Hello. This is Truett Cooper from the University of Virginia. I'm going to be giving a talk on basically an update on turf-toe and plantar plate pathology. And by plantar plate pathology, I mean that of the lesser toes. This is part of the four-foot module on the on-demand education course from the AOFAS. I don't have any disclosures related to this topic. Plantar plate of the great toe, which would be a turf-toe injury, and plantar plate pathology of the lesser toes I would say are very loosely related in that they're part of the connection of the base of the proximal phalanx plantarly, and that's maybe where the relationship ends. First MTP joint, when there's plantar plate pathology, it's almost always from an acute injury, whereas the lesser MTP joints, usually the second, it's most commonly going to be degenerative or attritional, although you can have an acute dislocation from a traumatic injury. The goal of this module is to provide a brief overview and more of an update on what recent advances in evaluation management of these two conditions, really focusing on the last three to four years, what's new in the literature. We do have some links at the end and as part of the module to some great webinars in the on-demand education center to supplement this material, as well as links to a couple of journal articles from Foot and Ankle International over the last three years related to this material that's part of the module. There will be some questions associated with this topic, and the answers to those questions will be based on this talk, as well as the journal articles and the webinar videos. So we'll start with turf-toe. So what is turf-toe? It's a traumatic injury to the first MTP joint, generally thought to be primarily a hyperextension injury. That's mostly what we think of when you see a diagram in a textbook. It's that hyperextension injury in a football player. It was first really described by Martin out of West Virginia in 1976, and during that time, you know, there was a sort of maybe an ongoing transition to artificial turf surfaces, and we're seeing a lot of these injuries. I think when you're thinking about turf-toe, it's important to consider all the different variants that go along with it. You can have a varus injury, you can have a valgus injury with damage to the collateral ligaments. You can also consider acute fractures to the sesamoid. I like to group these all together with these traumatic injuries to the first MTP joint. Historically, you know, these have been devastating, often career-altering or changing, sometimes career-ending injuries. Deon Sanders historically had a turf-toe injury, and ultimately, more recently, was in the news for having to subsequently have surgery for that. This is an anatomic diagram of the medial view of the first MTP joint. It's from Neri et al., Magnetic Resonance Imaging Clinics in North America, but I think it's a really good depiction of what the structures we're talking about are. You have the plantar plate here. It blends with the tendon, this portion of the flexor hallucis brevis distal to the sesamoids. You have your sesamoids. You have sort of what I consider sort of a suspensory ligament. There's the collateral ligaments that provide various endogastability, and then you have your FHV tendon up here. What are the injury patterns? I look at this as you can have a complete plantar plate injury with the medial and lateral injury disruption. You can have a partial plantar plate where it's either medial or lateral. You can have a plantar plate with medial or lateral collateral ligament injury. You can have a transtesmoidal turf-toe type of injury, which is going to be a fracture through the sesamoid, or you can have a pure medial or lateral collateral ligament injury without any connected plantar plate damage. That's not technically probably a turf-toe, but we see that in the traumatic hallux valgus, and then you have to look for any associated chondral damage. The classification, this is from Dr. Anderson, who really in a lot of ways led the way on treating these turf-toe injuries. This classification is probably getting close to 20 years old, but it's still often used. Basically, grade one is a sprain to the plantar structures, maybe some attenuation, but no loss of continuity. Those you treat symptomatically, maybe a little bit of mobilization, some rest, and they return to play as tolerated. Grade two would be partial tearing of the plantar ligament structures, plantar plate. Again, that's typically going to be non-operative treatment, two to three weeks, and then generally return to play with taping, shoe modification, such as a graphite plate or something like that. Then grade three would be disruption of the plantar plate, which usually necessitates either casting or surgical repair, and that can be four to five months to return to athletic competition. This classification is still really used pretty regularly. When you're looking at evaluating these injuries, a clinical exam may be the most important, and there's really nothing new here in the literature. Nobody's come up with a new proven diagnostic test. You want to look for any instability or deformity. It's very hard to test these patients with sort of a drawer or lockman type test because they're swollen, they're sore, they're stiff, and they're guarding. Imaging, you always want to start with standing, if possible, standing radiographs and compare it with the contralateral foot. You want to look for sesamoid position as well as for any fractures in the sesamoid. This is a college football player. The AP you look at, it looks pretty normal. You don't see too much here. There's no fracture, but when you look at the lateral, and this is without even any significant stress, he's not up on a block or anything. This is just sort of resting position. That looks to me to be enlarged in that space there, and you have to really compare it to the contralateral side. Dr. Waldrop, several years ago, published a paper and suggested that stress fluoroscopy can be useful, and they found that basically a greater than three millimeter difference in excursion between the injured and uninjured side would indicate a more severe injury and potentially one that requires surgical intervention. MRI is very useful and often done, maybe considered still sort of the gold standard, but you have to combine it with the other modalities to really evaluate these. MRI is useful to evaluate the plantar plate itself, the collateral ligaments, and chondral damage. This is the same individual whose x-ray I previously showed, and this is looking at the medial side, the medial tibial sesamoid. You can see there's really no soft tissue connecting the sesamoid to the proximal phalanx. This is a T1-rated image in T2, lots of edema passing all the way through there, or fluid passing between them, and then looking on the lateral side, same thing. So this is a complete plantar plate injury. The medial collateral ligament is also injured in this individual as well, and so again, I think that's really important to recognize because it will affect your treatment and management of these. Ultrasound has been becoming more widely available throughout orthopedics. I think we're seeing it more and more in clinics. Lots of sort of advanced providers such as PAs and nurse practitioners have been trained, at least in our practice, using the ultrasound. It's quick. It's right there, and it allows for visualization of these ligamentous structures as well as a dynamic evaluation, so you can see how the sesamoids are moving. I think you do have to be a fairly skilled ultrasonographer to really evaluate these small structures like the plantar plate, but it is becoming useful in this treatment. Most of the treatment guidelines are based still on the original classification by Dr. Anderson. Very little high-level or recent evidence to guide us. Surgical indications would be an unstable joint on an exam, which is difficult. Retraction of the sesamoids three millimeters or greater compared to the other side. Complete rupture of all the plantar structures, and that typically would be based on an MRI. Diastasis of a sesamoid fracture. If you see, like, to me, if I see someone who's resting posture is already demonstrating some clawing of the great toe, that's going to push me towards surgery. A traumatic hallux valgus. I think catching those earlier makes them much easier to fix. Any loose bodies would be another indication. So, what's new? And this is where I said we're limited, and so I did a pretty extensive review of all the literature over the last three to four years regarding turf toe and first NTP joint traumatic injuries, and there's really not a lot of high-level evidence. One thing that was interesting was Seattle's group with Dr. Kennedy from New York tried to perform a systematic, or they did perform a systematic review. They actually were going to attempt, according to the article, meta-analysis looking at treatment options, and they found that really there's just not enough evidence out there that fit the criteria they could even do a meta-analysis. They were only able to include 16 total patients out of, I believe, four studies when they looked at all the studies that included either a classification system, or included a classification system, as well as outcomes criteria. So, really, there's really a dearth of true evidence for best treatment practices for these plantar plate turf toe type injuries. Another study that's related but not directly considering turf toe injuries is from Canada and Foot & Ankle International in 2021, and there's a link to this article in the module. This is a case report examining medial sesamoid fractures in NCAA football players in their return to play. They had four players. They treated these with excision of the small fragment, repair of the flexor hallucis brevis, and an abductor hallucis tendon transfer. I think that's an interesting part to include because a lot of times with these medial injuries, or even in the turf toe type injuries, if the medial structures are very attenuated or damaged, you can often consider transferring that abductor hallucis tendon to bring more tissue and perhaps strength into that defect. They found that all four of these players were able to return to sports between five and six months. Maddy and Preck, they looked at a study, which is sort of a different way to look at these. Sports analytics has become a big thing, and so they looked at outcomes of turf toe injuries in the NFL using a power ranking system over six subsequent seasons to see how much long-term deficit this created. They only have these power ranking systems and sort of skill type players on offense, such as running backs, wide receivers, quarterbacks, or tight ends may be included, but what they found was there were 67 players and 71 injuries. It's not entirely clear how this number was calculated. It said a lot of it was internet-based searches, and they found no difference in the outcomes looking at power rankings over the following six seasons for the injured players compared to those who had not suffered a turf toe. So that's showing that, at least at the NFL level, that perhaps these are being managed well and the outcomes are different than they were 20-plus years ago, when a lot of times this could be a career-ending injury. In summary, outcomes for turf toe injuries are generally favorable at this time if they're identified and treated early. There really is a minimal level of high-level evidence or a minimal degree of high-level evidence or recent evidence to support any particular treatment options for these injuries. And the high-grade injuries requiring surgery are generally fairly rare, but you have to have high index of suspicion when evaluating them. You don't want to miss them. So now we're going to move on to part two, which, again, in name only, do I really consider this to be a related pathology, lesser-toe plant or plate pathology? Most commonly, this is going to be a degenerative condition. You're going to see it a lot. You'll see it in patients with rheumatoid arthritis, other inflammatory arthropathy, but also just poor foot deformity. Traumatic injuries are possible. I've seen a handful of traumatic second and PP joint dislocation or other lesser-toe dislocations in practice. A lot of times those can be reduced and they will be stable, but occasionally they will demonstrate long-term instability. Most commonly, by far, it involves the second digit, but you can have it in third or fourth, really. It's a common cause of metatarsalgia, which I consider to be just pain in the metatarsals. We just don't know the specific etiology off the top, you know, right away. I think it represents a spectrum of disease, and I'm not alone, including crossover toes, hammer toes, or what we consider MTP joint capsulitis or synovitis. Really, all these precursors are part of the spectrum of instability of these lesser MTP joints. Historically, most of the treatments are what I would call workarounds, not really addressing the pathology directly, but doing things like straightening the toe with a PIP orthodesis. Some people consider that to be able to transfer the flexor forces more proximally. How well that works is debatable, as a lot of these people's toes will still sit up and it doesn't affect the coronal plane alignment. We would shorten metatarsals to unload the joint and decrease the stress on the tissue. We excise metatarsal heads in severe cases, perhaps dislocations or inflammatory arthritis. We'd transfer tendons, flexor, extensor tendon transfer to try to stabilize the joint, but none of them really addressed any of the plantar plate pathology that we know is there. In the last 15 years, I think there's been more interest in direct repair of the plantar plate. Although, if you look back even further, as far back as 1998 and forward, it all published a repair technique for this back then. This is taken from a paper from Jim Jasper that describes an anatomic rate of plantar plate tears. A lot of it's based on cadaver studies, looking at hammer toe and crossover toe deformities. I think it's a useful way to look at this, but your grade zero would be, maybe some inflammation, mild attenuation of the plantar plate. Grade one, which is in figure A here, is going to be transverse, less than 50 percent. It's typically going to be the distal part, maybe mid-portion. You rarely see any proximal tearing. Grade two is transverse, greater than 50 percent. You can see it start to creep across here, and it may be, again, distal or mid-portion. Grade three is transverse or longitudinal and extensive tearing. If you look, it's all the way across, degenerating into further back, approximately. Grade four is going to be an extensive tear with a buttonhole and a dislocated toe, most likely. That's one way to look at these. I think the implications for treatment aren't entirely known yet. As far as evaluating these, ultrasound has been proposed by McCarthy and Thompson. Skeletal radiology is being one of the best ways to look at this. They felt, in some ways, it may be superior to MRI due to the fact that it's dynamic, so you can actually take the toe through a range of motion and see any discontinuity in the plantar plate. That goes similarly for the terp toe injuries. They felt that they were able to identify tears, attenuation, as well as pericapsular fibrosis, and evaluate for frank instability due to the dynamic nature. They also mentioned that possibly ultrasound was better than MRI for evaluating or distinguishing between sort of like a more just aromatype pathology and this pericapsular fibrosis, which MRI was not as good at identifying. Often, there's some overlap. People come in all the time with a diagnosis of Morton's neuroma, and what they really have is second and TP joint pathology. The direct repair. It can be done either through a dorsal approach, maybe performed with or without a metatarsal osteotomy. I'll talk a little bit more about that. Suture is basically placed in a distal plantar plate, and it's secured to the proximal family space. There's different types of suture passers. People have made their own. Usually, they're going to be done through a drill hole into the proximal phalanx and pulled up and sutured down. A direct plantar approach is also described, and you can really repair the plantar plate directly. If you find it's sort of a more mid-substance tear, you can suture it in a pants or vest fashion, tighten it up, imbricate it, or you can advance it and reattach it to the proximal phalanx with a small suture anchor or drill hole. Either way, I think you have to address the other pathologies. If they have a rigid hammertoe, that needs to be fixed. If they have collateral ligament disruptions, it's appropriate to address that. Tali Sen et al. and their group have published two papers on the vascularity in the last three years of the plantar plate using a nano-CT imaging technique and cadaveric specimens. Those articles are linked to the module. Really incredible work they've done, and the images are spectacular. What they found is that in a torn plantar plate specimen, they demonstrated significant neovascularization around the torn region compared to normal plantar plates. It's not clear what the implications for treatment are, but it's evidence that this is damaged and is trying to heal. We see this in a lot of other sort of chronic degenerative pathologies, whether it's lateral left condylitis, others as well. The other thing they found in anatomic studies is that when you're looking at the blood supply to the plantar plate in just a normal specimen, the vascular supply comes primarily from the metatarsal, at least to the proximal part of the plantar plate. There's a secondary supply from the plantar fascia, but almost two thirds of it in most specimens, particularly the second NPP joint, had that supply coming from the metatarsal. The reason that's important is because we often, when we talk about these pathologies and we're doing either metatarsal osteotomies or releasing the plantar plate, a lot of the descriptions talk about releasing the plantar plate from the metatarsal head using something such as a McLamory elevator to peel it off, and that may have ramifications for the blood supply to the plantar plate. I published a study with Dr. Coughlin, it's been over 10 years ago I think now, looking at exposing the plantar plate for repair, and one of the primary things we found was if we used the McLamory elevator to release it off the metatarsal head, we could see it better. Some sequence studies show that may not actually be true, but something to consider as we go forward treating these pathologies. Other recent outcome studies, this is from Cook et al., a foot and ankle specialist from 2020. They did a one-year follow-up on their direct repairs through a dorsal approach. They did do sort of a myriad of other procedures with this, which makes it sort of a heterogeneous group, but they basically described a placation of the plantar plate and four medial collateral ligaments. Some of these had metatarsal osteotomies, some did not, but overall in their patient cohort they said they had 92% of them had improved stability and significant pain reduction, and at one year they had maintained their radiographic correction. Another outcome study by Fleischer et al., and I believe this is from Will Wallace's group, in the general foot and ankle surgery in 2020, compared a while osteotomy with a direct plantar plate repair versus a while osteotomy alone, and they did the repairs through a dorsal approach at the same time as the osteotomy. So all the patients had an osteotomy short of the metatarsals. Some of them had plantar plate repairs, some of them had osteotomy alone. These were not randomized, so yeah, I think we have to factor that in when considering this, but what they did find was that overall all the patients did better, or both groups did better, but the group with the combined procedures had significant improvements in patient-reported outcomes, specifically higher quality of life and better pain scores at one year than the osteotomy group alone. Overall, there was no difference in radiographic outcomes, so it doesn't seem to help maintain any of the coronal plane alignment or sedentary plane alignment. One thing, again, to point out, this was non-randomized, and they felt that looking at the combined group compared to the osteotomy alone group, preoperatively the combined group had more significant tearing of their plantar plates than the osteotomy alone group, so they felt, based on that and the fact that they actually had better scores afterwards, perhaps adding a plantar plate repair may be of some benefit to an osteotomy. So that's sort of an update on what's new in the literature. As you can see, it's not a lot, hopefully it's helpful. I do have some videos that are correlated with this that I recommend and are really part of the module. One is specifically against surgical erection of left stereotype deformity, and that's moderated by Dr. Taliesin, who published those papers on the vascularity. I highly recommend that. And then another is sports problems I hate, which has a good section on turpto. Again, a couple of FAI articles to look at, and I'll stop for there, and there will be some questions to answer. And through this module, you should be able to reach out with any questions to any of the faculty or presenters for a period of time after this is released. So thank you very much.

turf toe

plantar plate pathology

injury patterns

treatment options

direct repair

limited evidence