Disorders of the First Metatarsophalangeal Joint
Diagnosis of Great-Toe Pain
Loretta B. Chou, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 7 - JULY 2000
In Brief: Disorders of the joint at the base of the hallux are common in active patients. Great-toe sprains (turf toe) can range from mild to severe with associated fractures. Hallux rigidus, a painful flexion deformity, is often seen in athletes who stress the joint repetitively. Heredity may predispose athletes to hallux valgus (bunion) but improper footwear, injury, and hyperpronation can also be implicated. Weight-bearing activities, climbing stairs, or wearing high-heeled shoes will aggravate sesamoiditis. Stress fractures, osteochondral defects, and gout are other causes of toe pain. X-rays are essential for accurate diagnosis. Nonoperative measures can reduce pain, but surgery is an option for recalcitrant cases.
Injuries to the metatarsophalangeal joint (MTPJ) of the hallux have been reported with greater frequency as awareness and incidence increase, especially with the use of artificial turf, also known as AstroTurf. Sprain of the first MTPJ is called turf toe. In addition to turf toe, the differential diagnosis of pain of the first MTPJ includes hallux rigidus, hallux valgus, sesamoid disorders, stress fracture of the metatarsal, osteochondral defect of the first MTPJ, and gout. Such traumatic injuries can have devastating consequences for athletes and for those whose activities or careers require them to be on their feet.
The term "turf toe" was coined by Bowers and Martin (1) in 1976 to describe injuries of the first MTPJ that occur during play on artificial turf. The mechanism of injury is hyperextension of the first MTPJ as a fixed, dorsiflexed foot is forced into the ground (figure 1A). The capsule and plantar plate are stretched and torn. Also, it can be the result of a hyperflexion mechanism (figure 1B), in which the dorsal capsule is torn. There can be associated avulsion fractures of the base of the proximal phalanx, osteochondral fractures of the metatarsal (MT) head, or even frank dislocation of the MTPJ.
Discussion. Turf toe is an increasing problem attributed to the use of overly flexible shoes on a hard playing surface (2). Although most commonly seen in football players, this sprain can be found in participants in other sports.
Bowman (3) presented a classification system for turf toe, with recommended treatment for each grade. A grade 1 sprain involves stretching and minor tearing of the capsuloligamentous structures. Typical symptoms include pain, stiffness, and swelling. Physical findings are mild swelling, ecchymosis, and mild pain with weight bearing and motion. A grade 2 sprain is a moderate injury to the joint. The signs and symptoms are more severe pain, swelling, or stiffness than a grade 1 sprain.
A grade 3 sprain is more severe and can have associated fracture, such as a compression fracture of the MT head or an avulsion fracture with a complete tear of the capsuloligamentous structures (2). Physical examination reveals swelling and ecchymosis of the joint. Especially with severe sprains, there is tenderness with loss of range of motion and inability to bear weight. Radiographic examination is obtained to evaluate for fracture or dislocation.
The treatment for turf toe is RICE (rest, ice, compression, and elevation). The use of a cast boot and crutches helps with the initial symptoms. If the mechanism of injury was hyperextension, the hallux can be taped in neutral position during the healing process. Once the swelling and pain diminish, range-of-motion exercises are initiated. Mild sprains resolve in a few days; however, severe sprains may require 6 weeks before the athlete may return to sports. An orthotic device or stiffening the athletic shoe is recommended to help prevent a recurrence. Very rarely will sprains of the first MTPJ require surgical treatment.
Arthritis of the first MTPJ with stiffness and osteophytes, especially on the dorsum, is called hallux rigidus.
Case report. A 37-year-old woman had a 6-year history of pain in the first MTPJ of her right foot. She played field hockey three times a week on AstroTurf. The pain had a gradual onset, but it had worsened with time and was constant. She described the pain as an ache, but it was sharp when she palpated the affected area, and it significantly limited her sports activities.
