https://doi.org/10.

5005/jp-journals-10040-
1124
Journal of Foot and Ankle Surgery (Asia
MINI SYMPOSIUM: FOREFOOT
Pacific)
DISORDERS
Volume 7 | Issue 2 | Year 2020

Forefoot Injuries in Sports

Sean HS Lai1, Camelia QY Tang2, Gowreeson Thevendran3
1
Department of Infectious Disease, Tan Tock Seng Hospital, Singapore
2Department of Orthopedic Surgery, Tan Tock Seng Hospital, Singapore
3Department of Orthopedic Surgery, Mount Elizabeth Hospital, Novena, Singapore

Corresponding Author: Sean HS Lai, Department of Infectious Disease, Tan Tock Seng Hospital,
Singapore, Phone: +65 82996706, e-mail: [email protected]
How to cite this article Lai SHS, Tang CQY, Thevendran G. Forefoot Injuries in Sports. J Foot
Ankle Surg (Asia Pacific) 2020;7(2):50–56.
Source of support: Nil
Conflict of interest: None

ABSTRACT
Forefoot injuries are common injuries in high-impact sports. The forefoot experiences a large amount of
stress during the late stance phase of the gait cycle. Repetitive load applied to the forefoot without adequate
rest can lead to tissue breakdown, resulting in injury. Forefoot sporting injuries can deteriorate gait function,
sporting performance, and quality of life. In this article, we review the typical presentation, approach, and
treatment modalities of the commonest forefoot sporting injuries. These include metatarsal stress fractures,
second metatarsophalangeal joint (MTPJ) instability, turf toe injury, sesamoid pathologies, as well as hallux
valgus and rigidus. Metatarsal stress fractures are frequent overuse injuries. They can be managed
conservatively with activity modification and protected weight-bearing or surgically with open internal fixation.
Second MTPJ instability typically involves disruption of the second MTPJ ligamentous joint capsule.
Management of this condition includes customized orthotics, physiotherapy, hydrocortisone and lignocaine
(HandL) injections, osseous procedures for phalangeal alignment, and plantar plate repairs. Turf toe injury
refers to a hyperextension injury of the plantar capsuloligamentous structure of the hallux MTPJ. Plantar
plate repairs are typically indicated in grade III injuries or when conservative treatment has failed. Sesamoid
injuries include stress fractures, infections, degenerative disease, and osteochondral lesions. Customized
orthotics limiting flexion across MTPJ while providing sesamoid stress relief is helpful, while surgical
treatment involves fixation with possible bone grafting or partial sometimes complete sesamoidectomy. While
hallux valgus and rigidus are not specific to sportsmen, treatment should take into account the patient’s
athletic demand. These conditions are typically treated surgically with realignment osteotomies if refractory to
conservative treatments such as foot orthoses and physiotherapy.

Keywords: Foot, Foot ankle surgery, Foot injury, Metatarsal, Sesamoid, Sports.

INTRODUCTION
Forefoot injuries are common in sportsmen who participate in high-impact activities involving
significant amount of running and jumping. Poor management of forefoot injuries can prolong
time return to sports and the preinjury level of sporting activities. For the purpose of this review,
we define forefoot as the structures in the foot extending from the tarsal-metatarsal joint to the
toes. Common forefoot sporting injuries include metatarsal stress fracture, second
metatarsophalangeal joint (MTPJ) instability, turf toe injury, and sesamoid pathologies. Other
common pathologies include hallux valgus and hallux rigidus. In this article, we will review the
diagnosis and management of these forefoot sporting injuries.

