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Background:
Traumatic hallux valgus is an increasingly common injury in the athletic population and represents a unique variant of turf toe. Failure to appropriately recognize and treat these injuries can lead to continued pain, decreased performance, progressive deformities, and ultimately degeneration of the hallux metatarsophalangeal joint. Lim...
Context in source publication
Context 1
... repair included resection of the medial eminence of the first metatarsal head (Silver bunionec- tomy), reefing of the MCL and capsule, and repair of the medial FHB rupture. Adductor tenotomy was performed through a separate incision over the dorsal first web space ( Figure 4) and relieved the deforming force on the medial soft tissue repair. In the event of a sleeve avulsion from the tibial sesamoid, repair was performed through a transverse drill hole created in the distal half of the sesamoid itself ( Figure 5). ...
Citations
... For patients with TT injury-associated traumatic hallux valgus, a formal bunionectomy can be pursued at the same time as repair. The modified McBride procedure has demonstrated success in these patients, where adductor tendon release, medial eminence resection, and medial capsular tightening can balance the forces acting on the MTP joint [8,31,35]. This also minimizes the risk of progressive hallux valgus deformity that can develop following a medial total sesamoidectomy [10]. ...
... Recovery duration, likelihood of return to sport, and long-term functional outcomes vary widely based on individual player characteristics, as well as injury severity and chronicity. Of those patients undergoing operative treatment, 71-90% are expected to resume pre-injury activity [30,35,44,47,48,51], although the level of performance may suffer in as many as 73% [46]. Coaches and training staff can generally expect a 2-to 4-month rehabilitation window before the player is able to participate in games, although more complicated injuries may further delay recovery [26,27,30,35,46,47,51]. ...
... Of those patients undergoing operative treatment, 71-90% are expected to resume pre-injury activity [30,35,44,47,48,51], although the level of performance may suffer in as many as 73% [46]. Coaches and training staff can generally expect a 2-to 4-month rehabilitation window before the player is able to participate in games, although more complicated injuries may further delay recovery [26,27,30,35,46,47,51]. ...
Purpose of Review
First metatarsophalangeal joint sprains or turf toe (TT) injuries occur secondary to forceful hyperextension of the great toe. TT injuries are common among athletes, especially those participating in football, soccer, basketball, dancing, and wrestling. This review summarizes the current treatment modalities, rehabilitation protocols, and return-to-play criteria, as well as performance outcomes of patients who have sustained TT injuries.
Recent Findings
Less than 2% of TT injuries require surgery, but those that do are typically grade III injuries with damage to the MTP joint, evidence of bony injury, or severe instability. Rehabilitation protocols following non-operative management consist of 3 phases lasting up to 10 weeks, whereas protocols following operative management consist of 4 phases lasting up 20 weeks. Athletes with low-grade injuries typically achieve their prior level of performance. However, among athletes with higher grade injuries, treated both non-operatively and operatively, about 70% are expected to maintain their level of performance.
Summary
The treatment protocol, return-to-play criteria, and overall performance outcomes for TT injuries depend on the severity and classification of the initial sprain. For grade I injuries, players may return to play once they experience minimal to no pain with normal weightbearing, traditionally after 3–5 days. For grade II injuries, or partial tears, players typically lose 2–4 weeks of play and may need additional support with taping when returning to play. For grade III injuries, or complete disruption of the plantar plate, athletes lose 4–6 weeks or more depending upon treatment strategy.
... Traditionally, in both acute and chronic situations, a wide plantar incision or a dual incision for medial and lateral access has been used for plantar plate repair of the MTPJ-1. 1,9,28 In this study, we present the symptoms and findings, the surgical procedure, and the results after a new arthroscopic procedure for plantar plate tear repair in patients with chronic plantar plate injury of the MTPJ-1. Our hypothesis was that arthroscopic repair of the MTPJ-1 plantar plate would result in a high return to preinjury level of activity. ...
