Stephen F. Brockmeier, MD Associate Professor, Team Physician UVA Athletics ACSM/AMSSM/AOSSM Advanced Team Physician Course December 8-11, 2016 San Diego, CA
Learning Objectives 1. To review prevalence of, presentation of, and management strategies for athletic turf toe injuries. 2. To critically review the current literature and evidence and potential research avenues to improve team physicians abilities to appropriately and safely treat great toe hyper-dorsiflexion turf toe injuries.
Disclosures Consultant Zimmer Biomet, MicroAire Speaker Zimmer Biomet, Depuy, Arthrex Clinical Trial (active) Zimmer Biomet Publishing Agreement/Royalties Springer Research Grant Arthrex Fellowship Grant DJO, Depuy Mitek, Arthrex, Editorial Board TSES, OJSM Board/Committee Appointments AOSSM
Acknowledgement Dr. Joe Park
Case Example 19 yo M UVA football player, starting DB Injury during game (1 st quarter). Evaluated by ATC, taped, CF insert, and finished game Following day, noted to have increased pain/swelling/ecchymosis PE: TTP plantar and medial 1 st MTP Painful ROM Stable varus/valgus/ant/post
Radiographs and MRI
Medial sesmoid-phalangeal ligament tear
Lateral sesamoidphalangeal ligament tear
Medial collateral ligament tear
Normal medial side
Lateral tear
Normal lateral side
Turf Toe Plantar plate Anatomy Diagnostic evaluation Treatment algorithms Return to play
Anatomy: Turf Toe Hyperdorsiflexion
Injury To the Sesamoido-Phalangeal Ligament Lateral Head Flexor Hallucis Brevis Medial Head Flexor Hallucis Brevis
Epidemiology First described in 1976 by Bowers and Martin WVU: Incidence of 5.4 injuries per football season Rodeo et al: Followed 80 NFL players: 45% sustained significant turf toe injuries, 83% occurred on artificial turf Hunt et al: 2014: 5 seasons: 0.062/1000 athlete exposures (0.83% of all injuries) Most common: running backs, quarterbacks, wide receivers
Evaluation-Clinical Presentation Swelling, ecchymosis Pain with weightbearing - toe-off Location of Pain, TTP Range of Motion (passive/active) R/o dislocation/subluxation Dorsal stress test, varus/valgus test Intrinsic-Minus? (MTP extension, IP flexion) FHB tendon disruption Strength of MTP flexion
Imaging Studies Weight Bearing XR: AP/lateral, axial sesamoid view, 40 degree medial/lateral oblique views Proximal retraction of sesamoids Medial > 10.4 mm from P1 Lateral > 13.3 mm from P1 99.7% sensitive for plantar plate rupture
Imaging Studies XR may show diastasis of bipartite sesamoids (turf toe variant) Stress dorsiflexion XR can show increased diastasis on lateral or AP XR.
Imaging Studies Bone Scan: Increased sesamoid uptake present in up to 29% normal individuals CT: irregular fracture margins (vs bipartite), osteochondral fragments MRI: fx lines/plantar plate complex, FHL, evaluate vascularity, osteochondral injuries, tear of synchondrosis for bipartite sesamoid.
Classification
Classification Grade I: normal range of motion, able to bear weight. XR normal, MRI intact plantar plate Grade II: Partial tear of Capsule/Plantar Plate Swelling/ecchymosis Motion painful, difficulty with WB XR normal, MRI soft tissue edema/high intensity signal partial thickness of plantar plate
Classification Grade III: complete tear Capsule/Plantar Plate Associated injuries: sesamoid fx, diastasis of bipartite sesamoids, metatarsal articular impaction, proximal sesamoid migration XR: above, can also obtain dorsiflexion stress lateral MRI: Full thickness injury through plantar plate. Sesamoid/chondral injuries
Management Grade I and II: Taping (to prevent excessive dorsiflexion), early ROM, strengthening (esp toe flexion FHL/FHB) Return to play: carbon fiber plate/custom orthotic with Morton s extension Grade II: at least 2 weeks before RTP
Management Grade III: casting/immobilization with plantarflexion of MTP x 6 weeks Surgery considered if sesamoid migration, severe injury/instability, high level athlete If no improvement with immobilization, PT, taping, can also consider operative intervention With bipartite sesamoid diastasis: repair unpredictable, casting likely best option
Kyrie Irving: 2011 sustained an acute injury to synchondrosis of his bipartite medial sesamoid Treated in a cast and progressive rehab: missed 3.5 months Returned for Duke s NCAA run lost to Arizona in Sweet 16
Surgical Management Direct repair of plantar plate via two-incision technique: medial/plantar-lateral Repair of collateral ligaments, FHL, osteochondral defects as necessary Plantar medial and lateral digital nerves adjacent to respective sesamoid
50% risk of injury occurs at 78 degrees of anatomic MTP dorsiflexion Shoe modification can help prevent turf toe injury
Limit DF <56 degrees Decreased Theoretic Risk of Injury
Anderson et al 17/19 collegiate/professional athletes were able to return to previous level of activity after direct repair of Grade III plantar plate injury Suggests more aggressive treatment may be beneficial for high level athletes
Back to our 1 st Year Defensive Back
Back to our 1 st Year Defensive Back Options: Non-Operative: Toe spica casting/taping with limitation in range of motion for six weeks Concerns: retraction of sesamoids, medial and lateral complete disruption of sesamoidophalangeal ligaments, injured in early part of season Surgical treatment: direct repair of medial and lateral plantar plate via two incision technique
Surgical Treatment Medial and lateral plantar plate repair Medial collateral ligament repair Splinting with toe in 10 degrees of plantarflexion to decrease stress on repair
Back to our 1 st Year Defensive Back
Plantar Incision (Fibular Sesamoid)
Completed Repair
2 nd Case Example 18 yo UVA outfielder who sustained a significant Right hallux MTP injury when his toe got jammed between ground and outfield wall when trying to catch fly ball. Significant swelling at MTP joint Able to flex at IP/MTP, with significant pain Pain with passive extension No significant varus/valgus deformity present Pain with valgus stress at MTP joint
MRI
MRI 1. Plantar plate injury with complete disruption of the medial and lateral sesamoid phalangeal ligaments and proximal retraction of the great toe sesamoids. 2. Edema within the distal abductor hallucis and adductor hallucis muscles, likely representing strain.
Suture Repair of Medial Plantar Plate
Lateral Repair
MTP maintained in plantarflexion after repair
Post-op Protocol NWB x 2 weeks WBAT in darco wedge with hallux taped in 10 degrees of plantarflexion Active plantarflexion beginning at 2 weeks post-op Neutral DF at 6 weeks, increase by 10 degrees per week 3 months: underwater running and weight room with stiff shoe/morton s extension Last visit: 5/5 plantarflexion strength, no pain with DF to +30
Conclusions Plantar plate injury can lead to significant impairment with foot biomechanics and ability to push off Appropriate diagnosis/non-operative management can allow for healing of the plantar plate Surgery reserved for severe medial/lateral injury, instability, valgus deformity/early clawing, retraction of sesamoids, chondral injury/loose bodies High Level Athletes?
Conclusions Two incision approach allows for medial/lateral repair with less risk of wound complications Watch out for plantar medial and lateral digital nerves! Early post-operative range of motion is critical to avoid stiffness Limit excessive dorsiflexion for 3 months, then transition to Morton s extension or carbon fiber plate Rehab: focus on strengthening of FHL/FHB!