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Rupture of the medial collateral ligament of the first metatarsophalangeal joint in a professional soccer player
Rupture of the Medial Collateral Ligament of the First Metatarsophalangeal Joint in a Professional Soccer Player Worldwide, more people play soccer than any other team sport. The Federation Internationale de Football Association (FIFA) registered more than 150 million players in 1984. Although foot injuries in soccer range from midfoot sprains to stress fractures to capsulitis of the first metatarsophalangeal joint, we could find no case reports of a rupture of the lateral collateral ligaments of the great toe in soccer players. This is a report of the diagnosis, treatment, and outcome of such an injury in a professional soccer player. (The Journal of Foot & Ankle Surgery 36(5):388-390, 1997) Keywords: medial collateral ligament, first metatarsophalangeal joint, rupture, soccer
Donald P. Douglas, MD 1 David M. Davidson, DPM 2
Joseph E. Robinson, MS, ATe, PT Deepak G. Bedi, MD3
The incidence of soccer injuries is similar to that of hockey and lacrosse injuries. Fifty to sixty percent of all soccer injuries are to the lower extremities and 9 to 19% are to the foot (1).
times each day, and return to activity as tolerated. He was to be monitored by the team trainers. During the following I-month period, the player continued to complain of pain over the same aspect of the joint and of "instability" of the joint. He reported that the symptoms were exacerbated during push-off maneuvers involving the right foot. Consequently, he was not able to play soccer. He continued anti-inflammatory treatment. However, he continued to complain of a sense that "the toe was going out of joint." Repeated examinations continued to reveal normal stability upon valgus/varus stress testing of the first metatarsophalangeal joint. Due to the player's continued complaints, magnetic resonance imaging was ordered. An MRI of the foot, with pulse sequences designed to suppress a fat signal and show edema, clearly demonstrated disruption of the medial collateral ligament on the Tl-weighted images accompanied by increased signal due to edema and inflammation on the short tau inversion recovery (STIR) images (Figs. 1, 2). Extensive infiltration of an increased signal around the first metatarsophalangeal joint indicated probable rupture of the joint capsule. The extensor, flexor, and adductor tendons appeared intact. During surgery, we found a tear of the medial collateral ligament through its midsubstance but no intraarticular pathology. The ligament was repaired end-toend with two D-Ethibond" sutures on an outpatient basis under local anesthesia. Sterile dressings and a bunion boot were applied postoperatively. The patient was allowed weightbearing as tolerated in the wooden-soled
Case History
A 20-year-old male, professional soccer player with no previous history of right foot injury, was slide-tackled during a practice. He presented to the office 4 days after the injury complaining of persistent pain in the first metatarsophalangeal joint but denied feeling a tear or any other sensation at the time of injury. Examination revealed erythema, ecchymosis, swelling, and tenderness over the medial aspect of the joint. No deformity was noted. Normal sensorimotor function of the joint was noted. No instability could be demonstrated on stress testing. No fracture or malalignment of the digit appeared on radiographs at the time of the initial visit. The initial diagnosis was a "moderate" sprain, and the recommended treatment was rest, 600 mg. Ibuprofen three
From The Meadowlands Professional Park, 1000 Youngs Road, Williamsville, NY 14221. I Clinical Instructor, Department of Orthopedic Surgery, Clinical Assistant Professor, Department of Family Medicine, State University of New York at Buffalo, Buffalo, NY. Address correspondence to: The Meadowlands Professional Park, 1000 Youngs Road, Williamsville, NY 14221. 2 Clinical Assistant Professor, Department of Orthopedic Surgery, State University of New York at Buffalo, Buffalo, NY. 3 Clinical Associate Professor, Department of Radiology, State University of New York at Buffalo, Buffalo, NY. The Journal of Foot & Ankle Surgery 1067-2516/97/3605-0388$4.00/0 Copyright © 1997 by the American College of Foot and Ankle Surgeons
388
THE JOURNAL OF FOOT & ANKLE SURGERY
4
Ethicon Co., Sommerville, NJ.
