Ligament sprain

Ligament sprain as an isolated injury (Turf toe)

In sports medicine, a specific injury is distinguished — «turf toe» injury. This is a sprain or rupture of the capsular-ligamentous apparatus of the first metatarsophalangeal joint (1st MTPJ).

• Mechanism: occurs acutely in athletes during forced hyperextension of the great toe.
• Pathoanatomy: the plantar plate (plantar plate) is injured. Severity ranges from a mild sprain to a complete capsule rupture.
• Differential diagnosis: pain in this area is also characteristic of sesamoiditis (tenderness on the plantar surface), joint stiffness (hallux rigidus — pain on the dorsal surface during flexion), and acute gout. It is critical not to miss septic arthritis, which can rapidly destroy the joint.
• Diagnostics: radiography is mandatory to rule out concomitant fractures of the sesamoid and other bones of the great toe. If conservative treatment fails, instrumental studies are indicated for an accurate diagnosis.

Ligament injuries in dislocations

Isolated sprains do not always occur. Any traumatic dislocation (accounting for 1.5–3.0% of all musculoskeletal injuries) is typically accompanied by a rupture of the joint capsule and ligamentous apparatus.

For example, in a lunate dislocation (occurring due to a fall onto the hand in maximum wrist extension), pressure from the radius and capitate bones causes a rupture of the dorsal radiolunate ligament, as well as the ligaments fixing the lunate to adjacent carpal bones.

Furthermore, adjacent muscles suffer in such injuries: reflex stretching of some muscle groups and sudden contraction (retraction) of others occur. This muscular retraction develops very rapidly and securely fixes the bone in an abnormal (malplaced) position.

Diagnostic errors: when a dislocation hides under the guise of a sprain

One of the most frequent diagnostic errors in traumatology is the misinterpretation of a perilunate (dorsal) wrist dislocation as a routine «ligamentous injury».

In this injury (a fall onto an outstretched hand supported by the palm in extension), the lunate bone maintains its normal position relative to the radius, while the remaining carpal mass is displaced dorsally and proximally.

• Clinical presentation: diffuse swelling, wrist pain, bayonet deformity, semi-flexed finger position, and springy resistance upon attempted movement.
• Diagnostics: to avoid missing a dislocation and treating it as a sprain, radiography in two projections is crucial (the lateral radiograph is particularly informative).
• Treatment: unlike a simple sprain, a fresh dislocation requires adequate anesthesia (general anesthesia, regional, or intraosseous anesthesia) followed by closed reduction and immobilization with a plaster splint.

Traction injuries of neural structures

Not only joint ligaments are subject to stretching, but also neural structures. Players in contact sports (rugby, hockey, American football) frequently experience transient brachial plexus (brachial plexus) plexopathy, known as a «stinger». Over 50% of football players experience at least one such episode during their career.

• Mechanism: rapid and forced lateral flexion of the neck during tackles leads to traction (stretching) or compression injury of the plexus.
• Symptoms: typically unilateral and resolve spontaneously in less than 24 hours.
• «Red flags»: if symptoms persist beyond 24 hours, bilateral symptoms, muscle atrophy, or lower limb pain develop — these are signs of a more severe pathology (e.g., spinal canal stenosis or cervical spine fracture). In such cases, an immediate MRI is indicated.

Class and exam questions

What else to study on this topic

• Differential diagnosis of pain in the 1st metatarsophalangeal joint (gout, sesamoiditis, hallux rigidus)
• Technique of closed reduction of perilunate wrist dislocation and immobilization rules
• Red flags in traction injuries of the cervical spine and brachial plexus
• Pathogenesis of muscle retraction and consequences of unreduced traumatic dislocations
• Complications in elbow joint injuries and causes of contracture development

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Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.