Background
Most plantar plate tears of the first metatarsophalangeal joint can be treated successfully by nonoperative means. Primary repair may be indicated to restore continuity of the plantar structures and joint stability. Inadequate or failed nonoperative treatment may cause persistent pain and disability and thereby represent a career-threatening injury to an athlete. The chronic plantar plate tears are difficult both to diagnose and to treat. When surgical treatment is indicated, traditionally a wide plantar or 2 parallel incisions are used. An arthroscopic approach allows for verification and visualization of the injury and, at the same time, repair of the injury.
Purpose
To describe findings of plantar plate tears, present a new arthroscopic procedure for plantar plate tear repair, and present the outcomes after surgery.
Study Design
Case series; Level of evidence, 4.
Methods
This was a retrospective study on the first 10 patients treated with the arthroscopic technique. The patients underwent surgery between June 2017 and January 2021. Patient data, clinical symptoms and findings, and operative details were obtained from the patient records. Patients were contacted via email to complete patient-reported outcome measures (Manchester Oxford Foot Questionnaire [MOxFQ] and Numeric Rating Scale [NRS] for pain).
Results
Four female and 6 male patients with a median age of 24 years (range, 12-44 years) were operated on at a median of 20 months (range, 2-38 months) after injury. Of the 10 patients, 8 had a hyperextension injury of the first metatarsophalangeal joint and 7 had a subtle valgus malalignment of the hallux; 8 patients were injured during sport activity. All patients reported plantar pain at pushoff. All but 1 patient returned to the same level of preinjury activity within 6 months. At a median of 29 months (range, 7-49 months) after surgery, the median MOxFQ score was 6 (range, 0-41) and the median NRS pain score was 0.
Conclusion
Arthroscopic plantar plate repair of chronic plantar plate tears resulted in a high rate of return to activity/sport and excellent outcome scores.
... The etiology of hallux valgus (HV) deformity continues to be controversial. Some of the factors that may contribute to its development include failure of the medial sesamoid and collateral ligaments (1), markedly decreased abductor activity and adductor tendon contracture (2,3), hypermobility (4) associated with predisposing elements such as trauma (5), and family history (6), among others. ...
Pronation of the first metatarsal is a risk factor for the formation and progression of the hallux valgus deformity. Recently, Yamaguchi et al. published a study that showed how the round sign increases on digitally reconstructed radiography taken from a CT scan when pronation is applied. In this study, the shape of the lateral edge of the first metatarsal head was evaluated on weight-bearing dorsoplantar radiographs. Yamaguchi's signs were presented to observers after the visual presentation of each foot as an image. The best-fit circle was drawn using the PACS drawing function. Ninety radiographs of adults presenting hallux valgus deformities were classified as mild-to-moderate, based on hallux valgus angle and intermetatarsal angle. The global average observations were 3.72 ± 3.92 (Range 2.3 to 4.6°). The interclass correlation (Fleiss Kappa index κ = 0.225) and the Spearman correlation (0.16 of Kappa) coefficients were poor for inter-observer measurements and statistically significant. Using the linear model, there was no significant variability between the repetitions corresponding to each observer (t-value -1.527, p-value 0.127). Our findings show that the Yamaguchi method can be very subjective and should not be the exclusive technique to assess the rotation of the first metatarsal or head roundness.
... The initial recommended diagnostic imaging for 'turf toe' includes weight bearing and comparison radiographs with AP, lateral, and sesamoid axial views with or without dorsiflexion stress lateral views and MRI for soft tissue and intra-articular pathology. 16,17,[20][21][22]25,28,29,31,32,34,35 On MRI, MCL integrity is best assessed in the axial plane while coronal short axial and sagittal are necessary to evaluate the plantar plate. 26,27,36 In this case, direct and dynamic sonographic visualization and sonographic comparison views of the MCL were obtained. ...
