0:00

This was one of our legendary players recently retired.

0:05

And what actually took him down was an ankle injury and a toe injury.

0:10

The toe came first, the ankle came second, and it happened over a,

0:14

over a period of years. So I'm gonna stick to my,

0:18

my protocol that I've shared with you, and that is,

0:22

I'm gonna look at the sagittal. And my first impression is, boy,

0:26

am I disappointed in the proton density stir.

0:29

Now these are toe coils. Um, so they're very,

0:33

very small round coils that you slip right under the toe or the finger.

0:37

I love them.

0:38

But sometimes if the technologist is not really dialed in and you do a lot of

0:42

fat suppression, you don't have enough signal. And that,

0:46

that was a mistake that was made here.

0:48

So all we can do with this is look at it as a bone scan. Oh,

0:51

it's so swollen right here. Um, now that's about it. You know,

0:56

it's a swollen, it's a swollen toe.

0:59

We can see the flexor lysis longest right there.

1:04

And, uh, I think we'll dismiss the rest of this proton density,

1:09

stir nuclear medicine type sequence and go over to our very robust,

1:15

uh, signal to noise, T two star gradient,

1:19

echo additive three D uh, imaging,

1:23

also known as Merge Medic or M F F E on some of the other vendors.

1:28

This one came off of the Hitachi scanner. And as we scroll back and forth,

1:33

and I said earlier,

1:35

I don't mind if the planter plate is beat up a little bit in a 50 year old

1:38

woman. I do mind when it's beat up in a, in a 29, 30 year old man.

1:44

I mind it a lot. I mean, not only is it beat up, it is just not there.

1:50

I mean, here's a piece of it. It's going ups, it's going vertical,

1:54

should go that way. And if I take my, if I take my drawing,

2:00

my drawing tool mean it should be looking something like that. And that, that's,

2:05

that's absent. So the planter plate is, is kind of messed up.

2:09

There's a fragment of something right here that doesn't belong there.

2:13

And the other thing that you'll notice,

2:16

even though the flexor lysis is a little swollen,

2:19

a little bit frayed but intact,

2:21

where is the sesamoid going?

2:26

The sesamoid is going to Brisbane in the,

2:30

in the northeast corner of, of the foot right here.

2:34

It's going east towards the beach. That sesamoid should sit over here.

2:39

So it is completely lost.

2:41

Its tether 'cause the sesamoid is anchored by several structures.

2:46

It's anchored by the capsule.

2:49

And it's also anchored by a group of ligaments that come down this way from the

2:54

side, the so-called suspensory ligaments or accessory

2:59

Collateral ligaments. They have all kinds of names in different countries. And,

3:03

um, and by the way,

3:04

you can also see he does have a little injury of his distal flexor lysis.

3:08

That one would be cons would be treated conservatively in, in a,

3:12

in a person like this.

3:13

And let's go over to the other sesame that doesn't look any better.

3:18

It's also migrated very proximal. Now, when you look at your sesamoids,

3:23

why are they being drawn proximally?

3:25

Because they are attached by the flexor digitorum

3:29

brevis. So here is, here's the brevis on the medial side,

3:34

and here is the brevis on the lateral side.

3:36

The brevis on the lateral side is not so good. It's still there,

3:39

but it is very swollen. Here's what a normal brevis attachment looks like.

3:44

So the brevis is pulling the sesamoids back, which is another,

3:49

uh, serious, serious problem.

3:52

So we've got plantar plate disruption,

3:56

we've got sesamoid displacement,

3:59

we've got one sprained, uh, flexor digitorum brevis.

4:05

We've got a small tear distally of the flexor lysis.

4:09

Longest and surprisingly for this very high performance

4:14

athlete who's constantly, you know, using his toes to, to, um,

4:19

to stay in bounds for certain, certain processes.

4:23

In the game of American football, he has an excellent looking joint. Um,

4:27

you can see the cartilage of the metatarsal head.

4:32

This dark area is the capsule,

4:34

and this white area is the cartilage of the base of the proximal

4:39

phalanx. So, uh, you know, with the right therapy,

4:42

this should do well because intrinsically the joint is pretty good,

4:45

but we're not done yet. Now let's see if we can three up this.

4:50

And let's go to the, the coronal projection

4:56

and we'll put up all the coronals together.

5:00

See if I can flip this one.

5:04

It's a rather complex case, all using the, all using the toe coil.

5:11

And there it is. The T one has a little bit of artifact from wraparound,

5:15

but I think you get the picture.

5:17

Great cartilage still corroborating our initial theory,

5:21

but look at what's happening with these collaterals. Wow,

5:26

this, remember, this is a young, this is a 30 year old professional athlete.

5:30

Look at this one. Boom. This one looks terrible.

5:34

It's very swollen over here. Very swollen over here, but it's still there. And,

5:38

uh, but this one on the, on the, the lateral side is just shot.

5:44

And then we're gonna keep up these two and we're gonna bring down our most

5:49

favored nation, uh, short axis view. I think we'll go with this one. The,

5:54

the T two,

5:56

Uh, maybe not a little too dark. Let's go with the T one.

6:01

That won't be too dark. I mean, wow.

6:06

Here's one of our sesamoids that's drawn backwards right here.

6:10

But look at what's happening over here. Remember we said that the,

6:14

the metatarsals, uh, sorry,

6:17

the sesamoids were fixed by the flexor digitorum brevis

6:23

by the capsule. Something I haven't described yet,

6:25

which is the sesamoid ligament, which is ruptured right here,

6:30

right there. That's the ligament. It should go right over to another sesamoid.

6:34

Where is that? Sesamoid proximally into the screen.

6:38

So we've got some suspensory ligament here. Uh,

6:42

but on this side we've got nothing.

6:45

The suspensory or quote unquote accessory collateral ligament

6:50

looks just absolutely rotten right here. There's nothing there.

6:54

And then we can go into the mid coronal plane and see what's happening with the

6:58

regular proper collateral ligaments. They don't look so good.

7:02

Look at that proper collateral ligament. Yes, it's there, but interstitial,

7:06

it's, it's darn swollen. It's too thick. And this other one is, is pulled off.

7:11

So you're talking about a, you know, a reconstruction, uh, for,

7:16

for this tow, uh, in this athletic individual. So in summary,

7:21

uh, we've got the entity and we're, we're gonna ignore the second tow right now.

7:24

That's just a stress phenomenon from, you know, him changing.

7:29

'cause he did try and play on this from changing the altered mechanics of weight

7:33

bearing and kinda walking on the second, running on the second metatarsal. Uh,

7:37

which was not problematic for him by the way. He did play for a while with this,

7:41

but eventually he just kind of ran outta ability to play.

7:45

So turf toe with, uh,

7:47

complicating planter plate rupture all the way from medial to lateral

7:53

reservation of the cartilage

7:56

sprain swelling and thickening of the medial collateral ligament,

8:00

tear of the lateral collateral ligament,

8:03

tear of the lateral dispensary ligament injury to the medial dispensary

8:08

ligament,

8:09

and injury to one of the flexor lysis brevis attachments,

8:14

uh, to the sesamoid. The phenomenon of turf toe,

8:18

which is usually seen with very, very, uh,

8:22

fluid extensible footwear on a rigid surface.