Mid and Forefoot Injuries in
Sports Medicine
Dr. Howard C H Chen
Athlete’s Care Sports Medicine Centres
Faculty/Presenter Disclosure
• Faculty: Dr. Howard C. H. Chen
• Relationships with commercial interests
• Not Applicable
• Relationships with commercial interests
• This program has received NO in-kind support
• Potential for conflict(s) of interest
• Not applicable
• Mitigating Potential Bias
• All efforts have been made to present information in an
equal and unbiased manner based on currently
available data
Objectives
• Review functional anatomy of the foot and arches
• Discuss diagnosis and management of several
common “not to be missed” foot injuries seen in
sports medicine
• Ottawa rules midfoot zone injuries related to inversion
sprains
• Transverse tarsal joint sprains
• Lisfranc’s sprains
• 1st MTPJ Flexor complex injuries/Turf toe
• Metatarsal Stress fractures
Anatomy of the Foot
Anatomy of the Foot
Roman Arches
Static load compression structures
Dynamic Arches
• Dynamic systems balance tension and compression
Kulripa Bridge, Brisbane – largest tensegrity structure in
the world
Damage from excessive tensile or compressive forces
Arches of the Foot
Dynamic Arch Supports
Windlass Mechanism
Dynamic adjustment of arch height/rigidity by Windlass mechanism PF/Triceps surae, FHL,
FDL, peroneus longus and intrinsic foot muscles
Affects longitudinal and horizontal arches
Ground reaction force attenuation and adaptation to ground contour
Provide rigid lever for push-off
Injuries
• Traumatic
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Ottawa Rules midfoot zone
Lisfranc, Chopart tranverse tarsal joint sprains
Cuboid Syndrome
1st MTPJ Flexor complex injuries
• Stress Fractures
• Navicular
• Metatarsals
• Sesamoids
Ottawa Ankle Rules
MT5 Fractures
MT5 Fractures
Zone 5
Zone 4
Zone 3
Zone 2
Zone 1
MT5 Fractures
• MT5 Metaphyseal Fractures
• Zone 1 - Avulsion tuberosity
• acute inversion injury - lateral band PF/peroneus brevis insertion
• Zone 2 – Jones fracture
• Inversion plantarflexion injury, overuse stress fracture
• IA # MT 4-5 joint, not exceeding distal border
• MT5 Proximal Diaphyseal Fracture
• Zone 3 - Proximal diaphysis stress fracture
• vascular watershed with increased rate delayed/non-union
• Zone 4 - Spiral fracture distal 1/3 shaft (fouette fracture)
• Dancers lose balance in demi-pointe, roll over outer border
• Undisplaced # WB rest, displaced # casting 6/52
MT5 Fractures
Imaging
• X-rays helpful in Diagnosis and Prognosis, but maybe
negative early in course
• MRI can ID stress injury if x-rays negative
• CT can confirm bony union prior to RTP in elite athletes
Management
(Polzer et al 2012 Injury )
• Metaphyseal # (zone1-2) functional treatment
• Diaphyseal stress # acute Tx SLNWB cast x 6-8/52, early
screw fixation +/- bone grafting
MT5 Fractures
Management
(Mallee et al SR 2015 BJSM)
• Athletes MT5 # average RTP 14 weeks
• RTP surgical 13.8 weeks vs non-surgical 19.2 weeks
(Mologne et al RCT 2005 Am J Sports med)
• RCT Jones # SLNWB cast x 8 weeks vs IM screw +
NWB x 2 weeks
• Non-surgical 44% failure rate
• Surgical 5% non-union, 32% discomfort resulting in
16% screw removal
Navicular Fractures
Epidemiology
• Common in sports - sprinting, jumping or hurdling
• Acute trauma vs overuse, training errors
• 14-35% of stress fractures, delayed Dx average 4 weeks
• Usually middle 1/3 in relative avascular area
• Increased risk of delayed or non-union
• MOI not certain, ? compression as key stone of arch
• ↑ risk if ↓ dorsiflexion, excessive pronation and tarsal
coalition requiring midfoot compensation
Navicular Fractures
Navicular Fractures
Clinical Features
• Acute localized point tenderness and pain, with swelling
and bruising, + x-rays  ortho
• Stress # insidious, poorly localized midfoot ache with
weight bearing and activity
• Radiates medial longitudinal arch or dorsum foot
• Improves with rest, non-wt bearing
• Point tender “N-spot” 81% proximal, dorsal navicular
• Requires high degree of clinical suspicion, so if +ve then
stress # until proven otherwise
Navicular Fractures
Imaging
• Poor sensitivity X-rays navicular 33%, cuneiform and
