Turf toe and sesamoiditis: what the radiologist needs to know

The development of recommendations for the assessment and management of sesamoiditis by podiatrists: A Delphi and content validity study

INTRODUCTION

Sesamoiditis is a common, and often painful, musculoskeletal pathology frequently encountered by podiatrists. However, there are currently no recommendations to guide podiatrists in the assessment and management of people with sesamoiditis. The aim of this study was to develop consensus-driven clinical recommendations on the assessment and management of people with sesamoiditis.

METHODS

A four-round online Delphi survey was conducted with a panel of New Zealand and Australian podiatrists. In the first round, panellists answered open-ended questions that were used to create statements. In round two, the panellists scored the statements from 1 to 9 (1 = not at all important, 9 = absolutely essential). Consensus was defined using the RAND/University of California Los Angles Disagreement Index. Panellists were asked to reconsider statements that did not achieve consensus in round three. In the final round, content validity and acceptability of the statements for inclusion in clinical recommendations were determined using content validity ratios and the Content Validity Index (CVI).

RESULTS

Eighteen panellists completed round one with 16 (89%) completing all four rounds. A total of 118 statements were generated following round one. Following rounds two and three, 78 statements were accepted by panellists as being important, with 62 statements achieving sufficient content validity for inclusion in clinical recommendations. The CVI for these 62 statements was 0.58. These recommendations provide guidance on subjective assessment (pain characteristics/symptomology, activity/sports/training history and medical history) objective assessment (establishing a diagnosis, identifying contributing biomechanical factors, footwear/orthoses, ruling out differential diagnoses) and management (temporary padding/strapping, education, footwear, foot orthoses and when to consider referral).

CONCLUSION

This consensus exercise has provided a set of consensus-based recommendations for the assessment and management of people with sesamoiditis. In the current absence of research-based evidence in this area, these recommendations are intended to support clinicians. The recommendations may also serve as a basis for future clinical trials evaluating the efficacy of conservative interventions for people with sesamoiditis.

Paediatric sand toe: radiographic, ultrasound and MRI findings of dorsomedial capsular injury

Hyperflexion injury to the metatarsophalangeal joint of the great toe, referred to as sand toe, can cause significant functional impairment. To our knowledge, there have been no radiological descriptions of this injury in the paediatric age group. Here, we report radiographic, sonographic and MRI findings in a male paediatric patient who sustained a sand toe injury, highlighting structural damage to the dorsomedial capsule and medial sagittal band, and discuss sand toe's favourable prognosis with conservative management.

The assessment and management of sesamoiditis: a focus group study of podiatrists in Aotearoa New Zealand

BACKGROUND

Sesamoiditis is a common inflammatory condition affecting the sesamoid bones at the plantar aspect of the first metatarsophalangeal joint (1MTPJ). However, there are currently no recommendations or clinical guidelines to support podiatrists in their assessment or management of sesamoiditis. The aim of this study was to explore the views of podiatrists in Aotearoa New Zealand on their approaches to the assessment and management of patients with sesamoiditis.

METHODS

This qualitative study included focus group discussions with registered podiatrists. Focus groups took place online via Zoom and were guided by a detailed focus group question schedule. The questions were designed to encourage discussion around assessment approaches used in the diagnosis of sesamoiditis and the treatment tools used to manage patients with sesamoiditis. Focus groups were audio-recorded and transcribed verbatim. Reflexive thematic analysis was used to analyse the data.

RESULTS

A total of 12 registered podiatrists participated in one of three focus groups. Four themes were constructed relating to the assessment of sesamoiditis: (1) obtaining a patient history; (2) recreating patient symptoms; (3) determining contributing biomechanical factors; and (4) ruling out differential diagnoses. Seven themes were constructed relating to the management of sesamoiditis: (1) consideration of patient factors; (2) patient education; (3) cushioning of the sesamoids to allow more comfortable weightbearing of the 1MTPJ; (4) pressure redistribution and offloading of the sesamoids; (5) immobilisation of the 1MTPJ and sesamoids; (6) facilitating efficient sagittal plane motion during gait; (7) referring to other health professionals to find different ways to treat or manage patient symptoms.

