Turf Toe: An Update and Comprehensive Review

Posttraumatic Pathologies of the First Metatarsophalangeal Joint

Injuries to the first metatarsophalangeal joint are often missed and not adequately treated, resulting in secondary deformities and degenerative arthritis. The particular anatomy of the joint puts mainly soft tissue structures at risk, which is why conditions such as turf toe injury and valgus or varus deformities can occur. Because the sesamoid bones are receiving high pressures, fractures should be considered. Many conditions can be treated conservatively by offloading, immobilization, or taping. Surgical options for high instability, dislocated fractures, or advanced cartilage damage should be recommended.

The magnetic resonance imaging appearance of the normal anatomy and injury pattern of capsuloligamentous complex of the first metatarsophalangeal joint

BACKGROUND

The capsuloligamentous complex injury of the first metatarsophalangeal joint (MTPJ) is a common cause of turf toe.

PURPOSE

To investigate whether high-resolution 3 T magnetic resonance imaging (MRI) could demonstrate all the normal anatomic structures and the MR features of the capsuloligamentous complex injury of the first MTPJ, and to evaluate the diagnostic performance of MRI in the diagnosis of the capsuloligamentous complex injuries of the first MTPJ.

MATERIAL AND METHODS

A total of 115 feet were included in this study, including 48 feet from 24 healthy volunteers and 67 feet from 67 patients with the capsuloligamentous complex of the first MTPJ injuries. All feet had MRI examination. The MRI features of the capsuloligamentous complex of the first MTPJ of the volunteers and patients were analyzed. Diagnostic sensitivity, specificity, and accuracy of MRI were calculated using the surgery as the standard of reference. The inter-observer agreement was assessed using kappa analysis.

RESULTS

The central portion of the plantar plate and ligament injury manifested as discontinuity, with an indistinct appearance with hyperintense signal within the involved structures. The sensitivities, specificities, and diagnostic accuracy value of MRI for diagnosing most structures of the capsuloligamentous complex injuries of the first MTPJ were 67%-100%, 93%-100%, and 0.82-0.99, respectively, and overall good to perfect inter-observer agreements (kappa=0.63-0.95).

CONCLUSION

High-resolution MRI allows adequate visualization of normal anatomic structures of the first MTPJ. The best visualized structure is sesamoid phalangeal ligament and the most frequent injury is complete tear of the medial sesamoid phalangeal ligament.

SSR white paper: guidelines for utilization and performance of direct MR arthrography

OBJECTIVE

Direct magnetic resonance arthrography (dMRA) is often considered the most accurate imaging modality for the evaluation of intra-articular structures, but utilization and performance vary widely without consensus. The purpose of this white paper is to develop consensus recommendations on behalf of the Society of Skeletal Radiology (SSR) based on published literature and expert opinion.

MATERIALS AND METHODS

The Standards and Guidelines Committee of the SSR identified guidelines for utilization and performance of dMRA as an important topic for study and invited all SSR members with expertise and interest to volunteer for the white paper panel. This panel was tasked with determining an outline, reviewing the relevant literature, preparing a written document summarizing the issues and controversies, and providing recommendations.

RESULTS

Twelve SSR members with expertise in dMRA formed the ad hoc white paper authorship committee. The published literature on dMRA was reviewed and summarized, focusing on clinical indications, technical considerations, safety, imaging protocols, complications, controversies, and gaps in knowledge. Recommendations for the utilization and performance of dMRA in the shoulder, elbow, wrist, hip, knee, and ankle/foot regions were developed in group consensus.

CONCLUSION

Although direct MR arthrography has been previously used for a wide variety of clinical indications, the authorship panel recommends more selective application of this minimally invasive procedure. At present, direct MR arthrography remains an important procedure in the armamentarium of the musculoskeletal radiologist and is especially valuable when conventional MRI is indeterminant or results are discrepant with clinical evaluation.

First MTP joint injuries: MR imaging findings in surgically managed patients

OBJECTIVES

Determine whether MR imaging findings or demographics predict surgical management in patients with first MTP joint injuries.

