Sports Medicine: Just the Facts

CHAPTER 65 • FOOT INJURIES 389

of conservative treatment and development of defor-

mity (Mizel and Yodlowski, 1995).

• Interdigital neuroma
  
  
  • Interdigital neuroma or Morton’s neuroma is a
    common cause of forefoot pain. Classically presents
    as neurogenic pain in the ball of the foot between
    the third and fourth toes, less commonly in the other
    interspaces. It is thought to be caused by irritation of
    the interdigital nerve as it passes beneath the deep
    transverse metatarsal ligament. It occurs in all pop-
    ulations, but is most frequently reported in runners
    and dancers.
    •Palpation of the interspace while compressing the
    forefoot by pressing on the first and fifth metatarsal
    heads may reproduce the pain. Radiographs are
    obtained to rule out other sources of pathology such
    as metatarsal stress fracture or metatarsaophalgeal
    joint abnormality.
  
  
  • The first stage of treatment is modification of shoe
    wear, avoiding heels and shoes with narrow toe-
    boxes that may cause compression of the nerve.
    Injection of corticosteroid with local anesthetic may
    give lasting or permanent relief. Failure of conser-
    vative treatment is an indication for operative man-
    agement. Excision of the neuroma has demonstrated
    good pain relief in 80% of patients (Kay and
    Bennett, 2003).
  
  
  
  


• Freiberg’s infarction
  
  
  • Freiberg’s infarction is an osteochondrosis of the
    metatarsal head. Although it may be an asympto-
    matic finding on radiographs, it generally involves
    some pain and limitation of motion. It is more
    common in women, typically in their late teens and
    early twenties. Involvement of the second metatarsal
    head is by far the most common.
    •Patients complain of forefoot pain exacerbated by
    activity. There is tenderness to palpation about
    the metatarsal head, with or without edema.
    Although radiographs may be normal early in the
    disease process, they typically show subchondral
    collapse and progressive flattening of the
    metatarsal head.
  
  
  • The goal of treatment is to minimize deformity.
    Most authors recommend a short leg cast and no
    weightbearing followed by a gradual return to activ-
    ity. Several surgical procedures have been proposed
    to address failure of conservative management.
    They range from joint debridement to metatarsal
    osteotomy or excision of the metatarsal head
    (Katcherian, 1994).
  
  
  
  

TURFTOE

• Injury to the first metatarsophalangeal joint has
  ranked third in collegiate athletes after knee and ankle

injuries. Forced hyperextension is the most common

mechanism, although metacarpal-phalangeal (MP)

sprain can also be seen with varus or valgus stresses,

as well as forced flexion.

•Turf toe is classified into three grades. In grade I the

plantar tissues remain intact, symptoms are minimal.

There may be minor swelling but no ecchymosis.

Grade II injuries represent a partial tear of the capsule.

Symptoms are pain, swelling, ecchymosis, restricted

motion. The patient will be unable to perform at his

usual level of sport. Grade III injuries are complete

capsuloligamentous tears. There may have been an

occult MP dislocation that spontaneously reduced. In

addition to pain, swelling, and ecchymosis, the patient

will have difficulty with normal ambulation.

Radiographs may reveal sesamoid fracture, diastasis,

or periarticular fracture.

• Differential diagnosis includes MP dislocation, acute
  fracture, stress fracture, osteochondral lesion, and
  flexor tendinitis. Stability of the MP joint should be
  assessed. With grade II and III sprains radiographs
  should be obtained.
  •Treatment is generally conservative, consisting of
  rest, ice, elevation, and possibly anti-inflammatories.
  Buddy taping or rigid orthoses to limit MP motion
  may also help. Operative treatment may be indicated
  in patients with symptoms refractory to conservative
  management. Surgery may also be indicated for
  osteochondral fracture, unstable MPJ, or proximal
  migration of the sesamoids. Turf toe injuries may pre-
  dispose toward osteoarthritis of the first MTPJ and
  hallux rigidus (Fleming, 2000; Clanton and Ford,
  1994).

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