Foot Toe Injuries

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Imaging Sports Medicine Injuriesof the Foot and Toes

Hilary R. Umans, MDAlbert Einstein College of Medicine, Division of Musculoskeletal Radiology, Jacobi MedicalCenter, Bronx, New York 10461, USA

The Lisfranc joint, aka the tarsal-metatarsal (TMT) joint, marks the transi-

tion between the more rigid midfoot and the relatively flexible forefoot. Itprovides critical stability in maintenance of both the transverse and longi-

tudinal arch of the foot. That stability is derived from both its osseous geom-etry and complex capsuloligamentous architecture.

The second metatarsophalangeal (MTP) joint is recessed with respect to theneighboring first and third MTP joints. Multiple facets at the second metatarsalbase articulate with all three cuneiforms. The second metatarsal base is shapedlike a keystone at the apex of the transverse arch of the foot. Intermetatarsalligaments connect the second through fifth metatarsal bases, but there is no in-

termetatarsal ligament bridging the first and second. Instead, the Lisfranc liga-ment, the most substantial and strongest at the TMT joint, courses obliquelyfrom the lateral surface of the medial cuneiform in a plantar and lateral direc-tion to insert on the plantar medial base of the second metatarsal [1] (Fig. 1).Disruption or avulsion of the Lisfranc ligament, or fracture of the second meta-tarsal base, results in TMT instability. Left untreated, a Lisfranc injury can re-sult in collapse of the longitudinal arch of the foot.

Although the majority of Lisfranc fracture/dislocations result from high-velocity trauma or crushing injuries, sports-related Lisfranc injuries typically

occur as a result of low-velocity indirect force. In athletes, the typical mecha-nism of injury is an axial load on a plantar flexed and slightly rotated foot[2]. These injuries are particularly common in but not unique to AmericanFootball, with offensive linemen most commonly affected [3]. Sports-relatedLisfranc injuries are considered in a spectrum of midfoot sprains. Midfootsprains may or may not include diastasis or fracture at the first intermetatarsalspace or second metatarsal base, respectively, and therefore may elude conven-tional radiographic detection.

Nunley and Vertullo [4] proposed a classification for midfoot sprains that dif-

fers from the standard classification systems used for high-velocity traumaticLisfranc injury. Stage I injury is characterized by a dorsal capsular tear without

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elongation of the Lisfranc ligament; weight-bearing radiographs are normal.Stage II injury includes elongation or disruption of the Lisfranc ligament,

with an intact plantar capsular ligament; weight-bearing radiographs demon-strate 2- to 5-mm diastasis at the first intermetatarsal space. Stage III injury in-cludes disruption of the dorsal capsule as well as the Lisfranc ligament and theplantar capsuloligamentous structures; weight-bearing radiographs demon-strate greater than 5 mm diastasis at the first intermetatarsal space, loss ofthe longitudinal arch height, and, often, associated fracture.

Even in the context of high-velocity traumatic Lisfranc injury, approximately20% of cases are prospectively missed on conventional foot radiographs [5]. Al-though alignment may be assessed by evaluating cortical registration across

each TMT joint, congruent alignment is most reliably evaluated at the medialcortex of the middle cuneiform and second metatarsal base on anteroposterior(AP) and oblique radiographs. Given a high index of suspicion based on mech-anism of injury, midfoot tenderness/swelling, or TMT instability on examina-tion, further imaging is indicated. Although some authors advocate stress viewsunder fluoroscopy, weight-bearing radiographs more effectively stress theTMT joint and permit detection of subtle diastasis at the first intermetatarsalspace [4,6] (Fig. 2). If pain precludes weight bearing, ankle block may facilitatethe examination.

