Pertinent Pearls On Treating First MPJ Injuries In Athletes

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A Brief Overview Of First MPJ Structures

Collateral ligaments
Flexor hallucis brevis muscle and tendon
Adductor hallucis muscle and tendon
Abductor hallucis muscle and tendon
Flexor hallucis longus insertion
Extensor hallucis longus insertion
Extensor hallucis brevis insertion
Intersesamoid ligament

A. Douglas Spitalny, DPM, FACFAS

   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.

Pinpointing The Source Of Cartilage Injuries

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.

In Summary

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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