CONCLUSION

Podiatrists in Aotearoa New Zealand demonstrate an analytical approach in the assessment and management of patients with sesamoiditis based on their clinical experience and knowledge of lower limb anatomy. A range of assessment and management techniques are selected based on the practitioners personal preferences, as well as the patient's social factors, symptomology, and lower limb biomechanics.

Association between forefoot pain and sesamoid rotation angle determined using a weight-bearing plantar ultrasound imaging device

Forefoot pain is a common symptom for several foot problems. This study aimed to determine whether parameters of forefoot structure (hallux valgus angle (HVA), transverse arch height (TAH) and sesamoid rotation angle (SRA)) are associated with forefoot pain. 547 feet of adult women were divided into two groups: without pain (n = 472) and with pain (n = 75). HVA was measured with a goniometer, TAH and SRA were measured using a weight bearing plantar ultrasound imaging device.Associations between forefoot pain and parameters of forefoot structure were analyzed using the Mann-Whitney U test and univariate and multivariate logistic regression analyses. The intra-rater and inter-rater reliability of the ultrasound images were also tested. SRA was significantly greater in the group with pain compared to the group without pain (p = 0.031) but not HVA (p = 0.057) nor TAH (p = 0.117). The association between forefoot pain and SRA was significant (univariate: p = 0.015 and multivariate p = 0.015), but not between HVA nor TAH. The intra-rater and inter-rater reliability were almost perfect (SRA: ICC1,1 = 0.94, ICC2,1 = 0.91 and TAH: ICC1,1 = 0.88, ICC2,1 = 0.81). We conclude that a higher SRA is related to forefoot pain and should be taken into consideration for assessment of patients with forefoot pain.

Presurgical Perspective and Postsurgical Evaluation of Plantar Plate and Turf Toe

Capsuloligamentous injury of the first metatarsophalangeal (MTP) joint (eponymously called "turf toe") mostly occurs in athletes and involves acute trauma, whereas tears of the lesser MTP joint plantar plate typically are an attritional-degenerative condition. This article reviews the anatomy, pathophysiology, mechanism and patterns of injury, grading and classification of injury, imaging appearances (pre- and postoperative), and management of first MTP joint capsuloligamentous injuries and lesser MTP joint plantar plate tears. These two distinct pathologies are discussed in separate sections.

Imaging of Turf Toe

Turf toe is a common injury of the hallux metatarsophalangeal (MTP) joint in athletes which is the result of hyperdorsiflexion injury. While the term turf toe has been used to describe a variety of first MTP joint injuries, the term is now typically used in imaging to describe tearing or injury to the plantar plate complex. This review article will cover normal anatomy of the first MTP joint, mechanism of injury, typical imaging findings in normal individuals on MRI and ultrasound, as well as the most common patterns of injury.

American Orthopedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Joint Scale: A Cross-Cultural Adaptation and Validation Study in the Persian Language

We evaluated the reliability and validity of the Persian translation of the American Orthopedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal joint scale (AOFAS Hallux MTP-IP). The translated AOFAS Hallux MTP-IP scale form was completed for 101 patients with hallux deformities; the subjective questions were answered by the patients, whereas the orthopedic foot and ankle surgeon and his assistant answered the objective questions. The validated Persian version of the 36-Item Short Form Survey Instrument (SF-36) was used for validity assessment. Eighty-five females and 16 males with a mean age of 49 years were enrolled. Hallux valgus and hallux rigidus was the diagnosis in 73 and 28 patients, respectively. Intrarater reliability had a high level of correlation (rho >0.6) for all subscales and total score. Although the correlation between the total score of the AOFAS Hallux MTP-IP scale and role: physical subscale of SF-36 was the highest (rho = 0.47), the total score of AOFAS Hallux MTP-IP scale and the other 7 domains of SF-36 had a correlation ranging between -0.17 and 0.43. Moreover, the correlation between total score of AOFAS-Hallux MTP-IP and SF-36 physical component summary scale was 0.50, which was higher than the correlation between total score of AOFAS and SF-36 mental component summary scale (rho = 0.35). Convergent validity was approved for MTP joint motion (0.59), IP joint motion (0.51), and callus (0.56) items of AOFAS-Hallux MTP-IP. Spearman's rank correlation coefficient between all items of the functional subscale of AOFAS Hallux MTP-IP scale with its own subscales was higher than the coefficient between these items and other subscales, including pain and alignment (discriminate validity). Floor and ceiling effects were calculated as 2% and 1%, respectively. Our findings indicate that the translated Persian version of the AOFAS Hallux MTP-IP scale is a reliable instrument, but its validity is not satisfactory.