MT bases due to obliquity and orientation #, bone
overlap
• X-rays used to r/o other bony abnormalities such as
tarsal coalition, DJD changes, accessory ossicles and
tumours
• MRI, bone scan (100% sens, poor spec and PPV) + CT
• CT needs correct angling and 2mm thin slices from
talus to navicular or may miss fracture
Navicular Fractures
Management
• NWB rest cast/castboot 6-8 weeks, or until non-tender,
80% successful return to sport rate
• Clinical reassessment, as poor correlation CT/MRI with
fracture healing
• Screw fixation +/- bone graft if significant
displacement/angulation, delayed or non-union
• Elite athletes - RTP 16.4 weeks ORIF vs cast 21.7 weeks
• Extensive rehabilitation – stiffness ankle, sub-talar, midtarsal joints
• Myofascial Tx, progressive strengthening prior to impact
activity
Cuboid Syndrome
• Subluxation cuboid inferomedial resulting in pain
with lateral WB
• Common in excessive pronators, lateral instability
and ballet dancers
• MOI
• Excessive peroneal longus traction
• Plantarflexion and inversion ankle injury
• Treatment
• Manual manipulation
• Taping, ankle brace
Cuboid Syndrome
Tansverse Tarsal Joint Sprains
Tansverse Tarsal Joint Sprains
Chopart’s Joint – talonavicular, calcaneocuboid
• Common in gymnasts, jumpers and football
• Usually injury to calcaneocuboid or bifurcate ligaments
(calcaneonavicular and calcaneocuboid ligaments)
• Dorsal calcaneocuboid injury usually due to inversion injury
• Bifurcate injury due to inversion injuries and forced
dorsi/plantar flexion
• Always do midfoot assessment with inversion injury
Tansverse Tarsal Joint Sprains
Clinical Features
• Calcaneocuboid ligament
• Pain lateral midfoot after inversion injury
• Dorsolateral tenderness, swelling calcaneocuboid joint
• Pain with stress inversion foot
• Bifurcate ligament
• May be associated with ant calcaneal process #
• Lateral midfoot pain and swelling after inversion/DF/PF
• Point tender ligaments and exacerbated by
simultaneous supination/PF
Tansverse Tarsal Joint Sprains
Imaging and Management
• X-rays, CT to r/o fracture
• +/- MRI to confirm ligament injury
• PT, taping, braces, orthotics, cast boot
• If fracture
• Non-displaced – cast x 4 weeks then brace
• Displaced – referral to Orthopedics
Lisfranc’s Joint Injuries
• Complex spectrum of injuries
• High energy leads to fracture/dislocations  Ortho
• Low energy injury second most common foot injury
in athletes
• Usually low velocity, indirect force
• High degree of clinical suspicion required in all
midfoot injuries, non-resolving ankle sprains
• Very poor outcomes if missed
Lisfranc’s Joint Injuries
•MT2 base keystone transverse
tarsal arch
•Low force  damage weak
dorsal Lisfranc ligament (C1M2)
•Higher force  plantar Lisfranc
ligament (C1M2,3) # MT or
cuneiform, capsular rupture
•MT may displace dorsally with
loss of arch integrity
• Widening 1st interspace
Lisfranc’s Joint Injuries
• Complex spectrum of injuries
• MOI
• Direct – uncommon, crush injury to TMTJ
• Indirect – plantar ligaments stronger than dorsal
ligaments, no D1-2 inter MT ligament
• Longitudinal axial load plantar-flexed mild rotated foot football, B-ball, running, dancing
• Plantarflexed hindfoot, fall backward with forced
forefoot abduction – equestrian, windsurfing with foot
strapped in
• Fall point of toes
Lisfranc’s Joint Injuries
Clinical Features
• Significant midfoot pain and difficulty weight-bearing
• ↑ with forefoot loading – heel raises, push-off,
sprinting
• Midfoot tenderness medial dorsal TMTJ +/- swelling
• Often delayed presentation as misdiagnosed as ankle
sprain
• Neurovascular exam for injury to dorsalis pedis A and
deep peroneal N
Lisfranc’s Joint Injuries
Low Energy Lisfranc Sprain Classification, Nunley et al 2002 Am J Sport Med
Lisfranc’s Joint Injuries
Nunley 2002
Gr 1 – no diastasis
Gr 2 – 2-5 mm diastasis, no loss of arch height
Gr 3 - >5 mm diastasis and loss of arch height
Lisfranc’s Joint Injuries
Imaging
• X-rays bilateral WB AP and lateral, oblique
• AP diastasis > 2mm D1-D2 MT bases, or > 1 mm asymmetry
• Lateral MT2 base elevation vs cuneiform, or flattening of medial
longitudinal arch asymmetry
• Fleck sign – small avulsion fragment MT2 base or medial cuneiform
