Varus instability of the hallux interphalangeal joint in a
Hyun Sik Gong, Yeun Ho Kim, Moon Seok Park
............................................................... ............................................................... .....
Br J Sports Med 2007;41:917–919. doi: 10.1136/bjsm.2007.035501
The hallux interphalangeal joint is stable in the transverse plane
and there have been only a few reports of varus instability of
this joint. A case is described of varus subluxation of the hallux
interphalangeal joint in a taekwondo athlete and the surgical
outcome after reconstruction of the collateral ligament.
Taekwondo athletes, who require fast powerful kicks, should
be warned about this type of forefoot injury.
of the collateral ligament, turf toe, sesamoid pathology and
metatarsal stress fracture.1–3The hallux interphalangeal joint is
a simple hinge joint which allows motion in the sagittal plane,
so this joint has been regarded as inherently stable and has
received little attention in athletic injuries compared with the
metatarsophalangeal joint.4We have found no report of
transverse plane instability of this joint in the English literature
and report a rare case of varus subluxation of the hallux
interphalangeal joint in a female taekwondo athlete.
njuries of the forefoot are common in sports activities
involving running, jumping or contact, and these occur most
commonly around the metatarsophalangeal joint as rupture
A 19-year-old female taekwondo athlete presented with pain
and instability of the hallux interphalangeal joint in her left
foot. The symptom occurred after spraining the big toe several
times when she rapidly raised the foot for a kick and the big toe
was caught in the side of the mat. The hallux interphalangeal
joint was apparently unstable and easily subluxable medially.
There was tenderness on the lateral side of the joint but not on
the dorsal or plantar side. Radiographic examinations showed
no structural abnormality but a varus stress radiograph
revealed a remarkable widening of the joint space laterally
compared with the contralateral foot (fig 1).
Buddy taping of the first and second toes was ineffective and
the patient needed a stable joint to continue training. We
thought repair of the ligament would be impossible or
unreliable due to the chronicity of the injury, so planned to
make a lateral collateral ligament. A lateral longitudinal
incision over the hallux interphalangeal joint was made and
the interphalangeal joint was reached dorsal to the volar
neurovascular structures. The middle portion of the ligaments
had healed with scar tissue but the quality of the tissue was
inadequate for direct repair or plication. Drill holes were made
parallel to the joint at the normal insertion sites of the collateral
ligament. A palmaris longus tendon was taken from the
forearm using two small transverse incisions. The tendon graft
was passed through the holes from the lateral wound and the
two ends were tied on the medial side separate wound after
checking for full range of motion of the joint (figs 2 and 3).
After 4 weeks of immobilisation the interphalangeal joint was
mobilised for active range of motion, and 3 months after the
operation the patient was allowed to participate in training.
One year after the operation the patient remained asympto-
matic and the interphalangeal joint was stable and congruent
without any varus instability, having 45˚of flexion and full
extension compared with 60˚of flexion of the unoperated toe
(figs 4 and 5).
The hallux interphalangeal joint is stable anatomically. The
collateral ligaments which attach to the lateral side of the
of the left hallux interphalangeal joint. Informed consent was obtained for
publication of this figure.
Stress radiograph showing marked widening of the lateral side
holes made in the normal insertion sites of the collateral ligament of the
interphalangeal joint. Informed consent was obtained for publication of this
A palmaris longus free tendon graft was passed through the
proximal phalangeal head and the dorsal tubercle at the base of
the distal phalanx act as a strong static stabiliser in the
transverse plane.4The joint capsule and its thickened fibro-
cartilaginous plantar plate and the flexor and extensor hallucis
longus tendon provide the sagittal plane stability. The
bicondylar shape of the joint and the short lever arm of the
distal phalanx also contribute to the stability.5When hyper-
extension force is directed on the joint, a traumatic dorsal
dislocation can occur. Generally, closed manipulation is
achieved easily and results in little morbidity, except for rare
cases of irreducible dorsal dislocation caused by incarceration of
the plantar plate, interphalangeal sesamoid or fracture frag-
ments.5 6When force is directed on the joint in the transverse
plane—like stubbing the toe against the step or the stones—
intra-articular fractures seem to occur more commonly than
ligament ruptures because of the strong collateral ligaments
and the stable joint structure.