Hallux sesamoid complex imaging: a practical diagnostic approach

A wide variety of pathologies can affect the hallux sesamoid complex of the foot, including traumatic, micro traumatic, degenerative, inflammatory, vascular, infectious, and neoplastic conditions. Symptoms are quite nonspecific, mainly related to pain in the plantar surface of the first metatarsal head. In this context, imaging is important for the etiologic diagnosis of hallux sesamoid complex pathology with implications in patient management. The hallux sesamoid complex has a complex anatomy, and pathologic processes of this region are poorly known of radiologists. Besides, some entities such as "sesamoiditis" remain poorly defined in the literature. Schematically, conditions affecting sesamoids will be divided into two major groups: intrinsic anomalies (sesamoid bone being the center of the pathologic process) and extrinsic anomalies (diseases secondarily involving sesamoid bones). Thus, in this article, after a review of anatomical key points and pathologies affecting the hallux sesamoid complex, a practical multimodality approach for the diagnosis of hallux sesamoid pathologies will be proposed.

Functional Outcome of Sesamoid Excision in Athletes

BACKGROUND

Sesamoid injuries can have a significant effect on the ability of athletes to return to play. The literature shows mixed results with sesamoid excisions and the ability to return to sports.

HYPOTHESIS/PURPOSE

The purpose was to describe patient-reported outcomes and return to sports in athletes after sesamoidectomy with a proper surgical technique and a well-structured rehabilitation protocol. It was hypothesized that sesamoid excision would demonstrate reproducible and encouraging long-term patient outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All patients from a single surgeon's practice who underwent sesamoidectomy between January 2006 and September 2015 were identified. Medial sesamoids were excised through a medial approach, and lateral sesamoids were excised through a plantar approach. The plantar structures were adequately repaired after excision. The Foot Function Index-Revised (FFI-R), 12-Item Short Form Health Survey (SF-12), and visual analog scale (VAS) were collected preoperatively and at subsequent follow-up appointments. A patient satisfaction survey and Single Assessment Numeric Evaluation (SANE) questionnaire were also collected. Athletes were defined as those who participated in sports at a high school level or higher.

RESULTS

Of the 108 feet that met the inclusion criteria, 26 werelost to follow-up, leaving 82 feet for analysis at a mean 31.3 ± 26.0 months. There were 72 female patients and 10 male patients included in the final analysis, with a mean age of 44.9 ± 20.2 years. There were 54 medial, 18 lateral, and 10 medial and lateral sesamoid excisions. There were 26 competitive athletes with follow-up appointments (dancer, n = 12; pivot sport athlete, n = 8; runner, n = 6). Both the entire study population and the athletes demonstrated a significant improvement in SF-12, SANE, VAS, and FFI-R cumulative at the latest available follow-up (P < .05). Among the athletes, 80% were able to return to competitive sports at a mean 4.62 ± 1.01 months after surgery. The median satisfaction score among all patients was 97.5%. There was no difference in the success rate between the different etiologies at any of the follow-up intervals.

CONCLUSION

Chronic sesamoid pain is difficult to treat, but this study confirms that with a meticulous surgical technique and a dedicated postoperative rehabilitation program, encouraging patient-reported outcomes can be expected with a minimal risk of complications. Moreover, in the current study, 80% of competitive athletes were able to return to sports at a mean of 4.62 months after surgery.

Bilateral Sesamoiditis as First Manifestation of Gout

Sesamoiditis secondary to gout is an extremely rare condition with few case reports in the literature. It is an important differential diagnosis because the treatment depends on targeted therapy, unlike the main causes of sesamoiditis that often involves immobilization with special orthoses and prescription of anti-inflammatory drugs. We report here a case of a 38-year-old male, athlete, with bipartite medial sesamoid, who had insidious pain in the base of the left hallux. Laboratory tests showed no alterations, and imaging examinations demonstrated sesamoiditis with suspicion of stress fracture. The patient was initially prescribed an immobilization boot and analgesic and anti-inflammatory drugs, but he did not respond to the measures taken. After the onset of the same condition in the contralateral foot and getting the same imaging findings, we began an investigation of systemic disease, focusing on gout, because of a positive family history, which was confirmed by dual-energy computed tomography.