Examination in stance demonstrated localized mild swelling of the first MTPJ. The joint showed a loss of motion: Active extension was 20° and flexion 5°. The neurocirculatory examination was normal. The bony osteophytes of the first MT head were tender to palpation, and range-of-motion testing caused discomfort. Radiographs showed loss of joint space with sclerosis and large osteophytes, especially of the MT head (figure 2). Treatment options included use of a stiff-soled shoe with an orthotic device or surgical treatment. She chose to undergo a cheilectomy (procedure described below), and 2 weeks later the sutures were removed and range-of-motion exercises were begun. Four weeks following surgery, her motion had improved and her swelling had diminished, and she was able to return to playing field hockey with some minor limitations.
Discussion. Hallux rigidus is seen more commonly in athletes, especially runners, than in sedentary patients because of repetitive stress. Also, an injury such as a dislocation or subluxation with a capsule injury can result in posttraumatic arthritis with similar symptoms. Sports positions that require squatting, such as football or baseball, cause repetitive stress on the first MTPJ. Ballet dancers who bend in demi-pointe place increased stress on the joint.
The patient has pain and stiffness localized to the first MTPJ that is exacerbated by activity, especially extension of the joint. Rest from activity generally decreases symptoms. There can be associated swelling, redness, and increased warmth. Physical examination demonstrates a dorsal eminence that can be erythematous, swollen, and tender and is larger than the contralateral side. The pain is reproduced with extension and sometimes with flexion. Radiographs show degenerative joint disease findings, such as sclerosis, loss of joint space, osteophytes, and the enlarged dorsal eminence.
Treatment begins with nonoperative measures, such as instructing the patient to wear shoes with a wide toe box, perhaps extra depth, and stiff soles. Activity modification and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) are usually helpful in decreasing symptoms. For persistent symptoms, a surgical procedure called a cheilectomy can be done. The procedure involves removal of the large dorsal osteophyte of the first MT head, the primary cause of impingement. In addition, the osteophytes of the proximal phalanx base and medial and lateral osteophytes of the first MT head are excised.
The cheilectomy is an effective procedure for hallux rigidus (4) to improve motion and reduce pain. For severe cases of first MTPJ arthritis, a cheilectomy is ineffective in relieving symptoms because of significant loss of cartilage. An arthrodesis would be the salvage procedure for a severe degree of arthritis.
Following cheilectomy, range-of-motion exercises are begun. When the patient can wear an athletic shoe and has adequate range of motion, he or she may gradually return to play.
Also known as a bunion deformity, hallux valgus is a prominent medial eminence of the first MT head with lateral deviation of the great toe.
Case report. An active 23-year-old woman had a 2-year history of bilateral foot pain, with the right foot worse than the left. She was active in softball and worked in a supermarket bakery. She complained of severe pain at the end of a workday and when playing softball. The pain was localized to the right medial eminence, which sometimes became swollen and red. She had tried orthotic devices without success, and she usually wore wide, well-cushioned shoes. When standing, the patient had prominent medial eminences bilaterally. The motion of her feet was equal and full, and her neurocirculatory examination was normal. Gentle palpation produced tenderness over the eminence on the right foot, and she had a positive Tinel's sign on the dorsomedial aspect of the right medial eminence. Standing radiographs showed an enlarged medial eminence of the right first MT (figure 3).
She underwent a chevron osteotomy in which the medial eminence was removed, a chevron cut of the distal first metatarsal was made, and lateral displacement of the metatarsal head was completed. Following range-of-motion exercises and resolution of swelling, she was able to return to work as well as playing softball.
Discussion. The etiology of hallux valgus involves hereditary or extrinsic factors (footwear) (5). This deformity occurs almost exclusively in shod populations. Although there is not a greater incidence in athletes, there are special considerations because of their physical demands. Infrequently, the deformity can occur from the result of an injury of the capsule or plantar plate, such as a dislocation or subluxation, or from chronic stress to the medial hallux, such as with hyperpronation in running.
