0:00

Moving on.

0:01

Um, there's also, um, very important structures of each

0:06

of the MTP joints known as the plantar plate.

0:10

So the plantar plate, um, is basically, uh, think of it

0:14

as analogous to the VOR plate, uh,

0:16

in the hands, but not exactly.

0:18

It is a sort of, um, thickening of the capsule, um,

0:23

uh, fibro alila structure, um,

0:26

along the plantar aspects of the joints.

0:29

And, um, it's gonna be deep to the flexor tendon

0:34

for each of the joints.

0:35

And, um, you need good high resolution

0:38

images to see it well.

0:40

But as I zoom in here,

0:45

what you're gonna see for each of the toes is

0:48

that there's a, a flexor tendon.

0:50

But then if you look just on the bottom part of the,

0:53

of the joint, you're gonna see a black structure.

0:57

Here again, is a plantar plate here of this,

1:02

uh, fourth MTP joint.

1:06

Notice that there's a little bit of a fluid recess here, so,

1:09

um, try not to overcall tears of the plantar plate.

1:14

Um, near the fla, uh, the phlange attachment,

1:17

you will see a little thin, um, sliver of fluid.

1:20

That's a normal recess.

1:22

Um, there was a talk, uh, just at the RS NA, uh, and,

1:26

and I've heard in the past where basically if this fluid

1:30

slit, um, is more than two and a half millimeters,

1:33

and that will be more concerning for a tear.

1:35

Uh, so a little tiny bit of fluid is okay,

1:38

but you don't wanna see a bigger fluid, uh, gap

1:40

as you keep going to the bigger joints.

1:42

Again, you can see this plantar plate, sort of think of it

1:44

as a thickening of the under surface of the capsule,

1:47

little tiny, uh, recess of fluid there.

1:50

And then, um, as we get to, um, the, the biggest, uh,

1:54

joint you kind of have, we're gonna discuss here the, uh,

1:57

the first mtp.

1:58

So when you talk about the first MTP, there's a lot

2:02

of structures and we, we've mentioned a bunch of them

2:04

so far, but to keep going,

2:06

and remember, you have the first metatarsal head

2:09

and the proximal phalanx.

2:10

You're gonna have the join here of the MTP,

2:14

and you're gonna have the sesamoid articulations,

2:16

the planter plate of the first MTP is shown here.

2:21

You can see this kind of, um, hypot intense structure,

2:24

linear structure, and there is, again, a recess here

2:28

between the phalanx and the planter plate.

2:30

So try to avoid, um, calling tears,

2:33

unless it's a more of a larger gap for the plantar plate.

2:39

Now, the plantar plate structures, um,

2:41

are really at the midline, so

2:44

that's an important thing to remember.

2:45

So right here, we're at the midline.

2:47

What I'm gonna do is actually go off to the side here.

2:50

This is the lateral part of the joint.

2:54

And if you see here, we have the sesamoid,

2:56

but then we have a black structure going from the

2:59

Moid to the proximal failings.

3:02

This is the CSS moid phalangeal ligament.

3:06

Uh, so it is a ligament, again, a supportive structure

3:09

that you want to check,

3:10

because that can be, um, torn in the setting of turf toe.

3:14

So you have the, uh, ligament going from the CSS moid

3:18

to the phalanx on the medial side.

3:22

You, again, are gonna have

3:24

a ligament going from the medial Hal sesamoid

3:27

to the proximal phalanx.

3:28

Again, this is nice and intact.

3:30

You see hypertense, uh, ligament there again,

3:33

we talked about how this CSM might have a bit of edema,

3:36

have some stress reaction,

3:37

but the ligament itself is intact.

3:41

You also have, um, ligament stitch that aren't, aren't

3:44

as commonly torn, but you still wanna look, um,

3:46

that go from the smite to the metatarsal,

3:49

the sesamoid metatarsal ligament.