Functional and patient reported outcomes following lateral hallucal sesamoidectomy

BACKGROUND

Lateral hallucal sesamoidectomy is an infrequently performed procedure indicated for patients with sesamoid pathology failing conservative treatment. Concerns exists regarding patient satisfaction, plantar scar pain, hallux malalignment and metatarsophalangeal joint (MTPJ) movement restriction following sesamoidectomy. This study aims to assess patient satisfaction after lateral hallucal sesamoidectomy via the plantar approach.

METHODS

In this retropective study with prospective follow-up, all patients who underwent lateral hallucal sesamoidectomy between January 2004 and December 2017 were reviewed. Twelve patients (14ft.) were available for final assessment. Outcome measures were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) clinical rating scale and the Self-Reported Foot and Ankle questionnaire (SEFAS). Patients were assessed clinically and radiologically. The average postoperative follow-up was 111.5 months (range 28-177 months).

RESULTS

All patients reported excellent outcome scores with a mean SEFAS score of 46.08 (range 43-48) and a mean AOFAS score of 92.33 (range 78-100) at final follow-up. All twelve patients reported their outcome as being excellent. No malalignment was noted clinically, however, three patients had a noticeable increase in the gap between the hallux and second toe when compared to the contralateral side. Range of motion at the MTPJ was preserved with a mean dorsiflexion of 80.83° (range 70-90°) and a mean plantarflexion was 25.83° (range 0-30°). None of the patients experienced any pain, discomfort or irritation related to the plantar scar. One patient developed neuroma like symptoms in the first web space.

CONCLUSION

Lateral hallucal sesamoidectomy via a plantar approach is an effective and reliable treatment option as demonstrated by the high levels of patient satisfaction, preservation of function, excellent PROM scores and limited complications in this study.

LEVEL OF EVIDENCE

Level 4.

High-Resolution MRI of the First Metatarsophalangeal Joint: Gross Anatomy and Injury Characterization

The first metatarsophalangeal joint (MTPJ) is vital to the biomechanics of the foot and supports a weight up to eight times heavier than the body during athletic activities. The first MTPJ comprises osseous and cartilaginous surfaces along with a complex of supporting structures, including the dorsal extensor tendons, collateral ligaments, and a plantar plate complex. In contradistinction to the lesser MTPJ plantar plates, a single dominant fibrocartilaginous capsular thickening does not exist at the first MTPJ. Instead, the plantar plate complex comprises a fibrocartilaginous pad that invests the hallux sesamoids and is inseparable from the plantar capsule, the intersesamoid ligament, paired metatarsosesamoid and sesamoid phalangeal ligaments (SPLs), and the musculotendinous structures. Acute injury at the first MTPJ is typically secondary to forced hyperextension-turf toe-and can involve multiple structures. During hyperextension, the resulting forces primarily load the distal SPLs, making these structures more susceptible to injury. SPL injuries are best seen in the sagittal plane at MRI. Radiography can also aid in diagnosis of full-thickness SPL tears, demonstrating reduced sesamoid excursion at lateral dorsiflexed (stress) views. Hallux valgus is another common condition, resulting in progressive disabling deformity at the first MTPJ. Without appropriate treatment, first MTPJ injuries may progress to degenerative hallux rigidus. The authors detail the anatomy of the first MTPJ in cadaveric forefeet by using high-resolution 3-T and 11.7-T MRI and anatomic-pathologic correlation. Injuries to the plantar plate complex, collateral ligaments, and extensor mechanism are discussed using clinical case examples. Online supplemental material is available for this article. ^©RSNA, 2020.

Turf Toe Review

Turf toe is a term used to describe myriad injuries to the metatarsophalangeal complex of the great toe, which have been associated with the introduction of artificial turf surfaces in sport. If not diagnosed early and treated properly, these injuries can result in chronic pain and loss of mobility. Accurate injury grading through physical exam and advanced imaging is essential to guide treatment, thereby minimizing long-term complications and maximizing an athlete's recovery and return to play. Levels of Evidence: Level V.

