Morphometric analysis of the plantar plate apparatus of the first metatarsophalangeal joint

Turf Toe Injuries in the Athlete: an Updated Review of Treatment Options, Rehabilitation Protocols, and Return-to-Play Outcomes

PURPOSE OF REVIEW

First metatarsophalangeal joint sprains or turf toe (TT) injuries occur secondary to forceful hyperextension of the great toe. TT injuries are common among athletes, especially those participating in football, soccer, basketball, dancing, and wrestling. This review summarizes the current treatment modalities, rehabilitation protocols, and return-to-play criteria, as well as performance outcomes of patients who have sustained TT injuries.

RECENT FINDINGS

Less than 2% of TT injuries require surgery, but those that do are typically grade III injuries with damage to the MTP joint, evidence of bony injury, or severe instability. Rehabilitation protocols following non-operative management consist of 3 phases lasting up to 10 weeks, whereas protocols following operative management consist of 4 phases lasting up 20 weeks. Athletes with low-grade injuries typically achieve their prior level of performance. However, among athletes with higher grade injuries, treated both non-operatively and operatively, about 70% are expected to maintain their level of performance. The treatment protocol, return-to-play criteria, and overall performance outcomes for TT injuries depend on the severity and classification of the initial sprain. For grade I injuries, players may return to play once they experience minimal to no pain with normal weightbearing, traditionally after 3-5 days. For grade II injuries, or partial tears, players typically lose 2-4 weeks of play and may need additional support with taping when returning to play. For grade III injuries, or complete disruption of the plantar plate, athletes lose 4-6 weeks or more depending upon treatment strategy.

Arthroscopic Repair of Chronic Plantar Plate Tears of the First Metatarsophalangeal Joint: A New Surgical Technique With Patient Outcomes

Background

Most plantar plate tears of the first metatarsophalangeal joint can be treated successfully by nonoperative means. Primary repair may be indicated to restore continuity of the plantar structures and joint stability. Inadequate or failed nonoperative treatment may cause persistent pain and disability and thereby represent a career-threatening injury to an athlete. The chronic plantar plate tears are difficult both to diagnose and to treat. When surgical treatment is indicated, traditionally a wide plantar or 2 parallel incisions are used. An arthroscopic approach allows for verification and visualization of the injury and, at the same time, repair of the injury.

Purpose

To describe findings of plantar plate tears, present a new arthroscopic procedure for plantar plate tear repair, and present the outcomes after surgery.

Study Design

Case series; Level of evidence, 4.

Methods

This was a retrospective study on the first 10 patients treated with the arthroscopic technique. The patients underwent surgery between June 2017 and January 2021. Patient data, clinical symptoms and findings, and operative details were obtained from the patient records. Patients were contacted via email to complete patient-reported outcome measures (Manchester Oxford Foot Questionnaire [MOxFQ] and Numeric Rating Scale [NRS] for pain).

Results

Four female and 6 male patients with a median age of 24 years (range, 12-44 years) were operated on at a median of 20 months (range, 2-38 months) after injury. Of the 10 patients, 8 had a hyperextension injury of the first metatarsophalangeal joint and 7 had a subtle valgus malalignment of the hallux; 8 patients were injured during sport activity. All patients reported plantar pain at pushoff. All but 1 patient returned to the same level of preinjury activity within 6 months. At a median of 29 months (range, 7-49 months) after surgery, the median MOxFQ score was 6 (range, 0-41) and the median NRS pain score was 0.

Conclusion

Arthroscopic plantar plate repair of chronic plantar plate tears resulted in a high rate of return to activity/sport and excellent outcome scores.

