Tackling Sports Injuries of the Forefoot and Midfoot
As Rhett B. Mason, MD, FRACS, reviewed, turf toe involves injury to the plantar structures of the first metatarsophalangeal joint (MTPJ). He said turf toe has become more prevalent due to the development of artificial turf and lighter, more flexible running shoes.
Dr. Mason noted the clinical presentation of turf toe involves a hyperextension injury, pain on push-off during weight-bearing, swelling and tenderness, pain on passive extension, and a positive Lachman test. One should compare weight-bearing AP, lateral and sesamoid X-ray views. Favinger and colleagues advocated considering sesamoid diastasis if the sesamoid interval is greater than 2 mm on a routine AP radiograph of the foot.1
Dr. Mason noted Clanton and Ford classified turf toe in 1994 and McCormick and Anderson modified that classification in 2010.2,3 Grade 1 is a sprain, grade 2 is a partial tear, and grade 3 is a complete tear.
Conservative treatment for turf toe options include RICE (rest, ice, compression, and elevation), nonsteroidal anti-inflammatory drugs (NSAIDs), taping the toe in slight plantarflexion, rehabilitation, a Morton’s extension, and a carbon flber splint, said Dr. Mason. He advised patients can return to running if they have 45–60 degrees of passive range of motion (ROM) and can return to play when athletes are asymptomatic and has a normal ROM. McCormick and Anderson suggested the following times for return to sport after a turf toe injury: 1–2 weeks for grade 1, 2–6 weeks for grade 2, and 3–6 months for grade 3.3
George and colleagues studied 147 turf toe injuries over 5 seasons.4 They noted athletes were 14 times more likely to suffer injury during a game than in practice, with the mean loss of playing time being 10 days. Dr. Mason noted only 2% of patients required surgery.
As for surgical treatment, for selected grade 3 injuries, indications include an unstable MTPJ, proximal retraction of the sesamoid, diastasis of the bipartite sesamoid, a positive Lachman test, traumatic hallux valgus, a loose body in the joint chondral injury, and failed conservative treatment.5 Blundell, in a study of 9 patients, noted good results with open reduction and internal fixation in patients with sesamoid fractures.6 A study by Smith and Waldrop focused on plantar plate repair in 15 athletes with turf toe.7 Researchers noted the average playing time missed was 16.5 weeks, average dorsiflexion ROM at final follow-up at an average 27.5 months was 42.3 degrees, and the average visual analogue scale (VAS) pain score was 0.7 at rest and 0.8 with physical activity.
Treating Navicular Stress Fractures in Athletes
Tony K. Danesh-Clough, MBChB, FRACS, noted navicular stress fractures are relatively uncommon and mostly occur in athletes in track and field, gymnastics, basketball, and football. In a review of anatomy, he noted the navicular is a boat-shaped bone between the talus and 3 cuneiforms. He noted the talonavicular joint is the key link between hindfoot and midfoot.
Biomechanically, Dr. Danesh-Clough said compressive running stresses mostly exert on the central one-third of the navicular bone, especially with repetitive forefoot loading. He said the tibial posterior tendon creates a medial tension force. The typical navicular stress fracture, he said, begins at the dorsal aspect of the central third of the navicular and extends obliquely from dorsomedial to plantar lateral.
Extrinsic risk factors for navicular stress fractures include training regimen, dietary factors, and equipment factors such as footwear or playing surface, according to Dr. Danesh-Clough. He added that intrinsic risk factors are metabolic state, menstrual patterns, and levels of fitness and endurance. Foot structure is another intrinsic risk factor, and he noted this includes a short first ray and long second ray, as well as metatarsus adductus and cavus foot.
Dr. Danesh-Clough noted the presentation of navicular stress fracture includes medial pain that is worse with activity and improves with rest, a gradual worsening of symptoms, and “N” spot tenderness. He said patients often have a delayed diagnosis of 6 months or more.