Isolated disruption of the medial collateral ligament of the great toe is rare and often misdiagnosed as turf toe. It may progress to acquired traumatic hallux valgus, often requiring operative intervention and a longer return to play. This case of a grade II medial collateral ligament injury highlights the importance of a thorough physical examination and consideration of the mechanism of injury. It demonstrates the utility of diagnostic musculoskeletal ultrasound in establishing a specific diagnosis upon initial patient presentation with great toe pain. It is an example of the use of ultrasound in guiding treatment and monitoring interval healing. In this case, differentiation of the injury from the classic "turf toe" led to proper stabilization with a toe spacer and activity modification, thus preventing progression of traumatic hallux valgus and leading to successful nonoperative treatment with full return to sport.
Level of evidence:
Level V.
... ligamentous repair 1,3 . We present a case of an acute MCL tear resulting in posttraumatic hallux valgus deformity in a collegiate football lineman. ...
Case:
We report a rare case of posttraumatic hallux valgus in a collegiate football player after an acute medial collateral ligament tear of the first metatarsophalangeal joint. The patient was treated with a modification of the modified McBride technique, using an all-suture anchor for the medial ligamentous complex repair. There was return to sport at 5 months and a Foot and Ankle Outcome Score of 95% at 10 months.
Conclusion:
A modified McBride procedure further modified with the utilization of an all-suture anchor for the medial ligamentous complex repair can result in correction of deformity, pain-free movement and return to sport.
... While the literature is abundant regarding the etiologies of chronic hallux valgus, the literature on causes of acute hallux valgus are limited. To date, post-traumatic hallux valgus has been attributed to Lisfranc injury, 1 medial plantar neuropathy, 2 turf toe variant injuries, 3 first metatarsal fracture, 4 and medial collateral ligament (MCL) tears. 5,6 Rupture of the first metatarsal medial collateral ligament was initially described in 1997 in a professional soccer player. ...
... Lohrer 6 describes an end-to end repair of the ligament using 3-0 Vicryl reinforced by a periosteal flap. Fabeck et al. 5 and Covell et al. 3 ...
Post-traumatic hallux valgus, a turf toe variant, is a rare, yet limiting injury. According to the literature, the deformity has been associated with acute medial collateral ligament tears, turf toe variant injuries, Lisfranc injury patterns, and first metatarsal fractures. There have been few documented cases of post-traumatic hallux valgus secondary to medial collateral ligament tears, and the treatment has been variable. Some authors have described direct end-to-end repair of the ligament to address the deformity, while others have described a modified McBride bunionectomy involving a Silver bunionectomy, lateral soft tissue release, and medial capsular and ligamentous repair. We propose a modified technique similar to the modified McBride bunionectomy, however, with the use of an all-suture anchor in the medial capsular and ligamentous repair. Our belief is that the all-suture anchor will allow for a stronger repair that will meet the physical demands of everyday ambulation and athletic participation. We used this technique in an individual who had evidence of a medial ligamentous complex injury of the hallux on MRI and failed conservative management. Postoperatively, the patient is immobilized until they can begin working on range of motion, strengthening, and finally to achieve return to full activity and sports.
... In our case, we chose direct reinsertion, protected and augmented by a split of the abductor, to retrieve the original joint kinematic and proprioception. Additional adductor or plantar releases or bunionectomy, as described by Covell et al. [8], was unnecessary: in this case there was no fixed valgus deformity, therefore no reduction trouble, no inferior valgus moment (less lateral complex shrinking) and no plantar lesion. This case might reflect an early stage of a Traumatic hallux valgus deformity, but we believe that the plantar plate and accessory ligament integrities (e.g. a preserved sesamoidal tracking), had a protective role against an early valgus deviation. ...
Sport injuries of the first metatarsophalangeal joint are well described, especially with traumatic hallux valgus and turf toe reports. However, there is no description of infraclinical medial laxity and following articular disorders. We report the case of a thirty-year-old runner who suffered a sprain initially treated with retentive dressing and local injection. He developed microinstability of the first ray and quickly a bone cyst, pushing us to suggest surgical treatment. After one year of follow up after surgery, he returned to previous high-performance sport. This case highlights the probable undervaluation of post traumatic stability of the first metatarsophalangeal joint, and its potential consequences for the return to sport.