ANATOMY AND BIOMECHANICS OF THE FOREFOOT

The forefoot comprises of structures in the foot extending from the tarsal-metatarsal joints to the
tip of the toes, namely the 5 metatarsals, 14 phalanges, and 2 sesamoid bones. The first MTPJ is
surrounded by a capsular ligamentous complex that contributes significantly to the stability of the
first MTPJ. It consists of the medial and lateral collateral ligaments, plantar plate, adductor
hallucis, abductor halluces, and flexor hallucis brevis. The sesamoid bones arise within the tendons
of the flexor hallucis brevis and articulate with the plantar aspect of the first metatarsal head. They
act as pulleys to transmit forces from the flexor hallucis brevis through the plantar plate to the first
proximal phalanx base and elevate the first metatarsal head, thereby providing a moment arm that
augments plantar flexion of the first MTPJ.1–4

The foot experiences a high amount of stress during locomotion. Biomechanical studies have
shown that the peak vertical forces on the foot can increase up to 120% of body weight during
walking, and up to 220% of body weight during running.5 The center of pressure is shifted under
the forefoot during the late stance phase with the first to third metatarsal heads bearing the highest
concentration of pressure.5–8 Repetitive load applied to the forefoot in sporting activities without
adequate interim period of rest could hence lead to tissue breakdown with concomitant discomfort
and time off sports.

METATARSAL STRESS FRACTURE

Presentation

Metatarsal stress fractures are frequent overuse injuries that occur in athletes. They typically
present with an insidious onset of pain that occurs during periods of activity and is relieved by
rest. The second and third metatarsal bone accounts for 80–90% of metatarsal stress fractures.9–12
Due to the plantar-oriented forces that occur during weight-bearing, the most common area where
fractures occur is over the metatarsal neck.13,14 However, notable exceptions are dancer’s fracture
(proximal second metatarsal fracture) and Jones fracture (proximal fifth metatarsal fracture).15
Biomechanical alterations that result in repetitive stress over the metatarsals such as gastrocnemius
tightness, cavovarus foot, pes planus, or other altered foot biomechanics have been implicated in
the predisposition to metatarsal stress fractures.16–18

Imaging

Stress fractures can be detected via radiographs when bone reaction such as callus formation has
begun (Fig. 1).19,20 In view of its accuracy, earlier diagnosis, and prognostic value, MRI is the
modality of choice when working up for metatarsal stress fracture.21,22 When MRI examinations
are inconclusive, bone scintigraphy has been recommended by some to aid in the assessment of a
stress fracture.23 In patients with multiple stress fractures, laboratory tests are useful in evaluating
for any underlying metabolic or endocrine cause.24

Management

Conservative treatment of metatarsal stress fracture comprises of activity modification with

protected weight-bearing.25 This involves the use of customized orthotics for shock absorption,
cast, or Velcro walking boots.26,27 Return to sports should be started at low-intensity level with
gradual increments.28,29 Such delayed return to sports, coupled with high nonunion rates, makes
operative treatment a preferred option for athletes whose priority is an early return to sports.18,30

Operative treatment typically involves open surgery with fracture site curettage with or without
reaming of the medullary canal and plate stabilization augmented by the autogenous or allogenic
bone graft.31–33 Underlying structural abnormalities should also be addressed, for instance,
corrective osteotomies for dorsiflexed first ray or cavus foot and gastrocnemius recession for
gastrocnemius tightness.34–36 Adjunct treatments to improve bone healing in stress fractures, such
as low-intensity pulsed ultrasound (LIPUS) and extracorporeal shockwave therapy (ESWT), have
been proposed, though their efficacy still remains a subject of controversy.37–39

SECOND METATARSOPHALANGEAL JOINT INSTABILITY

Presentation

The proposed pathogenesis of second MTPJ instability is varied in the current literature but
generally involves lateral capsule and collateral ligament disruption together with plantar plate
rupture.40–42 Patients typically complain of tenderness over the plantar aspect of MTPJ, tender
plantar hyperkeratotic lesions, and toe deformities.40,43 First ray pathologies, such as hallux
valgus, excessive second metatarsal length, trauma, improper footwear, tight Achilles tendon, and
inflammatory arthropathy, have been implicated second MPTJ instability.44–48 A dorsal drawer
test, or Lachman’s test, where increased mobility of the second MTPJ is observed, indicates
plantar plate insufficiency.

