gets, he's going to solve all our problems. But really, I'm going to make it worse for you, because I do not have all the answers. But I do have a slide at the end. When the question was asked, when do I operate? And a recent study showed that less than 2% of turf toads actually need surgery. But obviously, when they're looking us right in the eye in the training room, and we're looking at the video, we're all asking each other the same questions. What do we do with this? So no disclosures for this talk. So a little bit on the anatomy, which is essentially important here. First discovered and reported in 1976 in West Virginia with a hyperextension injury of the MTP joint and disruption of the plantar soft tissues. When you really look at the stability of the MTP capsule, the ligamentous construct is critically important. You have the short flexor complex, and also the FHB critical, and also sesamoids. And that associated anatomy of the sesamoid bones, when individuals are complaining about they've had pain in that area for years, when you have a more experienced athlete, or someone who says, you know what, I've always had some issues here. And they never can quite tell you whether they had a fracture previously. Did they ever have any type of anatomic variance when they were younger? And so it's just an area that becomes complex. But the anatomy of this area is very complex. And so instability is something you just have to really tease out. And so occurs in about 0 point, again, 0.062 in 1,000 athletes. Risk is higher on artificial surfaces. That's just the reality. And if you look at all the studies and all the recent meta-analysis that continues to carry through, that these injuries are more common than natural grass. But who knows, after this year's Super Bowl, that may change the studies altogether. Acquired via contact with playing surfaces, or contact with another player. So this is one, if you have the opportunity to peel back on a video, particularly in football, it's ideal just to get an idea of how this occurred. Because it can occur, sometimes not contact, but often when someone's at the bottom of a pile. And so again, that mechanism, that hyperextension, and you essentially have a disruption of those plantar tissues. But also, if someone is landing on another object, causing that hyperflexion is also common to occur. So you'll see this mechanism as well, commonly. And so the grade one is a sprain of the plantar plate. And so the plantar plate has taken on a life of its own over the years. But essentially, if we look at the entire complex here, that grade one, essentially just a small sprain, plantually, okay? You usually do not have any level of retraction of your sesamoids, or you should not. And also when you look at grade two, partial tear, grade three complete. And essentially going down the path of a mild, moderate, and severe pathway. And we'll talk a little bit about the imaging that I like to get on all of these. They will have pain, stiffness at the MTP joint, swelling, tendons to palpation along the entire complex, collaterals, dorsal capsule, and the plantar sesamoid complex. And they sometimes, if you can really examine them acutely, they may have a vertical, what we describe as a vertical Lachman, where you can take their metatarsal head and their great toe, distal to that area, and essentially shuck their toe dorsally and plantally. However, in the acute setting, that usually does not buy you any friends. And so the radiographic evaluation is critically important. Now this is just a single AP, and I'll talk a little bit about the approach we take. So you really, the more x-rays you look at, just look at their sesamoids, even when they just come in with no problems. There are three areas that I look at on every foot film, regardless, and I try to remind myself of it. I teach my residents this. Sesamoid complex, fifth metatarsal, navicular. And because those are the three areas, when you go back and you look at an x-ray a year later, and you find out, ooh, they've always had a bipartite sesamoid, or they did not. They've always had chronic thickening or a stress fracture of their fifth metatarsal as listed earlier, or they've had a small crack that's just gotten thicker and thicker and sclerosis of their navicular. So those are the three areas. So just look at their sesamoids. And the more normal ones you see, the more comfortable you'll see looking at the abnormal. And also getting a good lateral. This is not possible without a weight-bearing lateral. They have to be weight-bearing or at least simulated weight-bearing so that you can appreciate whether sesamoids are sitting in the lateral plane. MRI is the best image for soft tissue assessment with these injuries. And as you can appreciate here, again, looking at this complex from the lateral, and then essentially, whether it be a T1 or a T2 image, being able to look at those soft tissues, and again, appreciating any edema and also changes within the sesamoids. So advanced imaging is commonly used for these, but start with a plain film x-ray. A few things on return to sport, and this is a little wordy slide. It's really affected by the injury severity. You will have some individuals who have a horrible mechanism, and if their swelling goes down, they recover, they're able to bounce back pretty quickly. Most turf toe injuries are treated with our traditional rice method, orthotics, antisteroidals, and also anti-inflammatories, and also acute relief of symptoms will occur. For grade one injuries, these usually lead to return to sport pretty well. Some individuals can take three to five days off or a long weekend, go into a stiff shoe. Anti-inflammatories have helped them. Very little loss of playing time, but it will nag them. Grade two injuries are treated based on symptom severity, and these are the ones, I was just speaking with Dr. West in the back, where you're just kind of wondering, can they perform? Particularly with skilled players, and particularly with, in my experience, exterior linemen, who essentially, if it's on their drop back foot, it creates a major issue for them. And then when we look at grade three injuries, these usually require six to eight weeks, closer to eight weeks, because they often require surgery for the recovery period in time, and so often a season is lost with those. But the non-operative management, again, grade one, taping of the toe in a plantar flex position, stiff sole shoe, most elite athletes do not want to be in a boot. However, if necessary, I will immobilize them in a boot while I allow the swelling to go down in passive range of motion, and again, the rice method. Grade two, the walking boot, protected weight bearing, and then the capsular injury will usually calm down. If they have instability, I will potentially tape them to the second toe. And also, with grade three, as we will talk about, that is often surgical intervention, eight weeks of immobilization. If not surgery, it can take up to six months. And this is when you have to repair one of these, it's better just to advise them if their season may be done. But very important in your orthotic, my approach is usually a semi-rigid orthotic with a Morton's extension to help minimize dorsiflexion. Some go with a full carbon fiber plate extension or just a carbon fiber plate. You can get them off Amazon now, but essentially whatever the player feels most comfortable with. And again, this is the operative management piece. Less than 2% of these do require surgery. However, the major indications, large capsular avulsions, if they have diastasis of their sesamoids, which we'll show one of those here, a sesamoid fracture with diastasis, vertical instability, traumatic hollux valgus deformity, you'll see that in a number of athletes, a loose body or a chondral injury, or they've just failed conservative treatment, and then we have to move on to surgical management. And the operative technique, just to go a little bit on this, you wanna look at the flexor hollus' longest tendon. We look for any tears that may be present. If you're gonna go in, look for tears. If you're gonna repair something, make sure you repair everything that was there. The MRI report on these, essentially it sounds like a bomb went off in their great toe joint. And so you really, if you're gonna go in operatively, don't use the report, use what you see. And when you get in there, have the report just guide you. You wanna stabilize the first MTP joint. I usually do this either by anchoring the plantar plate with a resolvable anchor. I've also shifted now, this constantly changing. I've taken a technique from Martin O'Malley and Bob Anderson. I will sometimes drill through the base of the proximal phalanx and pass a suture and tie it over a knot. But an end-to-end repair can occur. It's a very thick capsule there. And I use a non-resolvable suture. If there's a sesamoid fracture or it's fragmented, I will try to preserve a pole of it. But if it is a huge fracture and I do not believe it's going to heal, I will just preserve a sleeve of the bone. I will take that shell out. I do not want it to be a pain generator in the future. Again, you will find a number of different approaches with that. I look forward to discussing with my other foot and ankle colleagues. Post-operative management, I splint them in plantar flexion seven to 10 days. Then I start passive range of motion. Nothing above neutral. They're non-weight-bearing in a removable splinter boot for four weeks. Then I increase their motion and allow ambulation in the boot. Modified shoe at two months, return to contact with protection and minimizing excessive dorsal flexion for three to four months. Usually complete recovery is six to 12 months. A couple of things, complications that can occur with these, loss of push-off strength, stiffness. They can develop hollow-lux rigidus, which is progressive arthritis of the MTP joint. A cock-up toe deformity was one that was really a concern years ago. A lot of our modification splints help prevent that, but they can have problems with that in the future. A traumatic bunion deformity, loose bodies in the joints. You want to keep an eye on that. And essentially joint fibrosis. They become so stiff and scarred. So painless and stiff is a friend. But if they are stiff and they have tons of pain, that obviously creates downstream issues that you have to manage. The prognosis is really based on the grade of injury. More severe injuries require additional time. Some cases, you really do get an incomplete result. They will be stiff, or they will have progressive arthritis. So you have to use shoe modifications, occasional medication modifications to address that. And really prevention of re-injury is paramount. And so this is just one case, an acute injury. Had a sprain and a college running back. Unable to return to play. MRI showed a 50% partial plantar plate tear. We tried to treat this conservatively. On the stress X-ray, he had a three to four millimeter side-to-side difference, which I will show you. Tried initially four weeks in a boot. Never really calmed down from a pain standpoint. So we moved forward with surgery. So the reason I put this here is, I get bilateral AP foot images on anyone who comes in with foot pain. Everyone gets a bilateral, and that's when you get used to looking at normal toes and metatarsal heads. But if you look at this side versus the injured side, there's proximal migration of the sesamoids consistent with the injury with the stress X-ray gloves that I have there. And so in this particular case, this was at a point in my career when I wanted to be able to see where the anchors were on X-ray forever. I now use an anchor that you can see on X-ray, but placed two of those. Individual return was able to finish the season. But the hype is, this has given a lot of people major problems. Shaquille O'Neal still jokes about his big toe being problematic. And we all know about the issues of Deion Sanders and his toes. But turf toe was one of his major issues in the latter part of his career. And I still remember my mentors talking about that when I was a fellow. But the reality is this, a number of these injuries can be prevented with the appropriate precautions. So with preventable shoe wear, either a stiff shoe, and a number of these studies have been published now. This just happens to be one I was involved in while a resident at University of Virginia. A lot of these dovetailed from the NFL, a lower extremity injury grants that were performed. And essentially at that time, the athletic shoes were horrible. And now many of them are very flexible now, but they are getting better. So I would give credit to that. But turf toe can be prevented if you can minimize MTP dorsiflexion to less than 70 degrees. A good carbon fiber insert or a reinforced sole of a cleat can actually do that and decrease your injury risk and also decrease your grade of injury. So thank you. And don't forget what's important other than your great toe. Thank you.

turf toe injuries

anatomy of the foot

MTP joint stability

treatment options

prevention