Level of Clinical Evidence
Level 4.
... 2,3,5,6,14 Aggregate data were collected for 3 studies and inputted for individual participant analysis. 1,4,16 Grade level was assigned by the research team for 40 of the injuries. Table 1 summarizes the study characteristics. ...
... Recall bias was also present, as some studies were retrospective. 2,4,6,8 ...
Background
The prevalence of turf toe injuries has increased in recent years. However, uncertainty remains as to how to optimally treat turf toe injuries and the implications that the severity of the injury has on outcomes, specifically return to sport (RTS).
Purpose
To determine RTS based on treatment modality and to provide clinicians with additional information when comparing operative versus nonoperative treatment of turf toe injuries in athletes.
Study Design
Systematic review; Level of evidence, 4.
Methods
A systematic review and meta-analysis was performed using the PubMed/Ovid MEDLINE/PubMed Central databases (May 1964 to August 2018) per PRISMA-IPD (Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Individual Participant Data) guidelines. RTS, treatment, severity of injury, athletic position, and sport were recorded and analyzed.
Results
Of 858 identified studies, 12 met the criteria for the final meta-analysis. The studies included 112 athletes sustaining a total of 121 turf toe injuries; 63 (52.1%) of these injuries were treated surgically, while 58 (47.9%) were treated nonoperatively, and 53.7% were classified by the grade of injury (grade I, n = 1; grade II, n = 9; grade III, n = 55). Overall, 56 (46.3%) injuries could not be classified based on the data provided and were excluded from the final analysis. The median time to RTS for patients treated nonoperatively was 5.85 weeks (range, 3.00-8.70 weeks) compared with 14.70 weeks (range, 6.00-156.43 weeks) for patients treated surgically ( P < .001); however, there was variability in the grade of injury between the 2 groups. Similarly, patients who sustained grade II injuries returned to sport more quickly (8.70 weeks) than patients who had a grade I (13.04 weeks) or grade III injury (16.50 weeks) ( P = .016). The amount of time required to RTS was significantly influenced by the athlete’s level of play (16.50 weeks for both high school and college levels; 14.70 weeks for professional level) ( P = .018).
Conclusion
The time to RTS for an athlete who suffers from a turf toe injury is significantly influenced by the severity of injury and the athlete’s level of competition. Professional athletes who suffer from turf toe injuries RTS sooner than both high school and college athletes. However, there are a limited number of high-level studies evaluating turf toe injuries in the athletic population. Further research is necessary to clearly define the appropriate treatment and RTS protocols based on sport, position, and level of play.
... The frequency of first metatarsophalangeal (MTP) joint injuries in the athlete population is increasing, and therefore, this area has gained more importance recently. 1 These injuries could be challenging to diagnose and treat. Most of these cases are affecting the plantar MTPsesamoid complex resulting in a classical turf toe, which is a more easily recognizable entity. ...
Medial collateral ligament injury of the first metatarsophalangeal (MTP) joint is rare. If it is missed, chronic instability and traumatic hallux valgus develop, requiring surgical treatment. Different methods have been reported in the limited available literature aiming to restore the balance between the lateral and medial stabilizers by tightening the medial joint capsule with or without additional tendon graft. Our described method utilizes a suture button device (Mini TightRope, Arthrex, Naples, Florida) for reconstruction. This device applies tension to hold the hallux in the correct position, providing stability. Relevant diagnostic regimen, surgical technique, and postoperative care are described, along with a case of a handball player who underwent this procedure. He continues to perform at the same level 38 months postoperatively. Mini TightRope fixation for chronic medial first MTP instability has not been reported. It does not require postoperative immobilization and allows faster return to sport, so it seems superior to other methods when treating athletes.
