Pertinent Pearls On Treating First MPJ Injuries In Athletes

A. Douglas Spitalny, DPM, FACFAS

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.

When Turf Toe Injuries Occur

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.

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