Radiographic and Cadaveric Analysis of Minimally Invasive Bunionectomy Osteotomy Position-"MIS Bunion Sweet Spot"

Minimally invasive surgery (MIS) is a growing technique that favors faster recovery and cosmetic results. We propose a recommended osteotomy position or "MIS Sweet Spot" to make the procedure more reproducible and lessen the learning curve to improve outcomes. A total of 211 patients from 3 surgeons between 2 different study centers were included in a retrospective radiograph measurement analysis and a cadaveric dissection to confirm the safety of nearby anatomical structures. An average distance of 2.2 cm proximal from the first metatarsophalangeal joint was found as the "Sweet Spot" to perform the transverse osteotomy. At this distance, neurovascular and tendinous structures were unharmed and the osteotomy remained extracapsular. Furthermore, an average of 10.7° of intermetatarsal angle reduction and a reduction of tibial sesamoid position of 3 points were achieved. A predictable and measurable distance for osteotomy placement will help to provide more confidence in producing the bunionectomy osteotomy with the specialized tools used in MIS and can help to reduce operative time and improve results.Level of Clinical Evidence (LOCE): 3.

In-Season Management of Acute and Subacute Sports Foot Injuries

In athletes, foot injuries present with a variety of mechanisms, severity, and implications for return to play. Although potentially given less attention than knee and shoulder injuries by the team physician, foot injuries are common and thus require knowledgeable consideration. In this article, we review the anatomy, presentation, workup, and management of several of the most common athletic foot injuries, including turf toe, Lisfranc injuries, Jones fractures, and navicular stress fractures. The goal is to provide the team physician with the information necessary to evaluate and manage these injuries on the sideline and in the training room.

Classification of Hallucal Sesamoid Bone Correlated with Hallux Valgus Severity

The hallucal sesamoid bones (HSBs), having an important role in reducing load per unit area on the first metatarsal head, can be injured commonly which also affected the first metatarsophalangeal joint and the surrounding structure. Meanwhile, differences among each HSB type may be a major factor affecting the occurrence and development of HV. So far, many researchers had learned that there are three different conditions in hallucal sesamoid bone affecting the choice of clinical surgery corresponding to different solutions in clinic. Thus, it is necessary to study the anatomical morphological characteristics of the HSB which can be helpful in clinical diagnosis and treatment, especially hallux valgus (HV). 150 X-ray and three-dimensional (3D) computed tomographic (CT) images consist of 72 left and 78 right metatarsals were applied in this anatomic study between two variables and showed by a simple scatter plot. The first metatarsophalangeal joint is divided into four different types: type I (no HSB, 1.3%), type II (with one HSB, 0.07%), type IIIa (with two HSBs when THB is bigger, 28%), type IIIb (with two HSBs when FHB is bigger, 65.3%), and type IV (with three HSBs, 4.7%). There was no statistical difference between the left and right sides, except HVA, Meary, and pitch (P < 0.05); all a, b, c, d, and i have statistical difference between male and female (P < 0.05). Meanwhile, HVA and IMA and HVA and type group have a significant correlation. In summary, HVA and IMA and HVA and classification of HSBs have significant correlations. The classification and location of HSBs can be an important basis to choose operation methods and postoperation evaluation.

Outcomes of Chronic Turf Toe Repair in Non-athlete Population: A Retrospective Study

BACKGROUND

Turf toe injuries, though most common in athletes, can also occur in non-athletes. No study exists in the current literature investigating operative outcomes in non-athlete patients with chronic turf toe injury. In this study, we present our outcomes on operatively treated turf toe injuries in non-athletes in the only cohort yet studied.

METHODS

Using ICD-10 codes, we assembled a cohort of 12 patients who underwent operative repair of chronic turf toe injury from January 2012 through January 2018 at the investigating institution. These 12 patients were evaluated to determine demographic information, method of injury, length of time from injury to surgery, clinical and radiologic characteristics of the injury, and operative outcomes including mean preoperative and postoperative VAS (Visual Analog Scale) scores, preoperative and postoperative FFI (Foot Function Index) scores, and postoperative complications.

RESULTS

On initial clinical presentation, all 12 patients had local tenderness with associated painful range of motion. Four patients had restricted range of motion, all patients had a positive Lachman test, two had local edema, and eight had hallux valgus deformity. Mean VAS improved from 4.6 (range 2-9) to 1 (range 0-4). Mean FFI improved from 102.5 (range 56-177) to 61.75 (range 23-144). All patients had a negative Lachman test at final follow-up. No patients developed major complications or required revision surgery.