As for imaging of navicular stress fractures, Dr. Danesh-Clough noted plain X-rays have poor sensitivity, while magnetic resonance images (MRI) are very sensitive at detecting stress reactions and bone edema. Computed tomography (CT) scans provide better bony resolution to define the extent of the fracture. A single-photon emission computed tomography (SPECT) scan has excellent sensitivity to provide fracture definition, he noted.
Osteochondritis Dissecans and Cartilage Lesions of the Forefoot and Midfoot
Kirstina Olson, MD, noted that osteochondritis dissecans is distinct from hallux valgus. She advocated educating patients that the condition is a spot of arthritis and they may need additional surgeries. She tends to err on using the least invasive options first, saying lesions greater than 50 mm2 or cysts may receive osteochondral autograft transfer system (OATS) treatment.
Kim and colleagues retrospectively evaluated 24 cases of osteochondral defects of the first metatarsal head in 22 patients.8
Fourteen patients had subchondral drilling and 10 had treatment with OATS. As Dr. Olson noted, mean VAS and AOFAS scores in both groups were significantly improved. The authors noted defects of more than 50 mm2 subchondral cysts were significant predictors of unsatisfactory clinical outcomes in the subchondral drilling group, while these same factors were not associated with clinical outcomes in the OATS group. Dr. Olson emphasized that OATS could therefore be an option for patients who have an osteochondral defect larger than 50 mm2 or who have a subchondral cyst.
Kuyucu and colleagues studied arthroscopic treatment for focal osteochondral lesions in the first MTPJ in 14 patients, concluding that the treatment was effective in this patient population.9
In a study of 9 patients with symptomatic focal osteochondral defects of the first metatarsal head, Van Dyke and colleagues found particulated juvenile cartilage allograft transplantation to be effective.10 Dr. Olson noted no patients had postoperative infections or needed revision surgery, no patients had limitations in activities of daily living, and 7 patients had no limitations in recreational activity.
Ter Laak Bolk and colleagues studied 9 patients with symptomatic osteochondral lesions to the first MTPJ treated by arthroscopic bone marrow stimulation.10 Dr. Olson said 86% returned to sport at any level, with an average time back to sports of 4 months.
In a review of 11 articles on current surgical treatments for focal osteochondral lesions of the first metatarsal head, Dr. Olson notes Artioli and colleagues found an improvement in AOFAS, VAS, and hallux dorsiflexion but not in plantarflexion.12 The authors concluded there is limited evidence and knowledge regarding the surgical management of the first metatarsal head osteochondral lesions, urging more high-level comparative studies to design an evidence-based treatment algorithm.
Sesamoid Injuries: How a Little Bone Can Be a Big Problem
Kenneth J. Hunt, MD, pointed out the importance of sesamoids in athletes. He said sesamoids increase the mechanical advantage of flexors, stabilize the first ray, are the main weight-bearing focus in push-off, and protect the metatarsal head/flexor hallucis longus. Dr. Hunt emphasized that sesamoids are especially important in sports that involve jumping or sprinting, and in springboard diving, ballet and tae kwon do. Increased magnitude and frequency of force on the sesamoids can lead to injury, according to Dr. Hunt.
For patients with sesamoiditis, Dr. Hunt noted treatment options include NSAIDs, casts, boots, physical therapy, orthoses, or rigid shoes. For exostosis or intractable plantar keratosis, sesamoid shaving is an option, and Dr. Hunt noted Aquino and colleagues found an 89% success rate with this procedure in 26 patients, with no increased postop valgus.13 For acute sesamoid fractures, Anderson and McBryde noted 19 of 21 athletes healed with autogenous bone grafting, with an average 12 weeks to union.14
Sesamoidectomy is a treatment option and is compatible with most sports, noted Dr. Hunt. In a tibial sesamoid fracture, he advised performing a sesamoidectomy through a medial approach, protecting the nerve, repairing the flexor hallucis brevis, and advancing the abductor. In a fibular sesamoid fracture, perform a sesamoidectomy through a plantar incision, protect the nerve, repair the flexor hallucis brevis, and protect the flexor hallucis longus, noted Dr. Hunt.
