aspect of the plantar plate. The approach begins on the medial side with care taken to identify and protect the plantarmedial digital nerve as it courses near the tibial sesamoid (Fig. 7A). The soft tissues are carefully freed to identify the defect in the plantar plate that is typically distal to the sesamoids. Plantarflexion of the MTP joint can help visualize the defect.

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  • Figure 7. 

    (A) Medial exposure with arrow identifying the medial plantar nerve. (B) Lateral exposure with sutures in place. (C) Medial exposure with sutures in place. Arrow points to abductor hallucis tendon which was avulsed in this patient's injury. (D) Medial view with sutures tied (3 knots visible).

Once the plantar defect is identified medially, the second incision is made just lateral to the fibular sesamoid. The soft tissue is dissected carefully to identify and protect the common plantar digital nerve and its proper plantar branch to the lateral aspect of the great toe. The lateral aspect of the capsular rupture is then identified, typically just distal to the fibular sesamoid.

Beginning through the lateral incision, the plantar plate would be repaired with nonabsorbable sutures. Starting at the midline of the MTP joint, near the flexor hallucis longus tendon, sutures should be placed in interrupted fashion, toward the lateral-most extent of the MTP joint. Most often, there is adequate tissue at the base of the proximal phalanx for reattachment. If this tissue is inadequate, then suture anchors or drill holes can be used to assure fixation of the soft tissues. Generally, 3 or 4 nonabsorbable sutures are used. Care should be taken to pass a suture directly opposite its start to avoid any pronation or supination of the MTP joint through the repair. After the sutures are placed through the lateral wound and tagged, a similar method of repair is performed through the medial wound for the medial aspect of the joint capsule. Once all the sutures are in place (Figs. 7B and C), they are tied in the same order in which they were inserted (Fig. 7D). Care should be taken to place the MTP joint in approximately 15 degrees of plantarflexion as the sutures are tied. After repair, fluoroscopy is used to verify an improved, advanced position of the sesamoids as well as fluid excursion of the sesamoids with MTP joint dorsiflexion.

If the turf toe injury is a medial based soft tissue disruption leading to a traumatic hallux valgus deformity, surgical management is similar to that of a modified McBride bunionectomy. When a sesamoid fracture or diastasis of a bipartite sesamoid is present, we recommend excising the smaller fragment of the sesamoid, leaving the larger pole for soft tissue repair. If necessary, drill holes through the remaining sesamoid fragment can be used as an adjunct to fixation. If complete sesamoidectomy is necessary, the large soft tissue defect that remains may compromise flexor power or result in fixed deformity. In this situation, the abductor hallucis tendon can be detached from its distal insertion and transferred into the plantar defect. The transfer provides collagen for structural stability and also augments the flexion power of the MTP joint.

Postoperative management is challenging because finding a balance between protecting the soft tissue repair and early range of motion to avoid arthrofibrosis is difficult. Immediately after surgery, the toe should remain immobilized in 5-10 degrees of plantarflexion with a toe spica splint. With careful supervision, gentle passive range of motion can begin at 5-7 days, with care to avoid dorsiflexion. The patient should remain non-weight-bearing with a removable splint or protective boot and, at night, should wear a removable bunion splint with plantar restraint. The patient can begin protected weight bearing in a boot at 4 weeks. At this point, active range of motion can also begin, with slow progression as tolerated. By 2 months postoperative, the patient can discontinue the boot and begin using shoes modified with a turf-toe plate or Morton's extension. Activities can continue to increase as tolerated with protective taping. Return to contact activity is typically at 3-4 months. Despite a return to full activity, it should be clear that it will take at least 6 months, and often as long as 12 months, before obtaining full recovery.

Anderson reported on 19 high level athletes that underwent evaluation for disabling turf toe injuries, 9 of which were operatively repaired.34 All but 2 patients returned to full athletic activity with documented restoration of plantar stability. There were no operative complications. Coker et al35 reported on 9 athletes with a hyperextension injury to the first MTP joint, finding that the most common long-term complaints were joint stiffness and pain with athletic activity. Clanton had a larger group of 20 patients with a 5 year follow-up from a turf toe injury.36 Fifty percent of these athletes reported the persistence of pain and stiffness.

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Sesamoid Injuries 

Sesamoid pain has numerous etiologies. The most general term “sesamoiditis” defines pain in the sesamoid region with negative radiographs and an equivocal MRI. It should be considered a diagnosis of exclusion where there is often a history of overuse or minor trauma.37 Perhaps the term best describes a symptom rather than a diagnosis. Fracture of the sesamoid is another cause of pain, resulting from an acute injury, such as hyperextension or direct impact. A fracture can also result from stress injury, as in runners with repetitive impact through the forefoot. The medial (tibial) sesamoid is more commonly involved, with a fracture line typically transverse across the midwaist of the sesamoid.