We have reconstructed the collateral ligament of the hallux
interphalangeal joint with varus instability in a taekwondo
athlete and obtained a stable and mobile joint which enabled
the patient to continue training. Arthrodesis of the joint could
be an option and would have provided more definite stability
for daily activities, but we assumed that a martial art athlete
who frequently runs, jumps and kicks requires a mobile
interphalangeal joint with adequate flexion movement during
the push-off phase. The palmaris longus tendon was chosen for
a donor tendon. We thought taking this tendon might have the
least morbidity to the patient who uses the lower extremity
more often than the wrist during training because almost 80%
of the competitive techniques used in taekwondo are kicks.7
In studies comparing the rate of injuries in common martial
arts, taekwondo had the highest risk of injury and the lower
extremities tended to get injured more often in taekwondo
training than in the injuries of other martial arts.8 9This is
because taekwondo relies on fast powerful kicks using the
dorsum or lateral side of the foot.7 10Olympic-style full contact
sparring in taekwondo now requires protective equipment,
including not only head gear, chest protectors and shin pads
but also padding for the hands and feet. However, the feet
protectors commonly used do not cover the interphalangeal
joint, leaving the joint still vulnerable to high speed impacts.
Taekwondo athletes should be warned about this type of
joint. Informed consent was obtained for publication of this figure.
The two limbs of the tendon were tied in the opposite side of the
remained congruent. Informed consent was obtained for publication of this
One year after the operation the hallux interphalangeal joint
was slightly less than the normal side. Informed consent was obtained for
publication of this figure.
Flexion of the left hallux interphalangeal joint was 45˚ which
What is already known on this topic
N The hallux interphalangeal joint is inherently stable in the
transverse plane compared with the metatarsophalan-
N Taekwondo has a high risk of injuries of the lower
extremity because most competitive techniques are kinds
What this study adds
N We report a rare case of varus instability of the hallux
interphalangeal joint in a taekwondo athlete.
N Taekwondo athletes should be warned about this type of
forefoot injury and lateral collateral ligament reconstruc-
tion can be a reasonable treatment for chronic varus
instability of the hallux interphalangeal joint.
918 Gong, Kim, Park
forefoot injury and mat conditions should be carefully checked Download full-text
Hyun Sik Gong, Yeun Ho Kim, Moon Seok Park, Department of
Orthopaedic Surgery, Seoul National University Bundang Hospital,
Competing interests: None.
Informed consent was obtained for publication of figs 1–5.
Correspondence to: Dr Hyun Sik Gong, Department of Orthopaedic
Surgery, Seoul National University Bundang Hospital, Seoul National
University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-
si, Gyeonggi-do, 463-707, Korea; email@example.com
Accepted 27 March 2007
Published Online First 22 May 2007
1 Clanton TO, Butler JE, Eggert A. Injuries to the metatarsophalangeal joints in
athletes. Foot Ankle 1986;7:162–76.
2 Mullis DL, Miller WE. A disabling sports injury of the great toe. Foot Ankle
3 Watson TS, Anderson RB, Davis WH. Periarticular injuries to the hallux
metatarsophalangeal joint in athletes. Foot Ankle Clin 2000;5:687–713.
4 Salleh R, Beischer A, Edwards WH. Disorders of the hallucal interphalangeal
joint. Foot Ankle Clin 2005;10:129–40.
5 Noonan R Jr, Thurber NB. Irreducible dorsal dislocation of the hallucal
interphalangeal joint. J Am Podiatr Med Assoc 1987;77:98–101.
6 Nelson TL, Uggen W. Irreducible dorsal dislocation of the interphalangeal joint of
the great toe. Clin Orthop Relat Res 1981;157:110–2.
7 Serina ER, Lieu DK. Thoracic injury potential of basic competition taekwondo
kicks. J Biomech 1991;24:951–60.
8 Pieter W. Martial arts injuries. Med Sport Sci 2005;48:59–73.
9 Zetaruk MN, Violan MA, Zurakowski D, et al. Injuries in martial arts: a
comparison of five styles. Br J Sports Med 2005;39:29–33.
10 Zemper ED, Pieter W. Injury rates during the 1988 US Olympic team trials for
taekwondo. Br J Sports Med 1989;23:161–4.
Let us assist you in teaching the next generation
Figures from all articles on our website can be downloaded as a PowerPoint slide. This feature is
ideal for teaching and saves you valuable time. Just click on the image you need and choose the
‘‘PowerPoint Slide for Teaching’’ option. Save the slide to your hard drive and it is ready to go.
This innovative function is an important aid to any clinician, and is completely free to subscribers.
(Usual copyright conditions apply.)
Varus instability of the hallux interphalangeal joint919