Overlapping structures about the TMT joint often obscure midfoot fractureon conventional radiographs. Computed tomography (CT) permits improvedfracture detection and, although it is a nonweight-bearing examination, mayfacilitate detection of subtle osseous malalignment [7]. An advantage of MRIover CT is that it can detect trabecular microfracture and bone bruise, and per-mits direct visualization of the Lisfranc ligament and the capsuloligamentous

Fig. 1. Axial T1 weighted MR image demonstrates the normal, intact Lisfranc ligament cours-ing between the lateral aspect of the medial cuneiform to its insertion onto the medial secondmetatarsal base (curved arrow).

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structures about the TMT joint [8,9]. It is important to realize that the Lisfrancligament may appear intact on magnetic resonance imaging (MRI) in the con-text of mechanically significant injury (Fig. 3). Soft tissue edema on T2-weighted imaging in and around the ligament should be considered suspiciousfor injury, as should associated bone bruise or fracture at the ligamentous or-igin and insertion at the medial cuneiform and second metatarsal base (Fig. 4).

Fig. 2. AP weight-bearing radiographs of both feet. There is pathologic widening of the firstintermetatarsal space with lateral subluxation of the second metatarsal with respect to the mid-dle cuneiform (curved arrow); this is a grade II Lisfranc injury as described by Nunley and Ver-tullo [4]. Note the normal alignment in the comparison view of the right foot.

Fig. 3. Axial STIR image through the mid and forefoot demonstrates an apparently intact Lis-franc ligament with surrounding soft tissue edema indicative of midfoot sprain.

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FATIGUE FRACTURES OF THE MID AND FOREFOOTStress fractures are characterized by bone pain and tenderness without a historyof direct trauma. The fatigue type of stress fracture results from repetitive cy-clical loading and prolonged muscular force on bone that has normal elastic re-sistance. Conventional radiographs are often unremarkable at the onset ofsymptoms.

Fatigue fractures usually result from alteration of the duration, intensity, ormanner in which a physical activity is performed. Stress fractures of the footare relatively site specific based on the type of athletic activity. Recreationaland competitive runners, basketball and football players, ice skaters, ballet

dancers, and military recruits are particularly at risk.The most common midfoot stress fracture in athletes occurs in the tarsal na-

vicular [10,11]. It is typically oriented in the midsagittal plane of the navicular(Fig. 5). The fracture may be partial, isolated to the dorsal cortex, or complete.Complete fractures may be complicated by delayed or nonunion or osteonec-rosis of the lateral segment. Conventional radiographs are relatively insensitivefor detection of navicular fracture. Historically, nuclear bone scintigraphy hasbeen employed to detect clinically suspected, radiographically occult stress frac-tures. This has largely been supplanted by CT and MRI (Fig. 6). CT permits

visualization of cortical defects, gapping at the fracture site and callus formation[12]. CT may reveal cortication or sclerosis at the fracture margins suggestingdelayed or nonunion, whereas fragmentation, sclerosis, and cyst formation ofthe lateral fragment might suggest osteonecrosis (Fig. 7). MRI depicts the frac-ture as linear marrow signal abnormality, with surrounding marrow edema ap-pearing as a penumbra of reticulated, ill-defined low T1 or bright T2 signal,

Fig. 4. Axial T1-weighted (A) and STIR (B) images of the mid and forefoot demonstrate anoblique intra-articular Lisfranc fracture (curved arrows) at the medial base of the second meta-tarsal. The STIR image demonstrates vague residual marrow edema.

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diminishing over time unless there is chronic instability and motion at the frac-ture site.

Stress fracture of the lesser metatarsals most commonly occurs at the midto distal shaft, typically affecting the second and third rays. Many factors can

contribute to insufficiency of the first ray, shifting the stresses of weight bearingand ambulation from the first to the second and third rays. These include hal-lux valgus, metatarsus primus varus, previous corrective surgery of the first

Fig. 5. Close up radiograph demonstrates a vague linear lucency oriented in the sagittalplane in the central one third of the navicular, diagnostic of a stress fracture (curved arrow).

Fig. 6. Axial CT image (A) and axial T1-weighted (B) and STIR (C) MR images through themidfoot demonstrate a navicular stress fracture. CT reveals surrounding sclerosis. STIR MRI re-veals residual marrow edema.