First MTP joint instability - Expanding the concept of "Turf-toe" injuries

BACKGROUND

Although the classic definition of the Turf-toe injury refers to a very specific clinical and pathological picture, we think that the concept can be broadened to encompass a wide variety of traumatic lesions of the first metatarsophalangeal joint (MTP1). These are lesions typically difficult to diagnose, with a large variation of outcomes and a potential to impair patients' functional performance on a definitive and perennial basis. The objective of this study is to present the result obtained by treating 24 cases of traumatic injuries to the MTP1 joint in a midterm follow-up time.

METHODS

In the period from 1999 to 2016, 24 patients were treated with MTP1 joint instability - "Expanded Turf-toe" - diagnosis. All patients were performing sports activities when they were injured: soccer (33%); martial arts (17%); running (13%); tennis (8%); olympic gymnastics (8%) and others (basketball, slalom, motorcycling, surfing, and ballet) (21%). Injuries were classified as Grade I (2 patients - 8%), Grade II (8 patients - 33%) and Grade III (14 patients - 59%) lesions. All patients with grades I and II were treated conservatively whereas those classified as grade III were treated surgically.

RESULTS

After an average follow-up of 4.5 years we observed an improvement in the AOFAS hallux score from 42 to 82 points after treatment (p<0.001). The most frequent cause was axial load with various direction of stress at the first MTP. The mechanism of lesion varied among extension with hallux varism (42%), pure hyperextension (25%), extension with hallux valgism (21%), pure hyperflexion (8%) and hyperflexion with hallux valgism (4%). A separate analysis of each group showed a significant improvement in AOFAS Hallux scores after treatment: 51-84 (p<0.001) and 36-81 (p<0.001) for conservative and surgical groups, respectively. Four patients with GIII injuries (29%) and two with GII injuries (20%) did not resume their previous activities. Although pre-treatment AOFAS hallux scores were significantly different between groups, post-treatment scores were similar (p=0.615).

CONCLUSIONS

Turf-toe is a serious injury that may prevent a high percentage of patients from resuming their previous physical activities. Mechanism of lesion might be varied generating a wide range of lesions that fit into the expanded concept of the Turf-toe injury. Both forms of treatment lead to satisfactory results if well conducted. The correct identification, classification, and grading of first metatarsophalangeal joint (MTP) instability helps in decision making and selection of the adequate treatment.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Properties and Function of the Flexor Hallucis Capsularis Interphalangeus Tendon

INTRODUCTION

The fibrocartilagenous plantar plates of the forefoot are biomechanically important, forming the primary distal attachment for the plantar aponeurosis. They are integral to the function of the windlass mechanism in supporting the arches of the foot in gait. Dissection of the cadaveric hallux revealed an organised sagittal thickening of the dorsal side of the flexor hallucis longus (FHL) sheath, which attached the interphalangeal plantar plate to the metatarsophalangeal (MTP) plantar plate. A description of a similar structure was made in 1984 when it was termed the flexor hallucis capsularis interphalangeus (FHCI) - however, it has not been researched since, and we aim to study it further and identify its characteristics.

METHOD

Eight specimens were dissected from four cadavers. Two were stained and examined under magnification in both polarized and non polarized light. The remaining 6 were subjected to micrometer testing of their tensile properties.

RESULTS

Both the histological features and mechanical properties were consistent with tendon; with cross sectional area, ultimate tensile strength and stiffness varying between specimens.

CONCLUSIONS

Based on its location and properties, the FHCI tendon may be involved in limiting dorsiflexion of the first MTP joint and could have clinical relevance in pathological processes around both the first and second MTP joints. Clin. Anat., 33:689-695, 2020. © 2019 Wiley Periodicals, Inc.

Turf Toe Injury - Current Concepts and an Updated Review of Literature

Turf toe injuries can be a disabling if not recognized and treated early. A high index of suspicion, based on the mechanism of injury and appropriate imaging, helps in the timely diagnosis. These injuries are frequently known to occur on artificial playing surfaces, because of the increased traction at the shoe-surface interface. Stress and instability testing are key components to assess the need for surgical intervention. Accurate timely diagnosis and treatment can allow full return to physical activities for most athletes, back to their pre-injury level.

Turf toe: A clinical update

Turf toe is a condition that describes injury to the plantar metatarsophalangeal-sesamoid complex of the great toe.