CONCLUSIONS

Our study is the first to investigate operative outcomes following chronic turf toe injury in non-athlete patients. Based on our study, surgeons and patients can expect significant improvement in overall pain and function following surgery.

Establishing a common instantaneous center of rotation for the metatarso-phalangeal and metatarso-sesamoid joints: a theoretical geometric model based on specific morphometrics

BACKGROUND

Previous research has identified separate sagittal plane instantaneous centers of rotation for the metatarso-phalangeal and metatarso-sesamoid joints, but surprisingly, it does not appear that any have integrated the distinctive morphological characteristics of all three joints and their respective axes into a model that collectively unifies their functional motions. Since all joint motion is defined by its centers of rotation, establishing this in a complicated multi-dimensional structure such as the metatarso-phalangeal-sesamoid joint complex is fundamental to understanding its functionality and subsequent structural failures such as hallux abducto valgus and hallux rigidus.

METHODS

Based on a hypothesis that it is possible to develop an instantaneous center of rotation common to all four osseous structures, specific morphometrics were selected from a sequential series of 0.5-mm sagittal plane C-T sections in one representative cadaver specimen randomly selected from a cohort of nine, seven which were obtained from the Body Donation Program, Department of Anatomy, University of California, San Diego School of Medicine, and two which were in the possession of one author (MD). All mature skeletal specimens appeared grossly normal, shared similar morphological features, and displayed no evidence of prior trauma, deformity, or surgery. Specific C-T sections isolated the sagittal plane characteristics of the inter-sesamoidal ridge and each sesamoid groove, and criteria for establishing theoretical sesamoid contact points were established. From these data, a geometric model was developed which, to be accurate, had to closely mimic all physical and spatial characteristics specific to each bone, account for individual variations and pathological states, and be consistent with previously established metatarso-phalangeal joint functional motion.

RESULTS

Sequential sagittal plane C-T sections dissected the metatarsal head from medial to lateral and, at approximately midway through the metatarsal head, the circular nature of the inter-sesamoidal ridge (crista) was isolated; other C-T sections defined, respectively, the elliptical characteristics of the tibial (medial) and fibular (lateral) sesamoid grooves in each specimen. A general plane model representing the most basic form of the joint was developed, and its center of rotation was established with a series of tangential and normal lines. Simplified tibial sesamoid and fibular plane models were developed next which, when combined, permitted the development of a spherical model with three separate contact points. Based on the morphometrics of each sesamoid groove and a more distally positioned tibial sesamoid, the model was modified to accurately define the center of rotation and one distinctive sagittal plane geometric and functional characteristic of each groove.

CONCLUSION

Consistent with our hypothesis, this theoretical geometric model illustrates how it is possible to define an instantaneous center of rotation common to all three joints while simultaneously accounting for morphometric and spatial variability. This should provide additional insight into metatarso-phalangeal-sesamoid joint complex functionality and the physical characteristics that contribute to its failure.

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.

Epidemiology and imaging appearance of the normal Bi-/multipartite hallux sesamoid bone

BACKGROUND

Turf toe is a hyperextension injury of the hallux metatarsophalangeal joint that can be difficult to diagnose on physical examination and imaging. Diastasis of the bi- or multipartite sesamoid of the hallux has been implicated as 1 potential radiographic finding of turf toe injury, and when present may require operative management. However, the normal interval for the bi-/multipartite sesamoid has not yet been established.

METHODS

A total of 671 foot radiograph series were reviewed in effort to quantify the dominant interval of the bi-/multipartite sesamoid bone with respect to potential influencing factors including right versus left foot, medial and/or lateral sesamoid involvement, patient age and gender, and weight versus non-weight-bearing radiograph technique.

RESULTS

The prevalence of a bi-/multipartite hallux sesamoid was 14.3% in our population. The dominant sesamoid interval ranged from 0-2 mm, with an average of 0.79 mm.

CONCLUSION

We conclude that sesamoid diastasis should be considered, in the appropriate clinical setting, when the sesamoid interval is greater than 2 mm on a routine AP radiograph of the foot.