• May reduce spontaneously with typical NWB x-rays despite severe
tissue injury, 50% NWB views N
• MRI sensitive for ligament tears
• High correlation Gr 2,3 injury C1MT2,3 and true instability
Lisfranc’s Joint Injuries
Management
• Grade 1 (no diastasis/instability)
• NWB cast/castboot x 6 weeks
• Orthotics to support MT2 base
• PT ankle/foot ROM, mobilization
• Grade 2-3 (+ instability)
• Orthopedics – early percutaneous/ORIF better results
• Delayed Dx/Mgmt results in poor outcome from chronic
disability due to ligamentous instability, loss of arch and
progressive DJD/OA
Turf Toe
Sprain of the 1st MTPJ with injury to plantar
capsule and ligament
MOI usually forced hyperextension/DF (85%),
axial load, valgus stress
Turf Toe
• Risk Factors
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Artificial turf
Pes planus or excessive pronation
Limited ankle/1st MTPJ ROM
Soft flexible footwear
• Clinical features
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Aggravated by movement 1st MTPJ, WB, push-off
Tender plantar/medial, dorsal in higher grade injury
Pain with ↓PROM PF/DF
Increased glide if ligament injury
+/- flexor tendon weakness
Turf Toe
• Classification
• Grade 1 – attenuation plantar structures, localized
swelling, minimal bruising and pain, no laxity ,
symptomatic Tx, RTP as tolerated 1-4/52
• Grade 2 – partial tear plantar structures with mild – mod
laxity, walking boot +/- crutches, RTP 2-4/52,
taping/orthoses
• Grade 3 – plantar structures disrupted, significant
swelling and bruising, weak flexion and frank instability,
associated with plantar plate and FHL/FHB tendon injury
Surgery if unstable with large capsular avulsion,
retraction of sesamoids, loose body or chondral injury
Turf Toe
Turf Toe
Turf Toe
Imaging
• Xrays usually N, occasional fleck # with avulsion
• Plantar plate injury assessed lat views with forced
DF, +ve if no sesamoid excursion
• MRI if grade 2-3 to assess degree of damage to
structures
• Significant delayed RTP, 3rd most behind knee/ankle
Sesamoids
• Embedded in the 2 FHB tendons
• 30% bipartite sesamoid present
• Functions
• Protect FHL tendon
• Weight bearing medial foot
• Pulleys to increase mechanical advantage of flexors
• Fracture, stress fracture, sprain sesamoid-MT
articulation or bipartite sesamoid from excessive
acute or repetitive load
• Basketball, tennis and dancers
Sesamoids
• Clinical features
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Pain with forefoot WB, compensates with LWB
Local swelling and tenderness sesamoids
Pain and ↓ROM 1st MTPJ
Pain increase with resisted PF 1st MTPJ
• Imaging and management
• X-rays with axial sesamoid view
• Bone scan and MRI often required to detect stress
fractures and to differentiate between sprained bipartite
sesamoid and fracture
Stress Fractures
• 38% stress fractures in lower limbs
• MT2 most common, always look for others
Stress Fractures
Imaging
• Poor sensitivity X-rays navicular, cuneiform and
MT bases
• If see one look for others
• r/o other bony abnormalities such as tarsal
coalition, DJD changes, accessory ossicles and
tumours
• MRI, bone scan + CT ( CT alone may miss in
navicular stress fractures, needs correct angling
and 2mm thin slices talus to navicular)
Stress Fractures
Clinical
• Metatarsals very common, Most common MT2 neck
• Excessive loading forefoot
• Pronators with dorsiflexed 1st ray and ↑ MT2
loading, Morton’s foot, ballet dancers
• Progressively ↑ forefoot pain with activity and focal
tenderness +/- swelling
• Modified rest from WB activity x 4/52, +/- aircast
• Graduated return to activity when pain free with
walking
Conclusions
• The foot is a complex combination compression and
tension arch structure that during the gait cycle,
attenuates ground reaction forces, adapts to surface
contours, and dynamically forms a rigid lever allowing
for efficient transfer of propulsive forces for push-off.
• Overload with excessive compression on the struts or
tension on the cable supports, can result in injury to
that component, but will also result in dysfunction in
the foot-arch complex due to loss of the dynamic
compression-tension equilibrium