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ray, congenital shortening of the first ray, or a low-lying arch, all of which maypredispose to stress fracture of the lesser metatarsals [13].

There are three different types of stress fracture of the proximal to midshaftfifth metatarsal. Fracture of the tip of the styloid process results from an inver-

sion injury and results from avulsion either by the lateral cord of the plantaraponeurosis or by the peroneus brevis [14] (Fig. 8). A Jones fracture occurs ap-proximately 1.5 to 2.0 cm distal to the tip of the tuberosity as a result dorsiflex-ion with the forefoot in supination [14,15] (Fig. 9); the distinction is important because of the tendency toward delayed healing or nonunion for these frac-tures at the junction of the metaphysis and proximal diaphysis. Midshaft frac-tures are related to chronic repetitive stress, and have been attributed infootball players to fatigue resulting from insufficient diaphyseal support as a re-sult of widely placed cleats [13].

Metatarsal stress fractures may be subtle or occult on conventional radio-graphs. Detection requires a discernible cortical defect, usually at the medial as-pect of the mid to distal diaphysis. Cortical stress reaction or callus mayobscure the lucent fracture line. MRI allows early visualization of stress-relatedmarrow edema, which may be accompanied by parosteal soft tissue edema(Fig. 10). This marrow edema is nonspecific, but in the proper clinical context,

Fig. 7. CT images in the axial (A), coronal (B), and sagittal (C) planes demonstrate a chronic,ununited navicular stress fracture complicated by osteonecrosis and fragmentation.

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may permit proper diagnosis and clinical intervention before progression tofracture [16]. On MRI a fracture appears as linear or band-like low signal onT1- or T2-weighted images contiguous with the cortex, with marrow edemamost conspicuously demonstrated on fat-suppressed or STIR sequences(Fig. 11).

Freibergs infraction is characterized by subchondral collapse of the secondor third metatarsal head with osteonecrosis and cartilaginous fissuring [17](Fig. 12). It may result from acute or repetitive injury with vascular compro-

mise to the subchondral bone. Radiographically, occult lesions may be visibleby MRI as subchondral dark T1 and bright T2 signal. Over time, flatteningand sclerosis of the metatarsal head will become radiographically evident, atwhich point MRI will demonstrate dark signal on both T1 and T2 weighting.

Stress fractures of the phalanges are decidedly rare [18,19]. Case reports ofstress fractures of the proximal phalanx of the great toe reveal a tendency to-ward the medial base, most commonly in the context of hallux valgus and a bi-partite tibial hallucal sesamoid. Stress fracture of the proximal phalanx of thesecond toe is exceedingly rare, presenting with pain in the region of the meta-

tarsal head. Most cases of phalangeal stress fractures occurred in young eliteathletes engaged in basketball, volleyball, running, or ballet.

SESAMOIDITISSesamoiditis is a clinical term used generically to refer to painful conditions inand around the region of the hallucal sesamoids. Some expand the term to refer

Fig. 8. Oblique radiograph of the foot demonstrates a subtle avulsion fracture of the styloidprocess at the base of the fifth metatarsal (arrow).



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to all painful conditions at the first MTP joint. Yet other authors have morespecifically reserved the term to indicate chondromalacia of the sesamoids. De-pending on its definition, this may account for up to 4% of overuse injuries ofthe foot [20] (Fig. 13).

There is a general consensus that the condition results from overload at theplantar aspect of the first MTP joint. This may be related to acute injury orchronic repetitive trauma. Predisposing risk factors include wearing high-

heeled shoes, dancing, sports, and a cavus foot deformity with a rigidly plantarflexed first ray [21].

Patients may present with symptoms of sesamoiditis in the context of inflam-matory arthritis, osteoarthritis, osteochondritis, or chondromalacia at the meta-tarso-sesamoid articulation. Alternatively, there may be stress fracture orosteonecrosis of the sesamoid [22] (Fig. 14).

Imaging must include standard weight-bearing AP and lateral radiographs toassess congenital forefoot deformities and possibly identify arthritic changes. Asesamoid view is essentially an oblique coronally oriented radiograph, obtained

tangential to the metatarso-sesamoid joint, which permits direct visualization ofthe joint space and articular surfaces, and eliminates osseous superimposition.Over time, radiographs may reveal fragmentation and sclerosis of the sesa-moids. Nuclear bone scintigraphy is sensitive for demonstration of pathologicradiotracer uptake in the sesamoid region but does not effectively narrow thedifferential diagnosis. As compared with conventional radiography, CT affords

Fig. 9. Close-up radiograph demonstrates a transverse fracture through the tuberosity of thefifth metatarsal; this is a Jones fracture.

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more sensitive and specific detection of fracture, and may permit visualizationof periostitis, callus formation, articular irregularity, and pseudocyst formation,as well as subarticular or articular collapse of osteonecrosis. MRI may be re-served for cases in which CT is unrevealing, as in stress-related marrow edema,occult fracture, early osteonecrosis, or chondromalacia [23]. In addition to elu-

cidating radiographically occult osseous changes, MRI delineates reactive softtissue changes, including synovitis, tendonitis, and bursitis.

TURF TOEThe introduction of artifical sports surfaces in the late 1960s heralded a markedincrease in injuries to the capsuloligamentous structures of the first MTP joint,presumably because of the higher friction coefficient of Astroturf as comparedwith grass. It is for this reason that the term turf toe was coined to describethis sports-related injury [24].

Turf toe is broadly defined by the Orthopedic Foot and Ankle Society asa plantar capsular ligament sprain of the first MTP joint. The mechanismof injury in the majority of cases is forced hyperextension. The injury occurswhen the forefoot becomes fixed as a result of high friction and is positionedplantigrade with slight dorsiflexion and elevation of the heel off of the ground.Subsequently, an external force (another player) forces the first MTP joint into

Fig. 10. Sagittal STIR (A) and coronal T1-weighted (B) MR images demonstrate stress-relatedmarrow edema in the midshaft of the fourth metatarsal without a discernible fracture line.



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dorsiflexion. Turf toe may be complicated by associated dorsal dislocation ofthe great toe [27].

Conventional radiographs may be used in the differential diagnosis of possi-ble fracture or dislocation about the first MTP joint. Alternatively, sesamoiditis,tendonitis, and bursitis may be considered; however, sesamoiditis may be

Fig. 12. Axial STIR (A) and sagittal T1-weighted and STIR (B,C) MR images demonstrate cres-centic low-signal marrow changes (arrows) in the subarticular second metatarsal head with flat-tening of the subchondral cortex and associated marrow and soft tissue edema.

Fig. 13. Coronal T1-weighted (A) and STIR (B) images through the forefoot at the level of thefirst metatarsal head demonstrate sesamoiditis, manifest as uniform loss of fatty marrow signallocalized to the tibial hallucal sesamoid (arrowhead). There is no contour defect or linear mar-row signal alteration to suggest fracture or osteonecrosis.



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differentiated clinically from turf toe by its more indolent onset and associationwith repetitive trauma rather than acute, traumatic hyperextension of the firstMTP joint. The gold standard for diagnosis of turf toe is MRI, which permitsdirect visualization of a tear through the plantar capsule [28]. MRI also allowsdirect visualization of concomitant soft tissue injury including synovitis, plantarsoft tissue swelling, and tendonitis of the flexor hallucis longus and adductorhallucis, as well as possible associated osseous or cartilaginous injury to the ses-

amoids or first metatarsal (Fig. 15).