Patients have pain over the medial eminence, which can be swollen, red, and warm. They can have problems with footwear, particularly in shoes that are stiff or have a narrow toe box, causing pressure over the deformity. With moderate to severe hallux valgus deformities, there can be second-toe disorders such as hammertoe, claw toe, metatarsalgia, and intractable plantar keratosis. The patient can experience neuritic symptoms from inflammation of the dorsomedial digital nerve overlying the medial eminence. Examination reveals a prominent medial eminence with erythema, edema, and tenderness. Radiographs show an increased hallux valgus angle and an increased valgus angle between the first and second metatarsals.
Treatment goals are to relieve pain and pressure over the bunion while maintaining range of motion of the first MTPJ. Therefore, initial treatment involves shoe modifications such as a wide toe box and a metatarsal pad or bar. An orthotic device with a medial arch will help correct hyperpronation.
If nonoperative measures fail and the patient continues to have pain that interferes with sports activities, surgical correction can be considered. This generally requires a corrective osteotomy. Following the procedure, a postoperative shoe is worn for 8 weeks with weekly dressing changes. This is followed by range-of-motion exercises, and, when motion improves and swelling resolves, the patient may gradually return to previous activities.
The sesamoids of the hallux are located in the flexor hallucis brevis tendon and are connected by an intersesamoid ligament. The medial sesamoid, also known as the tibial sesamoid, is larger than the lateral (fibular) sesamoid. The sesamoids are important for bearing weight, protecting tendons, and reducing friction. Because of its larger size and its location, the medial sesamoid is more commonly injured. Sesamoiditis is an acute or chronic inflamation of the sesamoids.
Case report. A 30-year-old medical intern had a 6-week history of right foot pain after running. She had gradually developed pain on the plantar aspect of her first MT head. She described the pain as an ache that was relieved with rest and ibuprofen. The pain was worse with weight bearing, palpation, and extension of the hallux. She denied previous symptoms and other medical problems. Her father had a history of gout. Physical examination demonstrated normal and symmetric gait and stance. Her neurocirculatory examination and range of motion of the feet and ankles were normal. There was localized tenderness of the right medial sesamoid. Radiographic examination of the foot did not reveal abnormalities. She was treated with NSAIDs and a walking cast with a toe plate for 6 weeks. After her symptoms diminished, a total-contact orthotic device was made that facilitated relief of the sesamoid area. Her symptoms continued to abate, and she was able to go trekking in Nepal for a month.
Discussion. Repetitive trauma can cause sesamoid disorders in runners. Also, increased plantar flexion of the first ray, hyperpronation, and a stiff first MTPJ can predispose a patient to sesamoiditis. The most common symptom is pain, usually involving the medial sesamoid. There can be associated swelling with an acute onset, but generally this does not occur. Weight-bearing activities will increase the pain, especially climbing stairs or wearing high-heeled shoes.
On examination, patients note tenderness to palpation of the affected sesamoid, and frequently the other sesamoid is tender to a lesser degree. Extension of the first MTPJ causes discomfort. There can be localized swelling from inflammation of the affected sesamoid. Radiographic examination includes anteroposterior, lateral, oblique, and axial views of the foot, and a bone scan may be helpful for diagnosis if the radiographs are normal. The bone scan may be negative, in which case sesamoiditis will be a diagnosis of exclusion.
Nonoperative measures are tried first. Limitation of activity and a walking cast with felt pads to relieve the area of the sesamoids are used initially. Once the patient's symptoms have eased, an orthotic device with an area of relief under the sesamoids is helpful. If the patient overpronates, a soft, medial-longitudinal arch should be placed on the orthotic device to help correct hyperpronation. The patient may need to use the orthotic device for up to 6 to 12 months. In most cases, symptoms will resolve.
Patients whose pain is not resolved by nonoperative measures may be evaluated for surgery. A cheilectomy can be performed to correct hallux rigidus. A patient with a hyper-plantar flexed first ray can be treated with a dorsal closing wedge osteotomy. Excision of a symptomatic sesamoid is possible but should be avoided in a young athlete until all other treatments have been tried. When the symptoms have resolved, the patient can gradually return to sports activities while using the orthotic device. If the patient remains asymptomatic, use of the insert may be discontinued.