Imaging

Radiographs and MRI are commonly used in the assessment of second MTPJ instability (Fig. 2).
Anteroposterior radiographs of the foot allow for evaluation of the forefoot cascade and shape of
the second metatarsal head, while lateral views allow for evaluation of the shape of the foot and
relative orientation of the metatarsal heads.49

The MRI is useful in evaluating the integrity of the second MTPJ plantar plate. Signs
suggestive of a torn plantar plate include discontinuity of the plantar plate with fluid interposition,
presence of pericapsular fibrosis extending from the proximal phalanx base into the intermetatarsal
space (pseudoneuroma sign), and increased plantar plate-proximal phalanx distance.50 Yamada et
al.51 found that a plantar plate to proximal phalanx distance of greater than 0.275 cm has a
sensitivity of 65% and specificity of 90% in diagnosing plantar plate tears.

When imaging investigations are inconclusive, lesser MTPJ arthroscopy is an emerging

diagnostic and therapeutic tool for synovectomy, direct plantar plate repair, and loose body
removal.50,52,53
Management

Conservative management of second MTPJ instability includes customized orthotics, shoe wear
modifications, and physiotherapy for calf stretches.54,55 Pharmacological treatment such as
nonsteroidal anti-inflammatory drugs and hydrocortisone and lignocaine (HandL) injections aid in
symptom relief, although multiple corticosteroid injections risk compromising MTPJ stability.50,56

Surgical management of second MPTJ instability mainly involves osseous procedures for
phalangeal alignment and soft-tissue repairs. Osseous procedures for phalangeal alignment include
a Weil’s recession osteotomy for excessively long second metatarsal, MTPJ synovitis, and
Morton’s neuroma, as well as a dorsiflexion osteotomy for Freiberg’s infraction.57,58 Increasingly,
there has been a focus on soft-tissue procedures, which include plantar plate reconstruction,
collateral ligament repair, and tendon transfers (extensor digitorum brevis, extensor digitorum
longus, flexor tendon). Plantar plate reconstruction is an increasingly popular procedure, with
direct repair of plantar plate back onto the base of the proximal phalanx of the toe with
nonabsorbable sutures or suture anchor devices.42,59 No standard postsurgical rehabilitation
program has been established but a postoperative anti-extension splint with a forefoot off-loading
orthotic for 4 weeks is recommended.

Figs 1A and B: Radiograph of right second metatarsal stress fracture in a dancer20

Figs 2A to C: Radiograph of forefoot (A) and MRI Forefoot coronal view (B) showing
fourth metatarsal head widening and flattening suggestive of dysplasia, secondary to chronic
 instability. Sagittal view of MRI (C) also show dorsal spurs and cyst formation

TURF TOE INJURY

Presentation

Turf toe injury is recognized as a hyperextension injury to the plantar capsuloligamentous structure
of the hallux MTPJ. It was first described in 1976 by Bowers and Martin60 at the University of
West Virginia who documented 5.4 cases of such injuries per season in football players at the
university. They attributed the injury to a combination of hard artificial tuft and flexible footwear,
which were recently introduced to football at that time. Turf toe injury has since been found not to
be exclusive to football and has been seen in a number of other sports such as basketball, baseball,
soccer, Taekwondo, and sprinting.61 The classical mechanism of injury involves a combination of
a hard artificial turf, flexible footwear, and an axial loading foot in equinus causing hallux
hyperextension.62

Apart from metatarsalgia, signs of turf toe injury include ecchymosis and tenderness over the
hallux MTPJ, weakness with plantarflexion, and a positive dorsoplantar drawer test. Turf toe
injury is graded according to the extent of plantar capsule disruption. A common grading system
proposed by Anderson63 classifies turf toe injury into three different grades, ranging from
stretching of and partial tears of the plantar complex to complete tears, each with their commonly
associated signs and symptoms (Table 1).

