What are the appropriate next steps in managing a hyperextension injury of the great toe that is now painful with weight bearing?

Management of Hyperextension Injury of the Great Toe with Weight-Bearing Pain

Obtain plain radiographs of the foot immediately, and if clinical suspicion remains high despite normal films, proceed directly to CT scan of the foot, as conventional radiographs miss 67-75% of significant injuries in hyperextension mechanisms. 1

Initial Imaging Approach

Plain Radiographs First

• Start with standard foot radiographs (anteroposterior, lateral, and oblique views) as the initial imaging study for acute foot trauma 2
• Weight-bearing views should be included when the patient can tolerate them 2
• However, recognize that plain films have only 25-33% sensitivity for detecting hyperextension injuries 1

Critical Pitfall to Avoid

• Do not rely solely on normal radiographs in hyperextension injuries—this mechanism carries a high rate of radiographically occult injuries that require CT for detection 1
• The majority of significant fractures, ligamentous disruptions, and joint malalignments are missed on plain films in this injury pattern 1

Advanced Imaging: CT as First-Line

When to Order CT

• CT of the foot without IV contrast is the first-line advanced imaging modality when plain radiographs are normal or equivocal in hyperextension injuries 1
• CT reliably identifies occult metatarsal fractures, tarsal fractures (especially cuboid), sesamoid injuries, and joint malalignment that plain films miss 1
• This is particularly important as hyperextension injuries can involve the plantar plate, capsular structures, and associated bony avulsions 1

Alternative: MRI When CT is Negative

• If CT results are negative but clinical suspicion for soft-tissue injury remains high (persistent pain, instability, inability to bear weight), obtain MRI of the foot without IV contrast 1
• MRI is superior for evaluating the capsuloligamentous complex, plantar plate integrity, and detecting bone contusions or occult fractures not visible on CT 1
• MRI and CT are considered equivalent alternatives for suspected tendon injury or occult fracture 2

Clinical Grading and Prognosis

Grade I Injury (Sprain/Attenuation)

• Involves stretching of the plantar capsular ligamentous complex 3
• Athletes typically return to play as tolerated, usually within 3-5 days once minimal pain with normal weight-bearing is achieved 4, 3

Grade II Injury (Partial Rupture)

• Partial tear of plantar soft tissue structures 3
• Requires approximately 2-4 weeks of restricted activity 4, 3
• May need taping or orthotic support when returning to activity 4

Grade III Injury (Complete Rupture)

• Complete disruption of the plantar plate and capsular structures 3
• Requires at least 10-16 weeks for recovery 3
• Less than 2% of turf toe injuries require surgery, but Grade III injuries with severe instability, irreducible dislocation, or significant bony injury are the ones that do 4
• Approximately 70% of athletes with Grade III injuries maintain their prior performance level 4

Additional Imaging Considerations

Ultrasound Role

• Ultrasound is sensitive for detecting acute tendon rupture or dislocation but is not routinely recommended as first-line advanced imaging for MTP joint injuries 1
• Can be used as a focused examination in selected scenarios for suspected plantar plate injuries 2

Fluoroscopy

• Can be employed as an adjunct to assess sesamoid tracking during forced dorsiflexion, helping evaluate MTP joint instability 1

Watch for Associated Injuries

Lisfranc Injury

• Hyperextension can cause Lisfranc (midfoot) injuries without obvious radiographic findings 1
• If midfoot tenderness is present on examination, CT or MRI should be considered even if initial radiographs appear normal 1

Sesamoid Pathology

• Hyperextension injuries commonly involve the sesamoid complex 5
• CT and MRI are both effective at identifying sesamoid fractures, avascular necrosis, or sesamoiditis 5