A fracture of the sesamoid can occur from an axial load such as a fall, or it can manifest as a stress fracture with an insidious onset. Fracture most commonly involves the medial sesamoid. There can be associated swelling in acute onset, but generally this does not occur. Weight-bearing activities will increase the pain.
Case report. A 23-year-old woman complained of a 5-month history of right foot pain. The pain initially occurred after wearing bubble sandals, and the following day she noted pain on the plantar aspect of the first MT head of her right foot. When she came for treatment, she noted intermittent pain, was unable to extend her hallux, and was unable to stand on her toes. She worked as a ballroom dance teacher and had problems with her shoes and difficulty performing required maneuvers. On examination while standing, no swelling was seen. Movement of the right first MTPJ produced discomfort and showed significant limitation. There was exquisite tenderness of the lateral sesamoid and mild tenderness of the medial sesamoid. Radiographs of the right foot, including an axial view, demonstrated a nondisplaced fracture of the lateral sesamoid (figure 4). The treatment options were discussed with the patient, and she was placed in a walking cast boot for 4 to 6 weeks. Treatment after the boot was removed included an orthotic device.
Discussion. The medial sesamoid is bipartite in approximately 10% of the population at random and, when present, is 25% bilateral (6). In contrast, the lateral sesamoid is rarely bipartite. Because of the prevalence of bipartite sesamoids, the diagnosis of an acute fracture may be difficult. The most common symptom of sesamoid fracture is pain of the sesamoid (plantar to the first MT head).
On examination, there is tenderness to palpation of the affected sesamoid, and frequently, the other sesamoid is tender to a lesser degree. Extension of the first MTPJ causes discomfort. Radiographic examination consists of anteroposterior, lateral, and oblique views of the foot and an axial view of the sesamoids. If a distinct fracture is not seen, then a three-phase bone scan may be needed to make the diagnosis.
Acute and stress fractures of the sesamoid are treated with a non-weight-bearing short leg cast with a toe plate for 6 to 8 weeks. Following cast immobilization and resolution of symptoms, an orthotic device with a dancer's pad is used for 6 to 12 weeks to relieve the affected area. A nonunion of a sesamoid fracture can be treated with placement of bone graft but may also be an indication for sesamoidectomy. Excision is indicated for displaced fractures or nondisplaced fractures that do not heal after 6 months of treatment. Complications following sesamoidectomy are hallux varus, hallux extensus, and a transfer lesion under the remaining sesamoid. Patients may have swelling for several months, but when this resolves they may return to play.
Other Disorders of the First MTPJ
Stress fracture of the first MT is rare. Stress fractures more commonly involve the second MT because it is the longest. The diagnosis can be made by history, physical exam, and radiographs. A bone scan or magnetic resonance image (MRI) may be required to confirm the diagnosis. The treatment is symptomatic, with rest from sports activities and a short course of cast immobilization.
Osteochondral defects can occur on the articular surface of the first metatarsal with an injury such as turf toe. The diagnosis may be elusive because of the small size of the bone. Radiographs may show a defect, and an MRI can help identify the lesion. The treatment is symptomatic, but if there is a loose body, then surgical excision is indicated.
Gout, also known as podagra, often affects the first MTPJ. An acute episode is treated with rest, ice, elevation, and NSAIDs. Chronic treatment includes diet modification, allopurinol, or colchicine. When symptoms resolve, the patient may begin range-of-motion exercises and return to sports gradually.
Pain in the MTPJ can have many causes, from simple sprains to acute fractures. Improper footwear, hyperpronation, and repetitive stress on the joint are often implicated in turf toe, hallux rigidus, and sesamoid disorders, and hereditary factors may also play a role in bunions. Nonoperative measures are often all that is needed to relieve pain, but surgery is an option in recalcitrant cases.