FIGURE 1 a, Coronal MRI of the foot shows an area of intermediate signal intensity (arrow) blurring the fine, linear, dark, low-signal ruptured, collateral ligament (curved arrows). b, Increased signal infiltrating the soft tissues around the joint (arrow) represents edema secondary to the rupture.
shoe. He was seen 2 weeks after surgery when the sutures were removed. He was asked to continue wearing the surgical shoe to avoid excessive flexion-extension stress to the joint. Although he missed the next two follow-up appointments, he returned for reevaluation approximately 6 weeks postoperatively. At that time, he had no subjective complaints. He was walking in normal shoewear and admitted to participating in "sandlot" basketball. There was no tenderness on examination, and he had a full range of active and passive motion with no instability. We recommended that he gradually return to full soccer activity over a 2-week period and that the team trainers monitor his progress. Discussion
The medial ligamentous structure of the first metatarsophalangeal joint is composed of the medial metatarsosesamoid ligament (suspensory ligament) and the medial metatarso-phalangeal ligament (2). The origin of these ligaments is the medial aspect of the first metatarsal
FIGURE 2 Axial MRI of the foot shows the same signal change from a, intermediate to b, increased. The ruptured collateral ligament (a) is shown by the interruption of the low-signal linear structure (curved arrow).
head. The medial metatarsophalangeal ligament is positioned distal to this origin and inserts into the base of the proximal phalanx. The suspensory ligament is positioned both volar and distal to the origin and inserts into the volar plate. Rupture of the first metatarsophalangeal joint's medial collateral ligament has not been reported previously in the literature. The patient on which this report is based complained persistently of joint instability. Although inflammation on the medial side of the joint was apparent clinically, radiographs failed to reveal osseous pathology or malalignment. In addition, repeated clinical examinations failed to reveal pathologic laxity. The MRI revealed a rupture of the ligament as well as adjacent edema that was hot clinically. It is worth noting that normal routing, spin-echo techniques may not reveal the findings, which appeared best on the fat-suppression images. The abnormality could also be seen on more than one plane, as demonstrated on the axial and coronal images (Figs 1, 2). The normal ligament is a thin, linear, low-signal structure that will VOLUME 36, NUMBER 5, 1997
389
be disrupted and replaced by an increased signal on T2-weighted images when ruptured.
tional disability. Direct surgical repair resulted in a full, functional recovery.
Conclusion
References
If radiographs fail to reveal bony or joint injury and a rupture cannot be demonstrated, but the patient persists in complaining of joint instability following a sports injury to the first metatarsophalangeal joint, an MRI evaluation should be considered to rule out a tear of the collateral ligament. The injury in this case led to func-
390
THE JOURNAL OF FOOT & ANKLE SURGERY
1. Lohnes, J. H., Garrett, W. E., Monto, R. R. Soccer, In Sports Injuries: Mechanisms, Prevention and Treatment, pp. 603-624, edited by F. H. Fu and D. A. Stone, Williams & Wilkins, Baltimore , 1994. 2. Sarrafian, S. Syndesmology, ch. 4. In Anatomy of the Foot and Ankle, Descriptive, Typographic and Functional, 2nd ed., p. 215, J. B. Lippincott Co., Philadelphia, 1983.
Donald P. Douglas, MD 1 David M. Davidson, DPM 2
Joseph E. Robinson, MS, ATe, PT Deepak G. Bedi, MD3
The incidence of soccer injuries is similar to that of hockey and lacrosse injuries. Fifty to sixty percent of all soccer injuries are to the lower extremities and 9 to 19% are to the foot (1).
times each day, and return to activity as tolerated. He was to be monitored by the team trainers. During the following I-month period, the player continued to complain of pain over the same aspect of the joint and of "instability" of the joint. He reported that the symptoms were exacerbated during push-off maneuvers involving the right foot. Consequently, he was not able to play soccer. He continued anti-inflammatory treatment. However, he continued to complain of a sense that "the toe was going out of joint." Repeated examinations continued to reveal normal stability upon valgus/varus stress testing of the first metatarsophalangeal joint. Due to the player's continued complaints, magnetic resonance imaging was ordered. An MRI of the foot, with pulse sequences designed to suppress a fat signal and show edema, clearly demonstrated disruption of the medial collateral ligament on the Tl-weighted images accompanied by increased signal due to edema and inflammation on the short tau inversion recovery (STIR) images (Figs. 1, 2). Extensive infiltration of an increased signal around the first metatarsophalangeal joint indicated probable rupture of the joint capsule. The extensor, flexor, and adductor tendons appeared intact. During surgery, we found a tear of the medial collateral ligament through its midsubstance but no intraarticular pathology. The ligament was repaired end-toend with two D-Ethibond" sutures on an outpatient basis under local anesthesia. Sterile dressings and a bunion boot were applied postoperatively. The patient was allowed weightbearing as tolerated in the wooden-soled
Case History
A 20-year-old male, professional soccer player with no previous history of right foot injury, was slide-tackled during a practice. He presented to the office 4 days after the injury complaining of persistent pain in the first metatarsophalangeal joint but denied feeling a tear or any other sensation at the time of injury. Examination revealed erythema, ecchymosis, swelling, and tenderness over the medial aspect of the joint. No deformity was noted. Normal sensorimotor function of the joint was noted. No instability could be demonstrated on stress testing. No fracture or malalignment of the digit appeared on radiographs at the time of the initial visit. The initial diagnosis was a "moderate" sprain, and the recommended treatment was rest, 600 mg. Ibuprofen three
From The Meadowlands Professional Park, 1000 Youngs Road, Williamsville, NY 14221. I Clinical Instructor, Department of Orthopedic Surgery, Clinical Assistant Professor, Department of Family Medicine, State University of New York at Buffalo, Buffalo, NY. Address correspondence to: The Meadowlands Professional Park, 1000 Youngs Road, Williamsville, NY 14221. 2 Clinical Assistant Professor, Department of Orthopedic Surgery, State University of New York at Buffalo, Buffalo, NY. 3 Clinical Associate Professor, Department of Radiology, State University of New York at Buffalo, Buffalo, NY. The Journal of Foot & Ankle Surgery 1067-2516/97/3605-0388$4.00/0 Copyright © 1997 by the American College of Foot and Ankle Surgeons
388
THE JOURNAL OF FOOT & ANKLE SURGERY
4
Ethicon Co., Sommerville, NJ.