LEVEL OF EVIDENCE

Level III, comparative study.

The sesamoids of the feet in humans: a systematic review and meta-analysis

The prevalence and distribution of the sesamoid bones in the feet has been reported in the literature with a high degree of variability. This systematic review aims to provide a better estimate of the frequency of the sesamoids of the foot and their association with variables such as ancestry, gender, and side. Thirty-seven studies met the inclusion criteria and were submitted for meta-analyses, sensitivity analyses and proportion difference tests, whenever possible. At the metatarsophalangeal (MTP) joint of the hallux, sesamoids were nearly always present. At the interphalangeal (IP) joint, the pooled true estimates of large-sampled studies were: (1) an overall prevalence of 22.4 %, (2) a cadaveric rate at 71.6 %, and (3) a radiological rate (based on X-ray images) of 21.1 %. The pooled partition frequencies of the hallucal medial and lateral sesamoids were 10.7 and 1.3 %, respectively. Bipartism was the most frequent partition type (92 %), followed by tripartism (7.5 %) and quadripartism (0.5 %). Middle Eastern ancestry was associated with significantly lower hallucal partition rate (P < 0.0001) and African ancestry with significantly lower prevalence of the IP sesamoid than all other ethnicities (P < 0.001). Feet with a hallux valgus deformity seemed to be associated with significantly higher rate of partition of the medial sesamoid (odds ratio = 3) than that of the normal feet. The respective values of the pooled true prevalence in adults at the MTP joint for the 2nd, 3rd, 4th and 5th toes were 1.9, 0.32, 0.9 and 13 %, respectively. There was a significantly higher prevalence of tibial sesamoids vs lateral sesamoids, with pooled odds ratio of 34.7, 8, 4.8, and 2.27, respectively. Partition was found in around 10 % of the sesamoids of the 5th MTP joint; no partition was noted in the other toes. For most 2nd-5th MTP joints, European ancestry showed the highest frequency whereas African ancestry showed the lowest; Middle Eastern ancestry was in between. No sesamoids were found at the 4th proximal IP joint and at the 4th and 5th distal IP joints. No sesamoids were found at any IP joint in the feet of Middle Eastern and African populations. The pooled rates of the IP sesamoids of the second and third toes in European populations were 1.2 % for the 2nd proximal, 0.33 % for the second distal and 0.6 % for both IP joints of the third toe. This anatomical meta-analysis yielded results that are likely to be more accurate regarding the rates of the sesamoids in the foot, their laterality and partition. It also provided solid evidence for the genetic basis of the frequency distribution among the different populations.

The plantar plate of the first metatarsophalangeal joint: an anatomical study

The plantar plate of the first metatarsophalangeal (MP) joint is a critical structure of the forefoot that has been identified as a major stabilizer within the capsuloligamentous complex. Many studies have clarified and documented the anatomy of the lesser toe MP plantar plates, but few have looked closely at the anatomy of the first MP joint. Ten cadaveric specimens were examined to identify and document the objective anatomic relationship of the plantar plate, tibial sesamoid, and surrounding osseus structures. The average distance of the plantar plate distal insertion from the joint line into the proximal phalanx was 0.33 mm. The plantar plate was inserted into the metatarsal head on average 17.29 mm proximal from the joint line. The proximal aspect of the sesamoid was 18.55 mm proximal to the distal attachment of the plantar plate to the phalanx. The distal aspect of the sesamoid averaged 4.69 mm away from the distal attachment into the proximal phalanx. The footprint of the distal plate insertion was on average 6.33 mm in length in the sagittal plane. The authors hope that these objective data measures can aid in the understanding and subsequent surgical repair of this important forefoot structure.

Hallucal sesamoiditis manifested on bone scan

The first metatarsal articulation bears one third of the weight of the forefoot. The hallucal sesamoids are embedded in the flexor hallucis brevis and connected by the intersesamoid ligament and plantar plate. The sesamoid apparatus acts as a pulley to help pull the big toe down against the ground during walking. Repetitive pressure, force, or tension can cause sesamoiditis. If the impact is great enough, the bones can break. Here we present a woman with big toe pain during walking. Our case highlights the role of 99mTc-MDP bone scan in reaching the diagnosis of hallucal sesamoiditis.

