0:00

Let's move now to a discussion of

0:03

what has previously been termed the turf toe described many

0:07

years ago in describing an entity that was a sprain due

0:11

to hyperextension of the first MTP.

0:14

When we consider normal gait with respect to the first MTP,

0:19

it's amazing the stress

0:21

and loading that happens through just normal walking, uh,

0:26

with respect to that first MTP joint.

0:29

And then when we consider things like athletic activity,

0:31

running and jumping, really, um, we're dealing with two

0:35

to three times the force that we have with normal walking,

0:39

40 to 60% of the body weight just with normal gait, two

0:44

to three times that with athletic activity, eight times that

0:47

with running and jumping.

0:49

So when we look at all

0:51

of the reinforcements here at the plant, our plate

0:54

of the great toe, it kind

0:55

of makes sense when we think about all of the stress

0:57

that it has to withstand the mechanism.

1:02

Again, axial low to the foot

1:04

and the flexi Aquinas position with the MTP in extension,

1:08

similar to plantar plate injuries in the Lester metatarsal

1:12

phalangeal joints, these can be traumatic

1:14

or they can be degenerative.

1:16

These get explored when there's retraction

1:18

of the sesamoid on x-ray when a stress radiograph

1:21

or fluoro shows differential movement of sesamoids

1:24

through range of motion when there's the suspicion

1:27

of a chondral injury that results in intractable pain

1:30

or there's failed conservative therapy.

1:33

So we think about, you know, big toe injuries

1:37

or even when you're thinking about things like phenal

1:40

fractures, and when you're looking at them,

1:42

maybe they seem sort of trivial,

1:44

but really the degree of pain,

1:47

biomechanical dysfunction in the athletes

1:49

can be career ending.

1:51

So these are really serious injuries as we consider, uh,

1:55

the turf toe and the plantar plate complex

1:58

of the great toe in particular.

2:00

So, uh, a theme I think that you've probably recognized is,

2:05

um, something that Don has really made a legacy in our

2:08

division, and I think, you know, elevates the level, uh, of

2:12

everyone's, um, evaluation, diagnosis,

2:15

and characterization of, of, um, disease and pathology.

2:20

So this idea of a very, very, um, advanced understanding

2:24

and of anatomy applies at the first MTP

2:27

because it is complex anatomy.

2:29

And again, it's something you've probably been hearing over

2:32

and over through the course of, of your time with Don

2:35

and the other faculty from UCSD, but it's really true.

2:39

So as we think about all of the structures

2:42

that reinforce the plantar plate complex,

2:44

there are actually 15 of them.

2:46

So don't turn off or feel overwhelmed by that.

2:50

There's really a way that it kind of makes sense

2:52

and you can put these things together so

2:55

that you'll really be able to have an, again, an

2:58

Elevated delineation

3:00

and characterization of the pathology that occurs.

3:02

So let's break this down into the separate groups and,

3:05

and it's really gonna be easy, I think, for you

3:07

to have a very systematic approach to the first MTP.

3:11

So let's think about sesamoids.

3:13

So there's the inters andoid ligament.

3:15

There's the ligaments that go from the sesamoid

3:18

to the metatarsal and from the sesamoids to the phalanx.

3:21

That's one group. We've got the capsule.

3:24

And, and while the plantar plate was

3:27

that big fibro cartilaginous plate in the second

3:30

through fifth MTPs in the first MTP, it's very delicate

3:35

and probably the least important of all the structures

3:38

that we're gonna talk about.

3:40

And then we're going to have the muscular tendus components

3:44

and, and there are a few of them,

3:46

but again, it becomes very manageable.

3:48

So you've got your flexor hallis longus,

3:50

you've got your sesamoids that reside within the medial

3:53

and lateral heads of the flexor haliss brevis.

3:56

And then you've got your abductor and your adductor.

3:59

And, and so with that simple system,

4:01

looking at the sesamoids, the plantar plate and capsule

4:04

and the musculotendinous system, you will account

4:07

for 15 structures that support the plantar plate

4:10

of the great toe.

4:12

This is a dissection.

4:14

And so what's happened here is

4:16

that the capsule has been transected.

4:18

We've opened it up here.

