High contact. High intensity. It’s no surprise that many injuries occur on the football field. An injury may occur as an athlete is blocking an opposing player or as he is being tackled by another player. Other injuries may occur when players either sprint downfield, make sharp cuts to avoid being tackled, or make other movements that involve much rotation in order to catch or deflect the football. Playing surfaces can also lead to injuries (see “Artificial Turf Vs. Natural Grass: Which Is Better?” on page 48).
Certainly, the first metatarsal phalangeal joint is one of the most injured joints in football and there is a much higher incidence of these injuries on artificial surfaces as opposed to grass.
“The hallux injury can shut people down. They can’t play without a functional big toe. I’ve seen it end careers,” notes Stephen Kanter, PT, ATC, the Head Athletic Trainer for the New Jersey Gladiators Arena Football Team.
These first MPJ injuries can occur when a player is being tackled or when he exerts a forceful pushoff in the midst of pushing another blocker at the line. At this time, he may slam the big toe into the hard artificial surface, which can cause an impaction injury to the cartilage of the first MPJ. This rotation of the joint may be the result of external forces (such as being hit by an opponent) or general rotational forces, which occur when one is cutting sharply and the foot sticks to the surface. In the latter situation, the forces cause the hallux to stay glued to the turf and it leads to hyperextension of the first metatarsal. Typically, this causes an osteochondral compression injury or a fracture dorsally. Plantarly, there can be a stretching or rupture of the flexor capsule or tendons or fracture of the sesamoid bones.
In addition, rotational forces may cause sprain or rupture of the medial or lateral collateral ligaments. Turf toe has been commonly used as a collective term to describe any pain around the big toe resulting from the big toe being bent beyond its normal range of motion.
Treatment Essentials For First MPJ Injuries
In order to diagnose these injuries correctly, you should do a clinical examination, obtain X-rays and sometimes MRIs. In addition to getting standard and oblique X-rays, I always take raised lateral X-rays to see if there is a fracture at the dorsal aspect of the base of the hallux. You can do this by placing a 1-inch roll of gauze under the big toe prior to taking the lateral X-rays. In addition, it is standard protocol to take axial sesamoidal views to help view the sesamoid-first metatarsal interface.
Treatment for these injuries ranges from immobilization to excision of bony fragments. Prophylactically, you can tape players with a Spica dressing or buddy splint the hallux to the adjacent toe. Semi-flexible turf toe plates are helpful for reducing the end range of motion where many of these athletes experience their pains. Of course, shoe selection is important. The more stable the shoe, the less twisting motions to the foot. However, this may hamper the athlete’s ability for a quick pushoff.
What About Metatarsal Fractures?
Getting one’s foot caught in a pileup or simply cutting hard can cause the metatarsal bone to snap. The football player’s foot is certainly not immune to the Jones fracture. These fractures occur when the peroneus brevis tendon pulls on the base of the fifth metatarsal as the forefoot is planted, pivoting and adducting. Tuberosity fractures of the fifth metatarsal base are also endemic to the sudden turning and twisting involved in a player’s path.
Generally speaking, when you’re dealing with a fracture gap less than 2 to 3 mm in width, you can use cast immobilization. However, when the fractures are dislocated or there is a fracture gap greater than 3mm, you should proceed with ORIF. For fixation, I prefer to use a single screw to engage the base of the fifth metatarsal and catch the distal lateral cortex of the fifth metatarsal bone. When an avulsion of the peroneus brevis tendon is involved, I use a screw with a spiked washer to reoppose the tendon.
Plating of the fracture is also an acceptable treatment. However, this is more invasive and surgeons more often use this for older or more severe fractures that require bone grafting. External fixators are gaining in popularity, but they may have higher complication rates.