Radiographic evaluation of plantar plate injury: an in vitro biomechanical study

BACKGROUND

The term turf toe has been generally applied to athletic dorsiflexion injuries of the hallux metatarsophalangeal (MTP) joint. Variations in injury patterns coupled with the complexity of the MTP joint makes the diagnosis of more severe injuries challenging and may lead to a failure in recognition of an unstable joint and a subsequently prolonged recovery. Although the proximal migration of one or both sesamoids has been previously identified with a plantar plate disruption, the current study proposes a quantitative grading system based on dorsiflexion stress radiographs, providing a predictable and reproducible test for evaluating the extent of injury to the first MTP joint.

METHODS

Twenty-four nonpaired fresh-frozen foot/ankle specimens with no history or physical evidence of prior injury were used in this study. The specimens were randomly assigned into 4 cutting groups, and the 4 main distal ligaments of the plantar plate were identified and sectioned. Lateral dorsiflexion fluoroscopic stress images were obtained in the intact state and with each subsequent cut. With each image, measurements from the distal margin of the sesamoids to the most proximal margin of the proximal phalanx were taken. Images were obtained at 45 degrees with both a fibrous loop wrapped around the interphalangeal joint and applying 15 N and also with a manual dorsiflexion stress. Statistical testing performed was a repeated-measures analysis of variance with Tukey post hoc to compare measurements between each group to determine if movement of the sesamoid bones relative to the phalanx quantitatively increased with each structure that was cut.

RESULTS

Our results demonstrate a relationship between the number of ligaments injured in the turf toe simulation and an increase in sesamoid phalangeal distance. We found that an increase of 3 mm in the distance from the sesamoids to the proximal phalanx was significant and predictive of a severe injury to the plantar plate.

CONCLUSION

Injuries producing differences of 3 mm or greater from the intact state have a high likelihood of having sustained injury to at least 3 of the 4 ligaments of the plantar plate complex. This study is the first to establish a quantitative grading scale for evaluating turf toe injuries radiographically based on changes in movement of the sesamoids relative to the intact state.

CLINICAL RELEVANCE

In assessing a turf toe injury, historically the evaluation has been qualitative, but our study provides quantifiable data for evaluation of the severity of plantar plate injuries, which may provide guidance to physicians for treatment decisions.

Turf toe: anatomy, diagnosis, and treatment

Context:

Despite an increasing awareness of turf toe injury, confusion still exists regarding the anatomy, mechanism, diagnosis, and treatment of this hyperextension injury to the hallux metatarsophalangeal (MTP) joint.

Evidence Acquisition:

This article reviews the anatomy, diagnosis, and treatment algorithm for turf toe injury by reviewing relevant studies and presenting information useful to clinicians, therapists, and athletic trainers. A literature search was performed by a review of PubMed and OVID articles published from 1976 to July 2010.

Results:

Grade I injury is a sprain or attenuation of the plantar capsular ligamentous complex of the hallux MTP joint; athletes are typically able to return to play as tolerated. Grade II injury is a partial rupture of the plantar soft tissue structures of the hallux MTP joint, typically requiring about 2 weeks to recover. Grade III injury is a complete rupture of the plantar structures of the hallux MTP joint, requiring at least 10 to 16 weeks to recover. Some complete ruptures require surgical repair.

Conclusion:

With accurate diagnosis, athletes can have an appropriate treatment plan, and their expectations can be tempered to the degree of injury. Careful management may allow successful return to play at a preinjury level of participation.

Sesamoid disorders of the first metatarsophalangeal joint

The sesamoid complex is located centrally and plantar to the first metatarsal head, where they are imbedded within the plantar plate, which transmits 50% of body weight and more than 300% during push-off, is susceptible to numerous pathologies. These pathologies include sesamoiditis, stress fracture, avascular necrosis, osteochondral fractures, and chondromalacia, and are secondary to these large weight-bearing loads. This article discusses sesamoid conditions and their relationship with hallux limitus, and reviews the conditions that predispose the first metatarsophalangeal joint to osteoarthritic changes.