Degenerative etiologies for sesamoid pain, such as chondromalacia, impingement, or osteophyte formation also exist. The mechanism and development of these pathologies usually stems from chondral injury or repetitive damage. Degeneration of the sesamoid articulation can occur as an isolated entity, with inflammatory disorders, or with osteochondroses. Etiologies include sequelae from crush injuries, stress fractures, or (AVN) of the sesamoid. AVN most frequently affects the lateral (fibular) sesamoid. The bone often fragments and flattens with cyst formation.

Plantar prominence of the sesamoids can also occur, typically in long-distance runners. Pain usually stems from bursitis or intractable plantar keratosis (IPK). Less commonly, osteomyelitis can result from the direct extension of an ulcer or puncture wound.38 Finally, tumors are rare, but can occur in the sesamoid, more frequently in the lateral (fibular) sesamoid.39

Presentation 

Evaluation of sesamoid pain should begin with a complete history. Typically, the patient reports pain along the plantar aspect of the hallux MTP joint, particularly with weight bearing. There may not be a single precipitating event, yet the pain worsens with athletic activity or stair climbing. The clinical examination should follow, with hopes of localizing the pain or tenderness. Plantarmedial tenderness suggests the tibial sesamoid as the source of pain, whereas tenderness at the more lateral aspect of the MTP joint points more toward the fibular sesamoid. The presence of warmth, swelling, or erythema should be noted. Joint motion and stability should be examined, keeping a turf toe injury in mind as an etiology of pain. If compression of the sesamoids produces pain and grinding with motion, it suggests arthritis at the metatarsosesamoid articulation. Presence of an IPK or sesamoid bursitis should be noted, and may be the result of a plantar-flexed first ray, described by Manoli and Graham as part of the subtle cavus foot posture.40

Radiographs 

Obtaining radiographs is mandatory in any thorough evaluation. Standing AP and lateral views should be obtained as well as axial or tangential views for improved assessment of the sesamoid articulaion (Fig. 8A). With these special sesamoid views, one is more likely to see focal arthrosis, bony prominence, plantar osteophytes, or even fracture. Placing a metallic object on the skin overlying the point of maximal tenderness can help differentiate which sesamoid is involved with pathology.

  • View full-size image.
  • Figure 8. 

    Imaging studies for a sesamoid fracture. (A) Plain radiograph—sesamoid axial view. (B) T1 weighted axial MRI. (C) Bone scan demonstrating uptake in the fibular sesamoid.

One should keep in mind that as many as 33% of the population has a congenital partition of the sesamoid (bipartite). The bipartite sesamoid will have smooth cortical edges with a relatively larger total size than a single sesamoid. A fracture, in contrast, will have sharp, irregular borders on both sides of the separation. Contralateral views might also be helpful if there is doubt because Zinman et al41 cited up to a 90% incidence of bilateral occurrence of bipartite sesamoids.

MRI may be needed in the diagnostic process to help differentiate between bone and soft tissue abnormality. The MRI can assess sesamoid viability, joint degeneration, and tendon/ligament continuity (Fig. 8B). A three-phase bone scan is another study that can be helpful in evaluating sesamoid pathology. Although it might have a high false positive rate, pinhole images can be helpful in distinguishing between the medial and lateral sesamoid as the source of pain (Fig. 8C). Computed tomography scan is optimal to define the bony structure of the sesamoids in their articulation and can define the degree of arthritis at the sesamoid articulation as well as evaluate fracture or fracture healing.

Nonoperative Treatment 

Nonoperative management of sesamoid pain begins with rest, ice, compression, and elevation. Athletes will often need to modify their training regimen. Anti-inflammatory medication can be used adjunctively for additional relief. In more severe injuries, a patient may benefit from a protective boot but can remain weightbearing as tolerated. In milder injuries, taping can help provide compression and limit movement. Although we do not advise intra-articular injections for return to athletics, one might consider an anesthetic alone for pain in a single nerve distribution. As patients return to normal activities, shoe wear can be modified with the addition of a turf-toe plate or Morton's extension. Other inserts, such as a metatarsal pad or arch support may be helpful in unloading some of the weight bearing forces at the sesamoids.

Surgical Treatment 

If conservative management fails, the choice of surgical procedure should be directed by the etiology of the sesamoid pathology. For instance, an IPK generally develops over a bony prominence or plantar exostosis, most commonly of the medial sesamoid. Shaving the plantar aspect of the affected sesamoid is the best treatment in this case. A plantarmedial approach is used to locate the sesamoid, with care taken to protect the plantarmedial digital nerve. The sesamoid is located, and the overlying periosteum is divided and reflected while maintaining continuity of the FHB expanse. The plantar 50% of the sesamoid is resected with a microsaggital saw and the overlying soft tissues are repaired. One should be sure to avoid injury to the flexor hallucis longus and to avoid violating the joint with this procedure. The patient is allowed to immediately weight bear in a hard-sole shoe. The patient can gradually resume normal shoe wear and activities as the pain and swelling subside over 6-8 weeks.

