Extensor Tendons and the Dorsal Aspect of Toes
Damage to the anterior or top of the foot most commonly affects the extensor tendons, which run along the dorsal surface and insert onto the toes, particularly the extensor hallucis longus (for the great toe) and extensor digitorum longus (for the lesser toes). 1
Anatomical Structures at Risk
The dorsal (top) aspect of the foot contains several key anatomical structures vulnerable to trauma:
- Extensor tendons are the primary soft tissue structures on the dorsal foot surface, responsible for toe extension and visible just beneath the skin 1
- The extensor hallucis longus specifically controls the great toe (hallux) and is particularly susceptible to acute tendon injury in dorsal foot trauma 1
- The extensor digitorum longus tendons extend to toes 2-5 and can be injured in forefoot trauma 1
Clinical Evaluation Priorities
When evaluating dorsal foot trauma, you must specifically assess:
- Tendon integrity through active extension testing of each toe, as acute tendinous injuries require different management than bony injuries 1
- Metatarsophalangeal (MTP) joint involvement, particularly for the hallux, as these injuries may involve the plantar plate, sesamoids, or capsuloligamentous complex 1, 2
- Toe alignment abnormalities that may indicate underlying tendon disruption or dislocation 1
Imaging Approach for Dorsal Foot Injuries
The diagnostic workup should follow this algorithm:
- Start with weight-bearing radiographs (AP, lateral, and oblique views) as the mandatory first-line study, even when Ottawa rules don't specifically address forefoot or toe trauma 1, 3
- Add MRI when radiographs are negative but clinical suspicion remains high for tendon rupture or dislocation, as MRI and ultrasound have similar sensitivity for acute soft-tissue trauma including tendinous disruption 1, 3
- Consider ultrasound as an alternative to MRI for acute tendon rupture or dislocation diagnosis, though it has lower grading scores for bony assessment 1
Common Pitfalls to Avoid
- Don't overlook toe injuries simply because Ottawa rules primarily address midfoot trauma—metatarsal heads and toes require separate clinical assessment 1
- Don't assume normal radiographs exclude significant injury in dorsal foot trauma, as purely soft tissue injuries (tendon ruptures, ligamentous injuries) won't show on plain films 1, 3
- Don't delay advanced imaging when tendon injury is clinically suspected, as early diagnosis of complete tendon disruption may alter surgical timing 1
The great toe (hallux) deserves particular attention in dorsal foot trauma, as injuries here—including turf toe, traumatic bunion, and sesamoid pathology—can result in long-term pain and disability if not properly diagnosed and treated 2