388 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE
extreme end of the turf toe continuum. The mecha-
nism is almost always forceful hyperextension.
Patients present with a clear history of trauma and
painful limitation of motion. Local swelling may
obscure obvious deformity. Radiographs reveal the
proximal phalanx dislocated dorsally over the
metatarsal head.- The sesamoids may be seen in their normal relationship
to each other, indicating that the hallux has dislocated
over the metatarsal head and neck with the sesamoids
still attached at its base (type I dislocation). This con-
figuration is generally irreducible by closed means.
•Wide separation of the sesamoids indicates rupture of
the intersesamoid ligament (type IIA). Fractures of
the sesamoids may also be seen (type IIB). Types IIA
and IIB are usually reducible by closed manipulation,
which should be followed by 3–6 weeks in a short leg
walking cast (Jahss, 1980).
SOFT TISSUE
HALLUX VALGUS
- Hallux valgus or bunion deformity is common in the
general population and occurs in athletes as well. Hallux
valgus in athletes demands different considerations and
treatment than in the general population. Hallux valgus
occurs with lateral deviation of the great toe and pro-
gressive subluxation of the first metatarsophalangeal
joint. The medial eminence of the first metatarsopha-
langeal joint becomes prominent. The overlying soft
tissue becomes irritated, swollen, and inflamed creating
the bunion (from the Greek for turnip).
•Several intrinsic and extrinsic factors may contribute
to hallux valgus. The most important extrinsic factor
is constricting footwear. Shoes with heels and a
narrow toe box have been associated with bunions.
Athletic activities that increase the lateral stress on the
first MTP joint can be another extrinsic cause.
Intrinsic factors include a pronated foot, contracted
heel cord, hypermobility of the first metatarso-
cuneiform joint, and metatarsus primus varus. Injury
to the first metatarsophalangeal joint, such as turf toe
or first MTP dislocation may weaken the joint capsule
and collateral ligament predisposing to hallux valgus.
•Patients typically present complaining of pain over
the medial eminence and irritation with shoe wear.
The skin and bursa over the medial eminence may be
irritated. - The patient’s feet should be examined sitting and stand-
ing. Standing may accentuate the deformity. Range of
motion at the first MTP should be noted, as well as any
hypermobiltiy at the metatarsocuneiform joint. The
foot is examined for pes planus and pronation.- Radiographic evaluation consists of AP, lateral, and
sesamoid views with the patient standing. The angle
formed by the proximal phalynx and first metatarsal,
or hallux valgus angle is measured. A normal hallux
valgus angle is less than 15°. An angle between 15°
and 20°is considered mild hallux valgus. Moderate
deformity is characterized by a hallux valgus angle
between 20°and 40°, with an angle greater than 40°
being severe deformity. Other radiographic angles
measured include the intermetatarsal angle between
the shafts of the first and second metatarsal and the
distal metatarsal articular angle, a measurement of
joint congruity. - Initial treatment is conservative. Modification of shoe
wear is paramount. Irritation of the medial eminence
may be relieved with a wider toe box, shoe stretching,
or pads around the bunion. Patients with pes planus
may benefit from an orthosis. Contracture of the
Achilles if present should be treated appropriately.
Persistent pain after exhausting nonoperative treat-
ment options is an indication for surgery. Surgery can
result in postoperative restriction of MTP motion,
which should be considered by athletes requiring a
great range of MTP motion, such as dancers and
sprinters (Baxter, 1994; Coughlin, 1997).
- Radiographic evaluation consists of AP, lateral, and
METATARSALGIA
•Metatarsalgia is a descriptive term for pain beneath
the metarsal heads that may have a number of etiolo-
gies including stress fracture, synovitis, Freiberg’s
infarction, or neuroma. Forefoot pain has been associ-
ated with tightness of the gastrocnemius-soleus com-
plex. Patients presenting with forefoot or midfoot
symptoms have less dorsiflexion on average than
asymptomatic controls (Digiovani et al, 2002).- Lesser MTPJ synovitis
- Synovitis of the metatarsophalangeal joint most
commonly affects the second metatarsal. It occurs
most frequently in middle-aged athletes. - Symptoms typically include pain in the forefoot
exacerbated by running, walking, or forced dorsi-
flexion of the MTP joint. On examination there may
be swelling dorsally and there is tenderness to pal-
pation of the MTP joint. Radiographs might reveal
joint space widening, or joint degeneration. It must
be differentiated from other conditions with similar
appearance, such as Freiberg’s infarction, metatarsal
stress fracture, degenerative joint disease. The natu-
ral history is one of progression and attrition of the
capsule, plantar plate and collateral ligaments lead-
ing to subluxation or dislocation of the joints.
•Treatment is initially conservative, including activ-
ity modification, shock absorbing insoles, NSAIDs.
Surgical management may be necessary with failure
- Synovitis of the metatarsophalangeal joint most