It is a relatively rare and debilitating condition, particularly seen in American footballers after the introduction of harder, artificial ‘turf’ surfaces.

Turf toe represents a significant injury to the hallux and requires a high index of suspicion.

If unrecognized, it can lead to chronic problems including reduced push-off strength, persistent pain, progressive deformity and eventual joint degeneration.

Patients with chronic injuries may have worse outcomes, and therefore early, accurate diagnosis and initiation of treatment play a vital role.

A multidisciplinary team approach is key for successful return to sport.

Cite this article: EFORT Open Rev 2018;3:501-506. DOI: 10.1302/2058-5241.3.180012

Turf Toe: An Update and Comprehensive Review

Turf toe is a spectrum of injury involving the first metatarsophalangeal joint originally described in football players on artificial surfaces. A detailed description of the complex anatomy and pathology involved in the turf toe injury is presented. We highlight potential pitfalls of image interpretation and emphasize what the referring physician needs to know.

MR imaging-anatomical correlation of the metatarsophalangeal joint of the hallux: Ligaments, tendons, and muscles

OBJECTIVE

To perform an MR imaging-anatomical correlation to elucidate the anatomy of muscles, tendons, and ligaments about the hallux as seen on MR imaging.

MATERIALS AND METHODS

Four fresh and 4 embalmed cadaver specimens were used for this study. The embalmed specimens and one fresh specimen were dissected by three investigators. The fresh specimens were preserved deep frozen. They were thawed and imaged with a 3 T MR system. Proton density weighted images were obtained. The specimens were refrozen and sectioned with a band saw into 3 mm thick slices.

RESULTS

Musculotendinous structures were equally well seen in the fresh and embalmed specimens. The capsular ligaments could best be studied in the fresh specimens. Proximal to the sesamoids the following muscle and tendon anatomy was delineated: the abductor hallucis tendon inserted on the medial sesamoid bone together with the medial belly of the flexor digitorum brevis; the adductor hallucis (transverse and oblique heads) inserted on the lateral sesamoid together with the lateral head of the flexor hallucis brevis. At the level of the sesamoid bones and distally, the ligaments making up the plantar plate were delineated, including the presesamoid band, the flexor hallucis longus pulley, the sesamometatarsal ligaments, the sesamophalangeal ligaments, and the capsular ligaments.

CONCLUSION

MRI allows for accurate assessment of the complex anatomy of the hallux. At the level proximal to the sesamoids the muscle and tendon insertions are well demonstrated. At the level of the sesamoids and distally, the ligaments making up 'the plantar plate' are well demonstrated.

Technetium-99m Methylene Diphosphonate Single-photon Emission Computed Tomography/Computed Tomography of the Foot and Ankle

The complex anatomy and function of the foot and ankle can make it difficult to determine the cause of symptoms in patients with foot and ankle pathology. Following initial clinical and radiographic assessment, additional imaging with magnetic resonance imaging may be required, which is often seen as the modality of choice. Although sensitive to pathological changes in bone metabolism and vascularity, technetium-99m (Tc-99m) bone scintigraphy often lacks the specificity and resolution required to evaluate the structures of the foot and ankle. Tc-99m methylene diphosphonate single-photon emission computed tomography/computed tomography (SPECT/CT) combines this sensitivity with the superior anatomical detail of CT, enabling better localization of pathological uptake and evaluation of associated structural changes. As a result, SPECT/CT has been growing in popularity for the assessment of patients with foot and ankle pathology where it can provide additional information that may change the initial diagnosis and subsequent management plan. Studies have reported modification of the surgical approach and site of intra-articular local anesthetic injections following SPECT/CT with good results. Interpretation of SPECT/CT studies requires an understanding of the pathological changes that result in increased tracer accumulation in addition to the CT changes that may be seen. This review aims to highlight the advantages of SPECT/CT, potential applications and explain the imaging appearances of common pathologies that may be observed.

[Acute sports injuries and chronic overuse stress damage to the forefoot and midfoot]

Sports injuries of the foot can occur as sequelae of acute trauma or chronic overuse. Besides clinical examination, imaging plays a major role in the detection of structural abnormalities and the differential diagnostics. This article reviews the most important sports-related soft tissue and bone pathologies of the forefoot and midfoot together with their typical findings on radiography, ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI).