Return to sport following toe phalanx fractures: A systematic review

Table 1 Inclusion and exclusion criteria

Inclusion criteria	Exclusion criteria
Acute toe phalanx fractures	Toe sesamoid fractures
Stress toe phalanx fractures	Toe joint dislocation without fracture
Elite or recreational athletes	Toe joint fracture dislocation
Return rate to sporting activity reported	Toe ligament injuries
Time to return to sporting activity reported	No sporting outcome data reported
Two or more injuries reported	Concomitant upper or lower limb fractures
Peer-reviewed journals	Reviews, case reports, abstracts, or anecdotal articles
English language	Animal, cadaver, or in vitro studies

Table 2 Demographic data - acute fractures

Ref.	n	Study type	Mean age (yr)	Male:Female	Follow-up, %	Sport	Level of sport	Most common MOI	Location	Modified coleman score	MINORS score
General cohort
Robertson et al[15], 2012	8	Case series	21.1	8:0	6 (75)	Soccer	General population	Tackle (50%)	Great toe (n = 6) 2nd Toe (n = 1); 3rd Toe (n = 1)	44	12
Larsson et al[16], 2016	18	Case series	N/A	18:0	18 (100)	Soccer	Elite/Professional	N/A	N/A	39	12
Chan et al[17], 2021	53	Case series	N/A	32:21	53 (100)	US Collegiate Sports	Collegiate	N/A	N/A	54	12
Diaz et al[18], 2022	69	RCS	N/A	69:0	69 (100)	Soccer	Elite	N/A	N/A	41	18
Intra-Articular (Physeal) base of proximal phalanx fractures
Maffulli[19], 2001	2	Case series	12.5	2:0	2 (100)	Soccer (n = 1), Judo (n = 1)	Recreational	Tackle	Great toe proximal phalanx	65	9
Perugia et al[20], 2014	4	Case series	13-15	N/A	4 (100)	Gymnastics (n = 4)	Adolescent high level	Dismount	Great toe proximal phalanx	67	11
Bariteau et al[21], 2015	2	Case series	12.5	0:2	2 (100)	Gymnastics (n = 2)	Elite	Dismount	Great toe proximal phalanx	62	11

MOI: Mechanism of injury; RCS: A retrospective cohort study.

Table 3 Demographic data - stress fractures

Ref.	n	Study type	Mean age (yr)	Male:Female	Follow-up, %	Sport	Level of sport	Location	Associated deformity	Modified coleman score	MINORS score
Yokoe et al[22], 1986	3	Case series	16.3 (12-21)	1:2	3 (100)	Sprinting (n = 1), Rugby (n = 1), Kendo (n = 1)	Amateur	Great Toe Proximal Phalanx	Hallux valgus (n = 3)	34	8
Shiraishi et al[23], 1993	3	Case series	13.7 (12-17)	1:2	3 (100)	Volleyball (n = 1), Long Distance Running (n = 1), Soccer (n = 1)	Amateur	Great toe proximal phalanx		51	9
Yokoe et al[8], 2004	10	Case series	16.3 (12-21)	2:8	10 (100)	Sprinting (n = 6), Distance Running (n = 1), Basketball (n = 1), Rugby (n = 1), Kendo (n = 1)	N/A	Great toe proximal phalanx	Hallux valgus (n = 9)	35	8
Pitsis et al[24], 2004	2	Case series	29 (17-41)	0:2	2 (100)	Triathlon (n = 1), Gymnastics (n = 1)	Non-professional/Elite	Great toe proximal phalanx	Hallux valgus (n = 1)	46	8
Munemoto et al[25], 2009	4	Case series	14.5 (13-17)	2:2	4 (100)	Short track running (n = 3), Soccer (n = 1)	Amateur	Great toe proximal phalanx	Hallux valgus (n = 3)	55	8
Yamaguchi et al[26], 2017	4	Case series	14.8 (13-16)	4:0	4 (100)	Soccer (n = 3), Baseball (n = 1)	N/A	2nd toe proximal phalanx	Claw toe (n = 1)	52	8

Table 4 Outcome data - acute fractures

Ref.	n	Treatment (%)	Return to sport (%)	Return to the same level of sport (%)	Return time to sport	Secondary surgery - return rate (RR)/Return time (RT)	Persisting symptoms (%)	Complications
General cohort
Robertson et al[15], 2012	6	PCM (100)	3 (50)	3 (50)	7.0 wk (mean)		3 (50)	Nil
Larsson et al[16], 2016	18	N/A	N/A	N/A	26 d (mean)		N/A	1 re-fracture
Chan et al[17], 2021	53	PCM (100)	53 (100)	N/A	8.5 d (median)		N/A	1 re-fracture
Diaz et al[18], 2022	69	N/A	N/A		30 d (median)		N/A	Nil
Intra-articular (Physeal) base of proximal phalanx fractures
Maffulli[19], 2001	2	PCM (50) PSM (50)	2 (100)	2 (100)	By 6 mo		0 (0)	0 (0)
Perugia et al[20], 2014	4	PSM (100)	4 (100)	4 (100)	By 3 mo		0 (0)	0 (0)
Bariteau et al[21], 2015	2	PCM (50) PSM (50)	1 (50) (PSM)	1 (50) (PSM)	5 mo	1 – RR 100%/RT 14 wk	0 (0)	1 re-fracture (PCM)

PCM: Primary conservative management; PSM: Primary surgical management.

Table 5 Outcome data - stress fractures

Ref.	n	Treatment (%)	Return to sport (%)	Return to the same level of sport (%)	Time to return to sport (mean)	Secondary surgery - return rate (RR)/Return time (RT)	Factors associated with secondary surgery	Persisting symptom (%)	Complications (%)
Yokoe et al[22], 1986	3	PCM (67) PSM (33)	3 (100)	N/A	PCM - 3 mo; PSM - N/A			0 (0)	0 (0)
Shiraishi et al[23], 1993	3	PCM (100)	3 (100)	3 (100)	6 wk			1 (33)	1 non-union for a patient who did not stop training (33)
Yokoe et al[8], 2004	10	PCM (100)	6 (60)	6 (60)	N/A	4 (40) – RR 100%	Hallux valgus deformity (n = 3)	0 (0)	3 delayed unions with PCM (50)
Pitsis et al[24], 2004	2	PCM (100)	0 (0)a	0 (0)a	N/A	1 (50) – RR 100%	2-yr delay to diagnosis	0 (0)	1 non-union with PCM (50)
Munemoto et al[25], 2009	4	PCM (50) PSM (50)	4 (100)	4 (100)	PCM - 8.5 wk, PSM - 10 wk			0 (0)	1 mild deformity with PCM (50)
Yamaguchi et al[26], 2017	4	PCM (100)	3 (75)	3 (75)	5 wk	1 (25) – RR 100%/RT 4 mo	1-yr delay to diagnosis/Claw toe deformity	0 (0)	1 non-union and claw toe deformity with PCM (25)

^a1 no return due to fear of re-injury. PCM: Primary conservative management; PSM: Primary surgical management.