Engasser and colleagues conducted a retrospective chart review of 29 feet in 27 patients having sesamoidectomy (tibial, peroneal, or both) with a burr through a medial approach to the sesamoid metatarsal articulation.15 Dr. Hunt noted that patient satisfaction was 81% and there was a 37.9% complication rate.
A study by Ford and colleagues focused on 92 patients undergoing an isolated fibular sesamoidectomy via a plantar approach.16 Dr. Hunt noted 70% were very satisfied, 88% would have surgery again, and only 4 needed reoperation.
Saxena and colleagues studied sesamoidectomy in 68 athletes, 41 of whom had tibial sesamoid fractures and 29 of whom had fibular sesamoid fractures.17 The authors noted the average return to activity was 11.1 weeks, and Dr. Hunt said no patients had varus or valgus.
With sesamoidectomy, Dr. Hunt advised being vigilant against malalignment, a loss of push-off strength, a cock-up deformity, and hallux rigidus.
Deciding When Injured Athletes Can Return to Play
When getting injured athletes back on their feet, David A. Porter, MD, PhD, said criteria include the injury, the player, the position, and the circumstances. For players, he emphasized showing transparency, empathy, and clarity. With parents of athletes, one should show communication, trust, and teamwork. With sports agents, he noted the importance of physicians showing competence and educating patients and agents. With trainers, Dr. Porter said one should be definitive as possible about when an athlete can return, while also being realistic and honest. With general managers, neutrality and selflessness are crucial.
A return to training participation, Dr. Porter said, is defined as the athlete may be participating in rehabilitation or sport but at a lower level than the desired goal, and may not be ready—medically, physically, or psychologically—to return to unrestricted training. Return to sport means the athlete has returned to a specific sport but not at a target level of performance, according to Dr. Porter. He noted return to performance means the athlete has returned to the sport and is performing at or better than the pre-injury level.
With forefoot and midfoot injuries, Dr. Porter said one factor is functional strength in the gastrocsoleus, posterior tibial tendon, and peroneals. Conditioning, mental status, and skill are other factors. For patients with fractures, he advised they should be clinically healed with minimal to no pain on palpation. Ligament injuries should be stable, nontender, have no swelling, and hold up to stress. Injured tendons should be structurally healed, able to hold up to 80% of the strength needed, without swelling or pain, according to Dr. Porter. Muscle injuries should be nontender, at 80–90% of full strength, have full ROM, and athletes should be functionally able to perform without pain.
Dr. Porter emphasized that the physician is part of a team treating injured athletes, with the team including athletic trainers, physical therapists, sports psychologists, nutritionists/dieticians, strength and conditioning trainers, position coaches, and head coaches. He said one should know where you fit in and should not minimize the roles of other team members.
“Don’t overestimate your role and don’t abdicate it either,” Dr. Porter concluded.
References
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9. Kuyucu E, Mutlu H, Mutlu S, Gülenç B, Erdil M. Arthroscopic treatment of focal osteochondral lesions of the first metatarsophalangeal joint [published correction appears in J Orthop Surg Res. 2019 Dec 23;14(1):460. doi: 10.1186/s13018-019-1456-7]. J Orthop Surg Res. 2017;12(1):68. Published 2017 Apr 27. doi:10.1186/s13018-017-0562-7
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11. Ter Laak Bolk CS, Rikken QGH, Dahmen J, et al. Back in action: high return to pre-injury level of sports after arthroscopic bone marrow stimulation for osteochondral lesions of the first metatarsophalangeal (MTP-1) joint. Cartilage. 2024;15(1):47-57. doi:10.1177/19476035231200332
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