MATERIALS AND METHODS

Retrospective study of 161 forefoot MRs for traumatic first MTP injury (M:F 92:69, mean age 33 ± 13 yrs.). Two radiologists reviewed imaging for ligamentous, osseous, and tendinous injuries. Ligaments and tendons were graded as 0:normal, 1:sprain or strain, 2:partial tear, 3:complete tear. Osseous injuries were classified as edema, fracture, or cartilage injury. Clinical data obtained included sex, age, injury acuity, sport participation, level of sport, and treatment. Imaging findings and demographic data were assessed to determine predictive factors for surgical management. Statistics included kappa, chi-squared, Fisher's exact, and logistic regression.

RESULTS

Logistic regression (odds ratio [95% CI], p-value) showed that grade 2 or 3 injuries of the plantar ligamentous complex (2.87, [1.10, 7.48], p = 0.031), grade 2 or 3 injuries of the medial collateral ligament (3.24, [1.16, 9.08], p = 0.025), and participation in collegiate or professional sports (4.34 [1.64, 11.52], p = 0.003) were associated with an increased rate of surgical intervention. k = ligamentous injury (0.71-0.83), osseous trauma (0.88-0.95), and tendon injury (0.78). All other imaging findings and demographic factors were not significant predictors of surgery (p > 0.05).

CONCLUSION

Participation in collegiate or professional sports and tears of the plantar ligamentous complex or medial collateral ligament predicted surgical management in patients with first MTP trauma.

The Utility of Ultrasound in the Evaluation of Traumatic Hallux Valgus

Isolated disruption of the medial collateral ligament of the great toe is rare and often misdiagnosed as turf toe. It may progress to acquired traumatic hallux valgus, often requiring operative intervention and a longer return to play. This case of a grade II medial collateral ligament injury highlights the importance of a thorough physical examination and consideration of the mechanism of injury. It demonstrates the utility of diagnostic musculoskeletal ultrasound in establishing a specific diagnosis upon initial patient presentation with great toe pain. It is an example of the use of ultrasound in guiding treatment and monitoring interval healing. In this case, differentiation of the injury from the classic "turf toe" led to proper stabilization with a toe spacer and activity modification, thus preventing progression of traumatic hallux valgus and leading to successful nonoperative treatment with full return to sport.

LEVEL OF EVIDENCE

Level V.

High-resolution 3T magnetic resonance imaging and histological analysis of capsuloligamentous complex of the first metatarsophalangeal joint

Background

There are discrepancies in the understanding of the structure of the capsuloligamentous complex of the first metatarsophalangeal joint (MTPJ); this study aims to investigate the differences with previous anatomical reports of high-resolution 3T magnetic resonance imaging (MRI) and histological analysis in illustrating the structure of the capsuloligamentous complex of the first MTPJ.

Methods

Nine fresh frozen cadaveric feet specimens (from two women and three men; aged 32 to 58 years) were used in this study. All specimens underwent MR examination with T1-weighted imaging and T2-weighted spectral attenuated inversion recovery in three planes. Subsequently, all cadaveric feet specimens were sliced into 2-mm-thick sections. The MRI features of the capsuloligamentous complex of the first MTPJ were analyzed in these specimens. Hematoxylin–eosin and Masson’s trichrome staining methods were used to explore the histologic features of the capsuloligamentous complex of the first MTPJ.

Results

Different from most previous studies, our results showed that the plantar plate could be divided into four portions including the central portion of the plantar plate, the intersesamoid, the sesamoid phalangeal and the metatarsosesamoid ligaments. The normal central portion of the plantar plate could be clearly visualized in the sagittal and coronal plane MR images. The intersesamoid ligament is a continuation of the central portion of the plantar plate on the sagittal plane on the gross specimen, the MR imaging, and the histological examination. On the coronal plane of the gross specimen and MR imaging, the sesamoid phalangeal ligaments and the central portion of the plantar plate can be seen as separate ligaments, but they appeared interwoven with the same continuous collagenous fibers on the histological analysis.

Conclusion

High-resolution 3T MRI allows accurate demonstration of the different anatomical details of the capsuloligamentous complex of the first MTPJ from previous anatomical reports. The histological analysis provides further understanding of the structures of the capsuloligamentous complex of the first MTPJ from previous studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02795-7.

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.