3:50

So again, you can see here on the proximal side,

3:53

there's a ligament going from the

3:55

sesamoid to the metatarsal.

3:56

You're gonna have one on each side.

3:58

So go to the medial side and then the lateral side.

4:05

So, um, going then to the short axis,

4:15

we're gonna see that

4:21

the CSMs are connected

4:24

by an modal ligament.

4:26

So again, this type one 10 structure

4:29

going between the ligaments.

4:30

So you wanna just check that as well.

4:32

And remember that the FHL,

4:34

the flexor holis longus is just superficial to that.

4:39

Also, when you're on the, um, when you're on the long axis,

4:43

remember that every joint is gonna have a medial collateral

4:46

ligament and a lateral collateral ligament.

4:48

So this is totally separate from everything

4:50

we've talked about so far.

4:51

But you also just wanna check that those, um,

4:54

ligaments are intact.

4:57

It's not uncommon to see

5:00

some cyst formation at the sites

5:03

of these ligament attachments.

5:04

I think of them as just uls cyst traction cysts.

5:08

Um, over time, if you have halal valgus, uh,

5:11

you might have some stress on those ligaments.

5:13

You might have osteophytes.

5:15

So remember the, the collateral ligaments

5:18

of the great toe as well.

5:20

So when I do my search pattern of the great toe, uh,

5:25

sesamoid complex, I'm looking at all those things.

5:27

So to review, you have your collateral ligaments,

5:30

you have the joint itself, you have the sesamoids.

5:33

You wanna assess if the sesamoids are bipartite,

5:35

are they fragmented?

5:36

Is there bone marrow edema?

5:38

Um, you want to look at the plantar plate, um,

5:43

for all of the joints, but particularly the, the gra toe.

5:47

Um, you want to look at the sesamoid phlange ligaments,

5:50

one on each side.

5:52

And one last thing I, I forgot to mention,

5:55

we talked about the flexor lysis

5:57

Longus, uh,

5:58

but remember that we have these two muscles here

6:01

with their individual tendons, flexor lysis, brevis,

6:05

and those, um, have an interesting attachment.

6:08

Uh, so where unlike the flexor Hals longus,

6:10

which goes all the way to the distal failings,

6:13

the flexor lysis, brevis, medial,

6:15

and lateral heads will attach to the back of the sesamoids.

6:19

So the sesamoids have a lot of things attached to them.

6:21

And so you wanna remember that, um, those muscles, uh,

6:26

that you can see are attaching, uh, to the back of the,

6:31

uh, sesamoids show that, um,

6:34

in these cases here, right there as well.

6:40

So you have muscles, tendons, ligaments, um, many things

6:44

to consider, uh, when you're looking at these, uh,

6:47

these four foot MRIs.

6:49

And so, um, but I think go

6:54

through the anatomy, look at the patient's,

6:56

uh, clinical history.

6:59

It's very important. Um, look at the X-ray.

7:01

Look at, look at an X-ray, if you have it.

7:03

Um, try to look at the clinical question that's asked

7:06

and focusing on those areas.

7:08

Um, and one thing, um, as well is if there's a part

7:13

of the anatomy that is, um, difficult for you, uh,

7:17

that you're kind of nervous to get that one case, uh,

7:19

that's evaluating for it.

7:21

Uh, for example, for me it was always a Liz Frank ligament.

7:24

I was always nervous. I would get a case

7:26

and not know if it was torn or not.

7:27

Um, what you should do, I encourage people,

7:30

is when you get a, a foot study for something else,

7:33

so stubb toe

7:34

or something, um, just look at the Liz Frank Ligament,

7:37

look at that ligament that you're always kind of afraid

7:39

to miss when you have a real case of, of an injury to it.

7:43

And you get a sense of the normal variability of what

7:45

that ligament will look like

7:47

and try to find these structures when you're not under

7:50

pressure, uh, to, to diagnose, uh, something at, at

7:53

that time.