Imaging

Radiological evaluations are part of the workup for hyperextension injuries of the toe. Initial
investigation includes an AP foot X-ray as well as a forced dorsiflexion lateral foot X-ray. In
complete plantar complex tears, proximal retraction of the sesamoid bones can be appreciated on
the lateral foot radiographs with the hallux in dorsiflexion.64 Comparison with the contralateral
foot radiographs would aid with detecting this difference.

Table 1: Classification of turf toe injury

Grade Description

I Stretching of plantar complex

Localized tenderness, minimal swelling and no ecchymosis over the first MTPJ

II Partial tears

Diffuse tenderness, moderate swelling, ecchymosis and restricted movement with

pain.

III Frank tears

Severe tenderness, marked swelling and ecchymosis, limited movement with

 Grade Description

pain, and positive dorso-plantar test

Clinical classification of turf toe injury as adapted from Anderson RB. Turf toe injuries of
the hallux metatarsophalangeal joint. Techniques in Foot and Ankle Surgery 2002;1(2):102–
111

MRI remains the imaging modality of choice when evaluating plantar plate injuries. Sprains and
partial thickness tear would appear as either thinning or thickening with indistinctness of the
plantar plate, while full-thickness tears would appear as focal discontinuity of the plantar plate
with retraction and a fluid gap.65 Nonetheless, plantar plate recesses at the proximal phalangeal
attachments can be a normal variant, and caution must be taken to not overcall partial tears.66
Acute injuries usually demonstrate soft tissue edema, which is absent in chronic injuries. Chronic
injury might lead to development of osteophytes at the first metatarsal head, leading to hallux
rigidus.67

Management

Treatment of turf toe injuries depends on the degree of plantar complex injury. Most turf toe
injuries can be treated conservatively with rest, ice, compression, and elevation (RICE) and
orthotics.68,69 Anti-inflammatories and analgesics can help decrease pain and swelling. A short
period in a walking boot or a toe spica extension is beneficial (Fig. 3).70 Taping the hallux helps to
decrease movement at the MTPJ while providing compression. The patient should be kept on a
weight-bearing as tolerated regimen.

Surgical interventions are typically indicated only for grade III injuries or when conservative
treatment has failed. Typical indications for surgery include large capsular tear with joint
instability, sesamoid diastasis, traumatic hallux, loose bodies, or chondral injuries.71
Reconstruction of turf toe injury classically involves a medial “J” incision, whereby the incision
extends along the hallux MTPJ flexion crease.72 Surgical repair of the plantar plate involves repair
with nonabsorbable sutures placed in an interrupted fashion, suture anchors, or a drill hole
technique followed by medial capsular imbrication. Alternatively, particularly when there are
complete plantar plate ruptures, a dual-incision technique with incisions along the medial and
lateral border of the hallux MTPJ can be used to gain access to both the medial and lateral aspects
of the plantar capsular ligamentous complex.73 Postoperatively, the patient is kept nonweight-
bearing in a removable toe spica splint, with gradual return to full weight-bearing from the 4th
week onward.
 Fig. 3: Toe spica taping70

SESAMOID PATHOLOGIES

Presentation

Comprising of 9% of foot and ankle injuries and 1.2% of running injuries, sesamoid pathologies
are a significant etiology that should be given due consideration during the workup of forefoot
pain.74 Given their location within the tendons of the flexors, sesamoids aid in transmission of
force during gait and are predisposed to repeated stress and trauma, making them susceptible to a
range of acute and chronic injuries.75 These includes sesamoid stress injuries or sesamoiditis that
are due to repetitive trauma, sesamoid fractures, infections, degenerative diseases, and
osteochondral lesions (Fig. 4).3,76,77 Structural variations such as pes cavus, significantly
plantarflexed first ray, ankle equinus, abnormal sesamoid size or rotations, and absence of
metatarsal crista have been implicated as predisposing factors to sesamoid pathologies.3,74,78,79
Sesamoid pain is classically described as an activity-related pain with localized discomfort on the
compression test.80

