Turf toe -how to prevent this injury, conservative treatment - PowerPoint PPT Presentation

Turf toe -how to prevent this injury, conservative treatment Michael J Coughlin, M.D.

Conflicts • None for this talk • Consultant with Arthrex, Stryker, Integra • Royalties from Arthrex, Stryker, Integra, Erchonia • Textbook royalties- Elsevier

NFL study of turf toe • Bob Anderson / Mike Coughin • Rich Kent , Jeff Crandall (Univ Virginia) • Studied injury films • Anatomic testing of Turf toe model • Assessment of NFL players • Computer modeling

NFL • Injury and survelliance • Kept statistics for > 30 years • Data entered by trainers • Incidence of Turf toe injuries over last 20 years

Cadaveric simulation-NFL study Di Tear Medial phalangeosesamoid ligament distal to medial sesamoid Pl Do Pr CENTER for APPLIED BIOMECHANICS-UVa Primal Pictures, 2009

Fundamental Research Driving Product Design through Assessment Injury risk Turf toe performance Low Toe flexion angle er limb Interpret Equipment Behaviors

Risk Factors • Increasing age • Increasing weight • Longevity of play • Pes planus • Decreased MTP ROM

NFL injury and safety committee What we perceived as causes • Lightweight flexible shoes used on turf • Increased flexion of forefoot

• Players want lighter, “faster shoes • Have little regard for possible injury • It wont happen to them

Biomechanics • Normal active 80 ° active & 105 ° passive ????? • 60 ° extension with barefoot motion • 40 ° extension in shoes • Sliding is replaced by compression at limits of extension • Extreme extension can result in impaction of phalanx on metatarsal!!!

Classification • Stretch, sprain • Grade 1 • Partial tear • Grade 2 • Disruption of • Grade 3 cap-lig complex • Articular crush • Grade 4 injury Coughlin MJ: Turf toe injuries to the Hallux MTP Joint. 2003.

Athletic Participation • Grade 4-”the ball game is over”

McDuffe film

Imaging Dorsiflexion stress views

Radiographic findings -Retracted sesamoids-

Imaging • Bone Scan – Differentiate bipartite and fracture

Ultrasound

Imaging • MRI – Definitive study of capsular disruption, plantar plate disruption, and articular damage – Sagittal images for capsular pathology

• T2 sagittal STIR sequence of the great toe. Arrow demonstrates rupture of the capsular ligamentous complex just distal to the medial sesamoid bone. McCormick and Anderson (2009)

5 year project • Goal-to diminish incidence of turf toe injuries in the NFL • One million dollar project • Headed-Bob Anderson,M. Coughlin • Hired engineers from Univ of Virginia – Jeff Kent, Rich Crandall

Turf Toe Testing-Univ. Virginia

What normally happens!!! 44 ° 40 °

Vulnerable Foot Position (Turf Toe)

Move the curve to the left 56 ° extension 99% of athletes low risk of injury

Stiffen the shoe We test all shoes now, and reject those that are too flexible

Prevention • We have installed regulations for turf in all stadiums • Probably less the turf that the shoe • OUR GOAL • Change in the shoe model • “a safer shoe”

Shoe inserts

Drawer test pre-op

Drawer after

Have we succeeded? • 2008-more frequent injuries • 2016-17- markedly decreased • Players still choose their shoes- - but we are making a difference!