Hallux, sesamoid, and first metatarsal injuries

Hallux, sesamoid, and first metatarsal injuries are common foot injuries and have implications in the biomechanical functionality of the first ray and foot. They are essential for propulsion in normal gait. As part of the first ray, it is an important contributor to normal locomotion. Any structure disruption or injury can create angular changes or arthritis, which can have biomechanical implications, including pain, disability, compensation, swelling, and reduced range of motion.

Rehabilitation following turf toe injury and plantar plate repair

The evaluation and diagnosis of turf toe injuries is improving as it becomes a more recognized pattern of injury to the hallux metatarsophalangeal joint. With an understanding of the anatomy of the injury and the ability to focus on important diagnostic and radiographic clues, turf toe can be diagnosed, assessed, and treated accurately, with surgical repair when indicated. Regardless of the grade of injury, rehabilitation of the athlete under the guidance of a physical therapist or athletic trainer is critical to complete recovery. With appropriate care, athletes can successfully return to play and efficiently reach their preinjury level of participation.

The great toe: failed turf toe, chronic turf toe, and complicated sesamoid injuries

Turf toe injuries and sesamoid injuries are challenging because of the variety of causes that exist as sources of pain. Through a systematic approach to evaluation, injuries to the hallux metatarsophalangeal joint can be diagnosed properly. Correct diagnosis leads to accurate and efficient treatment. If conservative measures fail, operative interventions are available to relieve pain and restore function. With careful surgical technique and appropriate postoperative management, athletes can return to play and efficiently reach their pre-injury level of participation.

Cross-sectional study to evaluate radiological parameters in hallux rigidus

BACKGROUND

Hallux rigidus (HR) is a common condition with X-rays used to evaluate its pathology, grade joint changes and to inform treatment.

METHOD

A cross-sectional study was undertaken to evaluate radiological foot parameters in HR. In 110 subjects (180 feet) aged 18-70 years (mean 52 years) standard weight-bearing X-rays were examined using dorsal plantar and lateral views.

RESULTS

Seventy (64%) subjects had bilateral HR and 73 (66%) were female. The mean onset of HR (denoted by first metatarsophalangeal (MTP) joint restriction/pain) was 44 (14-68 years) years and median HR duration was 6 years (1-33 years). Flat or chevron-shaped metatarsal heads presented in 131 (73%) feet and a history of first MTP joint trauma in 22% (74% of whom had unilateral HR). In 74% of feet hallux abductus interphalangeus angle (HAI degrees) was greater than normal (< or =10 degrees). Correlations between first MTP joint narrowing and sclerosis (r=0.76, p=0.01) and increased HAI degrees and first MTP joint narrowing (r=0.34, p=0.01) was found. The mean hallux equinus angle of 11 degrees was outside the normal range (16-18 degrees). Abnormal sesamoid morphology presented in 117 (65%) feet (30% irregular or hypertrophic). Proximal sesamoid displacement was greater than that seen in non-HR. Metatarsus primus elevatus was within normal range (< or =8 mm) in 160 (89%) feet. The first metatarsal was longer than the second metatarsal in 66 (37%) feet although the first metatarsal was longer than the third metatarsal in 131 (73%) feet and may be responsible for altered forefoot function in HR.

CONCLUSIONS

HR was associated with female gender, bilateral involvement, older age groups, flat or chevron-shaped metatarsal head, longer proximal phalanx, increased HAI degrees and a first metatarsal longer than the third metatarsal. For radiological parameters to be considered valid for inclusion in a classification of HR their content validity needs to be established by formal research.