Imaging

While MRI is diagnostic for sesamoid pathologies (Fig. 5), radiographs remain a useful modality
in evaluating sesamoid injury.81 Standard radiographs comparing contralateral foot X-rays are
useful, while an additional axial sesamoid view taken for a tangential view of the sesamoids and
less metatarsal heads can be very informative (direct beam at forefoot in a tangential manner with
forefoot in a dorsiflexed position) (Fig. 6).82 The existing literature has also suggested a role for
CT and image-guided injections targeting a symptomatic sesamoid.76,81,83

Management

Nonoperative treatment of sesamoid injury includes period of immobilization or enforced rest in

walking boots followed by customized orthotics, such as those limiting flexion across MTPJ or
providing sesamoid stress relief.84,85 However, symptomatic nonunion may persist after
nonoperative treatments.86

Operative treatment consists of options of surgical fixation with possible bone grafting, as well
as partial or complete sesamoidectomy.4,87–89 If surgical fixation is indicated, screws need to be
placed perpendicular to the fracture line to prevent fracture displacement and achieve
compression, thereby necessitating higher technical expertise. Sesamoidectomy is often advocated
as a good alternative, with a recent systematic review by Shimozono et al.,77 demonstrating that
sesamoidectomy for hallux sesamoid disorders yielded good clinical outcomes with high rate of
return to sports.87,89 The surgical approach for sesamoidectomy would depend on the sesamoid to
be removed and involves meticulous repair of the plantar capsule and flexor hallucis brevis
tendon.90,91 Potential complications of sesamoidectomy include cock-up hallux, loss of push-off
strength, neuritis or scar sensitivity, and hallux varus or valgus.92 As a result, a dedicated
postoperative rehabilitation program is often required.93

OTHERS
Other common forefoot conditions affecting sportsmen include hallux valgus and hallux rigidus.
While they are not specific to sportsmen, treatment for symptomatic hallux valgus and hallux
rigidus should take into consideration the patients’ athletic demands.94 Hallux rigidus is
commonly seen in runners and is generally perceived to be secondary to chronic repetitive trauma
to the first MTPJ (Fig. 7) and typically presents with pain during the toe-off phase of the gait
cycle.95 If the condition is refractory to conservative treatment with foot orthoses or taping and
physiotherapy, surgical treatment with dorsal first metatarsal cheilectomy may be
considered.94,96,97 The Valenti procedure is also advocated as it allows increased postoperative
dorsiflexion and range of motion, thereby quicker return to sport.97 First MTPJ fusion offers good
pain relief but should be offered judiciously as it will alter the forefoot loading patterns and the
gait of an athlete.

Fig. 4: Sesamoid chondral degeneration (Courtesy: G Thevendran)

 Figs 5A and B: Magnetic resonance imaging of fibula sesamoid stress fracture: (A) Axial
view; (B) Lateral view (Courtesy: G Thevendran)

Fig. 6: Radiograph shows fibula sesamoid fragmentation in sesamoid view (Courtesy: G

Thevendran)

Fig. 7: First metatarsal head osteochondral lesion (Courtesy: G Thevendran)

Akin to hallux rigidus, symptomatic hallux valgus should be treated conservatively.98 Failure of
conservative treatment may warrant a corrective osteotomy with debulking and tightening of
medial capsule.98 In the scenario where pain is isolated to a prominent medial eminence with only
mild deformity parameters, a minimally invasive hallux valgus correction may be considered.

CONCLUSION
There is a spectrum of forefoot sporting injuries. A careful history, meticulous physical
examination, and right imaging modality are key to identifying the underlying pathology. While
counseling on the course of treatment, it is critical to touch on time taken to return to sport and the
preinjury level of activity. While the role of biologics and treatment adjuncts are being
popularized, better training regimes, footwear, and minimally invasive surgical techniques will
likely polarize our management of forefoot sports injuries in the future.

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