Sesamoid fractures and stress fractures may require surgical intervention once a patient has failed conservative measures. Although in limited series, there have been reports of internal fixation to repair sesamoid fractures.42 Additionally, successful bone grafting has been reported in cases of sesamoid fracture nonunion.43 This technique can be challenging and is indicated for a waist fracture that has minimal diastasis (<2 mm). It is important that the fracture fragments are stable without gross motion and that the articular surface of the sesamoid is intact and free of injury. The medial sesamoid is typically involved, thus the standard plantarmedial approach is used. The capsule is incised along the superior border of the abductor hallucis and the cartilage of the sesamoid is examined. If there is no damage and no gross motion of the fragments, then an extra-articular approach to the sesamoid is performed (as with the sesamoid shaving). The nonunion site is debrided of fibrous tissue with care taken to preserve the intact articular surface. Cancellous bone is harvested from the medial metatarsal head through the capsulotomy site, and the autograft is then packed into the sesamoid nonunion site. The overlying periosteum and soft tissue is closed with absorbable suture, and the capsulotomy is repaired before the wound is closed. Internal fixation is not used.

Postoperatively, the patient is non-weight-bearing in a splint that extends beyond the toes. At 2 weeks, the splint is replaced with a short leg cast with toe spica extension. The patient can begin gradual weight bearing at 6 weeks when transitioned to a walking cast or boot. At 8 weeks, the patient may transition to normal shoe wear modified with a turf-toe plate, and, by 12 weeks, the patient should be able to bear weight without restriction. A computed tomography scan is obtained to confirm bony union before release to resume running activities. Anderson and McBryde43 reported on a series of 21 patients who had open bone grafting of a tibial sesamoid nonunion. Nineteen of these patients went on to union and regained their preinjury level of activity.

Patients with persisting pain that is worse with weightbearing may have developed osteochondrosis of the sesamoid. When nonoperative modalities fail for this diagnosis, sesamoidectomy is the surgical treatment. This is also the best option for sesamoids with degenerative disease, infection, or tumor. The patient should be aware that removal of the sesamoid results in loss of push off strength. Aper et al6, 44 determined that 10% of push off strength was lost with medial sesamoidectomy and 16% with lateral sesamoidectomy. If both are excised simultaneously, the loss is 30%. In the nonathlete, this loss of push off strength is not clinically important; however, in elite athletes, runners, or dancers it could lead to a decrease in the level of performance.

The approach for tibial sesamoidectomy is identical to the procedure for sesamoid shaving, except that the sesamoid is completely shelled from the FHB tendon (Fig. 9). This tendon must be carefully repaired with absorbable suture once the sesamoid is removed to avoid medial laxity that could lead to a hallux valgus deformity. If the sesamoidectomy leaves a significant defect in the plantar soft tissues of the hallux MTP joint, the abductor hallucis tendon can be transferred by releasing the tendon from its distal insertion and suturing it into the plantar defect. The transfer functions by adding collagen for soft tissue repair and by supplementing flexor strength.

A lateral (fibular) sesamoidectomy is most commonly performed through a plantar incision. The incision is curvilinear over the fibular sesamoid, just lateral to the weightbearing pad of the hallux MTP joint. This approach allows direct visualization and mobilization of the plantarlateral digital nerve (Fig. 10). Also, as with the medial sesamoidectomy, the FHB tendon should be directly repaired after excision of the bone to help maintain the soft tissue integrity of the MTP joint.

Rarely, both sesamoids need to be excised. We recommend staging the procedures to avoid the potential for a cock-up toe deformity. The more symptomatic or obviously pathologic should be removed first, and the other after 1 year. Meticulous repair of the FHB and soft tissues is critical to avoid instability at the hallux MTP joint.

Postoperatively, the toe is splinted in plantarflexion and slight varus for medial sesamoidectomy or valgus for lateral sesamoidectomy. After medial sesamoidectomy, patients may weight-bear as tolerated in a protective boot or hard-soled shoe. Patients should wear a removable bunion splint for up to 6 weeks postoperatively to protect the soft tissue repair. After lateral sesamoidectomy, patients need to remain non-weight-bearing for 2 weeks to allow the plantar incision to heal. Weightbearing is then initiated, but sutures are customarily left in for 3 or 4 weeks. At about 6 weeks, the patient can advance to hard sole shoes with consideration for a turf toe plate or Morton's extension in the athlete. Very good results have been reported following sesamoidectomy.45, 46, 47

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Conclusions 

Forefoot pain and dysfunction is relatively common in the athletic population. A careful history and thorough physical examination is the key to diagnosing and appropriately treating these disorders with the goal of safe and expeditious return to athletic activity. Special attention should be paid to the individual athlete's biomechanical alignment and gait in the treatment and rehabilitative course.

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PII: S1060-1872(09)00157-9

doi:10.1053/j.otsm.2009.12.001

Operative Techniques in Sports Medicine
Volume 18, Issue 1 , Pages 34-45, March 2010

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