A critical analysis of Dudley Morton's concept of disordered foot function

The name Morton is associated with a foot structure characterized by a short first metatarsal in comparison with the adjacent second metatarsal. Dudley Morton is credited with recognizing a short first metatarsal as being a primary defect of the foot. Morton, an anatomist, approached his observation from an evolutionary perspective. His theory of disordered foot function was based on the premise that human alignment centered on an "axis of leverage" and around an "axis of balance." Morton concluded that the presence of a short first metatarsal was compounded when the first metatarsal segment was hypermobile. Shortness and hypermobility diminished the capacity of the first metatarsal segment to carry weight, allowed pronation during activity, and led to an overload of the central metatarsals. The term Morton Foot sprang from his teachings. The extensive writings of Morton are commonly cited even today. This study compares Morton's teachings with research published during the last 70 years, which either supports or refutes his claims.

First ray injuries

The first ray differs from the other rays in its position and its importance with weight bearing. Because it is a critical structure in the formation of the tripod of the foot, injuries to this ray can cause critical alterations in the biomechanics of the foot. This allows for pathologic weight-bearing points of contact and deformity that lead to a disabling gait. Physicians who are involved in the care of the foot and ankle should be familiar with the spectrum of injuries that concern the first ray. These injuries, their management, and sequelae are reviewed.

The relationship of the position of the metatarsal heads and peak plantar pressure

We test the premise that peak plantar pressure is located directly under the bony prominences in the forefoot region. The right foot of standing volunteers was examined in three different postures by a CT-scanner. The plantar pressure distribution was simultaneously recorded. The position of the metatarsal heads and the sesamoids could be related to the corresponding local peak plantar pressures. The metatarsal heads 1, 4, and 5 had a significantly different position than the local peak plantar pressures. The average difference in distance between the position of the metatarsal heads and the peak plantar pressure showed a significant correlation: on the medial side the head was located more distally to the local peak plantar pressure, on the lateral side more proximally. The findings suggest that normal plantar soft tissue is able to deflect a load. The observations might improve insight into the function of the normal forefoot and might direct further research on the pathological forefoot and on the design of footwear.

A prospective comparison of clinical, radiographic, and intraoperative features of hallux rigidus

Forty-four patients (47 feet) underwent surgical intervention for symptomatic hallux rigidus between February 1998 and April 1999. Each foot was initially graded according to a four-stage hybrid hallux rigidus radiographic grading system. A subjective evaluation based on a modified American Orthopaedic Foot and Ankle Surgery clinical rating system was performed. An objective physical examination was performed. Angular and linear measurements were obtained from standard weightbearing radiographs. The extent of articular derangement for the first metatarsal head, base of the proximal phalanx, and tibial and fibular sesamoids were graded according to the American Orthopaedic Foot and Ankle Society intraoperative grading system. Finally, a means of quantifying the percentage of first metatarsal head articular derangement was performed. Significant differences were identified between joints radiographically classified as grade II, which had lower nonweightbearing, relaxed hanging position (p = .041); nonweightbearing assisted dorsiflexion (p = .000); actual nonweightbearing dorsal range of motion (p = .002); and actual plantar range of motion (p = .009) than those classified as grade I. The angle of deviation of the second metatarsophalangeal joint revealed a significant increase in degree of medial angulation as the grade increased (p = .000). None of the remaining radiographic measurements were significant. A correlation between the hybrid radiographic grading system and percentage of actual intraoperative articular derangement was shown to exist.

Hallucal sesamoid pain: causes and surgical treatment

The hallucal sesamoids, although small and seemingly insignificant, play an important role in the function of the great toe by absorbing weight-bearing pressure, reducing friction, and protecting tendons. However, the functional complexity and anatomic location of these small bones make them vulnerable to injury from shear and loading forces. Injury to the hallucal sesamoids can cause incapacitating pain, which can be devastating to an athlete. Although traumatic injuries usually can be diagnosed easily, other pathologic conditions may be overlooked. Careful physical and radiologic examinations are necessary to determine the cause of pain and allow a recommendation of the optimal treatment. Surgical treatment may include partial or complete resection of the sesamoid, shaving of a prominent tibial sesamoid, or autogenous bone grafting for nonunion. Excision of both sesamoids should be avoided if possible.