PLANTAR PLATE INJURY OF THE LESSER MTP JOINTSAND METATARSALGIAMetatarsalgia is a generic term applied to a spectrum of painful conditions inthe region of the metatarsal heads resulting from chronic repetitive stress atthe forefoot, most commonly affecting the second MTP joint. Differential diag-nosis of metatarsalgia includes plantar plate injury, MTP joint synovitis, stressfracture, Freibergs infraction (osteonecrosis of the metatarsal head), arthritis,

interdigital (aka Mortons) neuroma, and synovial cyst formation.The plantar plate of the lesser MTP joints primarily differs from that of the

first MTP joint by the absence of the hallucal sesamoids. That means that theplantar plate articulates directly with the plantar surface of the lesser metatarsalhead and functions without the benefit of the sesamoids to provide critical ar-ticular stability and shock absorption. Whereas turf toe represents a sports-related acute traumatic rupture of the plantar plate of the first MTP joint, ruptureof the plantar plate of the lesser MTP joints is typically a chronic acquired degen-erative condition, developed over time as a result of increased loading [29].

The plantar plate is a firm, flexible fibrocartilaginous structure that hasa mean length of 20 mm and average thickness of 2 mm at the second MTPjoint [30]. Similar to the hallux, the plantar plate serves as the central attach-ment for ligamentous, capsular, and tendinous structures at the lesser MTPjoint. It represents the distal insertion of the plantar fascia. The plantar thirdof the fibrocartilaginous plate blends with the deep transverse intermetatarsal

Fig. 14. Sagittal STIR image demonstrates marrow edema within the tibial hallucal sesamoid.The curved white arrow indicates a linear fracture line without displacement or diastasis.

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ligament, whereas the dorsal surface has a smooth, articular-like surface, glid-ing deep to the metatarsal head during ambulation.

Paired accessory collateral ligaments (ACL) course proximal-to-distal and

dorsal-to-plantar originating at the dorsal tubercle of the lesser metatarsals tobroadly insert on the medial and lateral margins of the plantar plate. Smaller,more obliquely oriented paired phalangeal collateral ligaments (PCL) also arisefrom the dorsal tubercle, but share a conjoint insertion along with the plantarplate at the medial and lateral base of the proximal phalanx [30]. The flexortendon sheath is cradled within a central concavity at the deep surface of theplantar plate, anchored by a fibrous pulley [31]. The tendon sheath containsthe flexor digitorum brevis (FDB) and the flexor digitorm longus (FDL) ten-dons. The FDB splits to straddle the FDL at the level of the proximal interpha-

langeal (PIP) joint to insert bilaterally onto the base of the middle phalanx,whereas the FDL inserts onto the plantar base of the distal phalanx. Dorsally,the extensor hood and sling represent a fibroaponeurotic expansion extending bilaterally from the borders of the extensor digitorum longus (EDL) tendonsheath, with direct insertions onto the plantar plate, the deep transverse inter-metatarsal ligament, and base of the proximal phalanx [30].

Fig. 15. Coronal (A) and sagittal (B) STIR images through the forefoot demonstrate soft tissueedema plantar to the first metatarsal head in the region of the sesamoids and plantar plate.Straight arrows (A) indicate the sesamoids; an arrowhead indicates the flexor hallucis longustendon. Curved arrows (A, B) demonstrate defects in the plantar plate in the intersesamoidalregion and at the capsular attachment. Sagittal (C) and axial STIR (D) images demonstrate as-sociated soft tissue edema in the adductor hallucis musculature.



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MTP joint synovitis most commonly results from chronic excessive loadingof the MTP joint [32]. At the lesser MTP joints, compressive and tensile forcesof weight bearing and ambulation are greatest at the second ray and are in-creased in the context of hallux valgus or developmental elongation of the sec-ond metatarsal. Shoe gear with elevated heels and a narrow toe box increasesaxial loading, to the greatest degree at the second MTP joint. Chronic synovitisoften stretches the joint capsule and contributes to MTP joint instability [33].Degeneration and attritional change of the plantar plate and collateral liga-ments may ensue.