4:20

You're looking down on the metatarsal head,

4:22

these arrowhead showing you chondral defects at the

4:26

metatarsal articular surface.

4:27

Here are your two sesamoids.

4:30

Here's the articular surface of the proximal phx.

4:33

And remember, there's a ligament connecting the sesamoids

4:36

ligaments that extend from the sesamoids

4:38

to the proximal phx, from the OIDs to the metatarsals.

4:42

And we'll start off with that.

4:45

So as you think about these OIDs,

4:48

and look at this Mr image, there they are

4:50

with the inters ligament.

4:53

So very simple when we think about that sesamoid complex.

4:57

Well, now let's take a look at these sagittal images,

5:00

clearly degenerative in nature.

5:03

Let's talk about the Mr images

5:04

and then we can briefly discuss the grading systems

5:07

that exist both clinically and through arthroscopy.

5:11

As you look at this sagittal set of images, the findings

5:15

of degenerative change, chondral loss,

5:18

cyst formation osteophytes.

5:20

Here, subc chondral bone changes, reactive marrow changes.

5:24

Now let's take a look at the sesamoids.

5:27

Remember, the sesamoid is supposed to have an attachment

5:29

to the base of the proximal feelings as well as

5:32

to the metatarsal.

5:34

When you're thinking about the metatarsal attachment,

5:36

here it is, it kind of swings back at the metatarsal head

5:39

neck junction with a very delicate attachment.

5:42

But look at this attachment here from the sesamoid

5:46

to the proximal phalanx base.

5:49

Remember, al changes are going to be a good secondary clue

5:52

that you've got abnormal ligament attachment.

5:55

In this case, you're directly visualizing this area

5:59

significant caliber changes.

6:01

You look at this image to this one, very thin,

6:04

with at least moderate grade partial tearing from that base,

6:08

proximal phx.

6:09

So the sesamoid phenal ligament

6:11

and the sesamoid metatarsal ligament.

6:14

Very easy to identify with the grading systems.

6:18

There's both a physical exam grading system

6:20

and an arthroscopic grading system.

6:22

But honestly, I think the imaging, having that magical look

6:27

inside the bone, inside the articulation to be able

6:30

to assess this complex area with

6:34

multiple different stabilizers becomes the best way

6:37

to give a global assessment of the MTP.

6:41

So now let's pick apart these different areas so

6:44

that you really have a good understanding of each one

6:47

of our systems or components of our complex evaluation

6:51

of the first MTP short axis images.

6:55

Here are your OIDs. Here's your inters ligament.

6:59

Superficial to that, you're gonna have your flexor, um,

7:03

your, um, flexor hallis long, this very delicate little area

7:07

that's the plantar plate.

7:09

So you see why this is probably the least important

7:12

with respect to stabilization.

7:14

So there's your sesamoid ligament.

7:16

Let's now move to the sagittal imaging claim.

7:19

Here's your sesamoid. Here's your metatarsal head.

7:22

Here's your feal base, sesamoid to phalanx.

7:25

Sesamoid to metatarsal. That's it. You're done.

7:28

So, inam ligament sesamoid to base proximal phalanx,

7:33

sesamoid to metatarsal.

7:34

You're gonna do that for both the medial

7:36

and lateral sesamoids to assess your sesamoid complex,

7:41

the plantar plate complex as a whole sagittal image here.

7:45

Short axis image here.

7:47

As you look at the sesamoid here, you can see

7:50

that attachment proximally to the metatarsal

7:53

as you look at it,

7:54

extending towards the base proximal phalanx.

7:57

And remember, you're gonna do that both on the medial

8:00

and lateral side of the sesamoid.

8:01

Here you can see the abnormality, the partial tearing,

8:05

looking in the short axis.

8:06

Look at the difference in signal intensity.

8:09

Also apparent there.

8:12

This grading system has been introduced with respect to

8:15

how much of that sesamoid phalangeal plantar aspect

8:20

of the capsule ligament is abnormal.

8:22

But honestly, the grading systems I think are,

8:26

are incompletely understood and used.

8:28

And so I really think it's just best to describe

8:31

what you're seeing and where you're seeing it with respect

8:34

to failure of the supporting ligament complex.