FIGURE 1 a, Coronal MRI of the foot shows an area of intermediate signal intensity (arrow) blurring the fine, linear, dark, low-signal ruptured, collateral ligament (curved arrows). b, Increased signal infiltrating the soft tissues around the joint (arrow) represents edema secondary to the rupture.
shoe. He was seen 2 weeks after surgery when the sutures were removed. He was asked to continue wearing the surgical shoe to avoid excessive flexion-extension stress to the joint. Although he missed the next two follow-up appointments, he returned for reevaluation approximately 6 weeks postoperatively. At that time, he had no subjective complaints. He was walking in normal shoewear and admitted to participating in "sandlot" basketball. There was no tenderness on examination, and he had a full range of active and passive motion with no instability. We recommended that he gradually return to full soccer activity over a 2-week period and that the team trainers monitor his progress. Discussion
The medial ligamentous structure of the first metatarsophalangeal joint is composed of the medial metatarsosesamoid ligament (suspensory ligament) and the medial metatarso-phalangeal ligament (2). The origin of these ligaments is the medial aspect of the first metatarsal
FIGURE 2 Axial MRI of the foot shows the same signal change from a, intermediate to b, increased. The ruptured collateral ligament (a) is shown by the interruption of the low-signal linear structure (curved arrow).
head. The medial metatarsophalangeal ligament is positioned distal to this origin and inserts into the base of the proximal phalanx. The suspensory ligament is positioned both volar and distal to the origin and inserts into the volar plate. Rupture of the first metatarsophalangeal joint's medial collateral ligament has not been reported previously in the literature. The patient on which this report is based complained persistently of joint instability. Although inflammation on the medial side of the joint was apparent clinically, radiographs failed to reveal osseous pathology or malalignment. In addition, repeated clinical examinations failed to reveal pathologic laxity. The MRI revealed a rupture of the ligament as well as adjacent edema that was hot clinically. It is worth noting that normal routing, spin-echo techniques may not reveal the findings, which appeared best on the fat-suppression images. The abnormality could also be seen on more than one plane, as demonstrated on the axial and coronal images (Figs 1, 2). The normal ligament is a thin, linear, low-signal structure that will VOLUME 36, NUMBER 5, 1997
389
be disrupted and replaced by an increased signal on T2-weighted images when ruptured.
tional disability. Direct surgical repair resulted in a full, functional recovery.
Conclusion
References
If radiographs fail to reveal bony or joint injury and a rupture cannot be demonstrated, but the patient persists in complaining of joint instability following a sports injury to the first metatarsophalangeal joint, an MRI evaluation should be considered to rule out a tear of the collateral ligament. The injury in this case led to func-
390
THE JOURNAL OF FOOT & ANKLE SURGERY
1. Lohnes, J. H., Garrett, W. E., Monto, R. R. Soccer, In Sports Injuries: Mechanisms, Prevention and Treatment, pp. 603-624, edited by F. H. Fu and D. A. Stone, Williams & Wilkins, Baltimore , 1994. 2. Sarrafian, S. Syndesmology, ch. 4. In Anatomy of the Foot and Ankle, Descriptive, Typographic and Functional, 2nd ed., p. 215, J. B. Lippincott Co., Philadelphia, 1983.