MTP joint instability often accompanies plantar plate degeneration and rup-ture. Symptoms include pain and capsular and submetatarsal swelling. Pain istypically worst in the toe-off phase of ambulation, at which time the tensileforces across the degenerated plantar plate are maximal. Instability is detectedand quantified by the Vertical Stress Test, which is simply performed by stabi-lizing the metatarsal head and forcibly displacing the proximal phalanx dor-sally. A positive test not only reveals instability, but elicits pain at the dorsalbase of the proximal phalanx.

Plantar plate rupture most commonly occurs at the distal, lateral insertiononto the base of the proximal phalanx.

High-resolution MRI of the forefoot is the gold standard for imaging of plan-tar plate rupture and differentiating it from other possible causes of metatarsal-

gia. Coronal (short axis) MR images through the forefoot demonstrate theplantar plate as a thick low signal band deep to the metatarsal head, thinnestcentrally and thickest distally. A shallow groove at the central plantar surfaceaccommodates the flexor tendon sheath (Fig. 16A). Collateral ligaments areseen as vertically oriented bands medially and laterally, inserting bilaterallyonto the margins of the plantar plate and the base of the proximal phalanx(Fig. 16C,D). Oblique sagittal images are plotted off of an axial localizer alongthe axis of the second metatarsal shaft. In the normal, oblique sagittal imagingpermits visualization of a distinct, narrow zone of high signal intensity repre-

senting hyaline cartilage undercutting the low signal fibrocartilage [34] nearthe distal insertion of the plantar plate, which should not measure more than2.5 mm [29] (Fig. 16B). In plane visualization of the ACL and PCL is incon-stant and fortuitous in the oblique sagittal plane. Whereas axial (long axis) im-aging is not useful in detection of plantar plate or collateral ligament rupture, itpermits qualitative evaluation of hallux valgus, second metatarsal protrusion,and identification of possible marrow signal abnormalities attendant to stressinjury, osteonecrosis, and arthritis.

In the context of plantar plate degeneration or rupture there is pathologic

elongation and marginal indistinctness of the high signal intensity zone at thedistal insertion of the plantar plate [29] (Fig. 17A). With capsular insufficiencyand its attendant plantar plate and ligamentous degeneration, there is progres-sive hyperextension of the toe at the MTP joint. Degenerative thickening orthinning and signal distortion of the plantar plate and/or collateral ligamentsis best demonstrated in the coronal plane. A rupture, seen as a high signal

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for identification of marrow signal changes in the absence of discernible corticaldefects. Timely detection of stress-related marrow edema may permit earlyclinical intervention and prevent evolution to fracture, hastening the athletesto return to training and competition. MRI has revolutionized the evaluationof soft tissue injury with or without associated occult osseous injury. As withfootwear, however, MRI of the foot is not a one-size-fits-all proposition. Inmost individuals, it is not possible to image the foot from heel to toe withoutexceeding the limits of the surface coil or compromising the quality of the ex-amination by field inhomogeneity or failure of fat suppression. It is important

to tailor the MR examination of the foot to address the specific area of clinicalconcern. Ideally, imaging should be focused to the region of interest, be it thehindfoot, midfoot, or forefoot, so that protocols can be optimized to permitsmall field of view, high-resolution imaging. This is particularly crucial in im-aging the forefoot in assessing small and subtle derangements of the capsuloli-gamentous, myotendinous, and osseous structures of the digits.

Fig. 17. Sagittal 2D-GRE image (A) demonstrates pathologic elongation of the high signalzone, indicative of degenerative tearing of the plantar plate; note hyperextension of the digitat the MTP joint. (B) Complete bilateral plantar plate rupture (arrow) with dorsal dislocation ofthe second toe. Coronal 2D-GRE image (C) demonstrates complete rupture at the lateral inser-tion of the plantar plate and phalangeal collateral ligament onto the base of the second prox-imal phalanx (black arrow). Coronal image (D) demonstrates a ganglion (white arrow) relatedto a partial tear at the lateral aspect of the plantar plate.

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