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Okay, this is a professional athlete.

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He's in his early 20s, and he is unable to

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push off his foot due to pain in the great toe.

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The great toe is an amazing structure.

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It'll bring down the biggest man or woman,

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even with the most minimal of injuries.

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Because there's so much force placed against

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his toe when pushing off your body weight.

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So let's look at the axial T1, the axial T2,

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and a sagittal.

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You'll note that the sagittal is not a

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straight up and down sagittal like this.

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It's oriented so that it is perfectly

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perpendicular to the axis of the toe and going

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right down the middle of this bumpy structure

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right here, which is known as the crista.

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Now on either side of the crista are grooves.

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Those grooves should be smooth and

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should have perfect conformity with

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the sesamoids that fit inside them.

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Unfortunately, all of us as we walk and play

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sport over time, develop a remodeling

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effect of these grooves so that our

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sesamoids no longer fit perfectly into them.

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For instance, look at this one.

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It has an extra little notch in it.

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That's not a coincidence.

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That's why this sesamoid, known as the tibial sesamoid,

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is a little blacker than that sesamoid.

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It's getting rubbed and scuffed and impacted

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more than the other one because it doesn't

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slide or fit very nicely into its space.

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Another finding of interest.

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Look at the suspension of this sesamoid.

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Now we'll look at the suspension

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of the other sesamoid.

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It's nice and black.

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This one is black, but too fat.

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And if we look at the T1, there is a little

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space between the insertion of the suspension

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of that sesamoid and this structure,

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which is called the phalangeal sesamoid ligament.

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It's a suspensory ligament.

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If it comes off the metatarsal,

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then we call it a metatarsal.

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Phalangeal suspensory or

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metatarsal sesamoid ligament.

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So there are two of them that come around.

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One more proximal, off the

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metatarsal, the proximal suspensory.

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And one that comes off the toe,

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the distal suspensory.

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This is the distal suspensory.

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This is the proximal suspensory.

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Neither one of them is attaching properly.

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They should be flush right on to the bone.

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And you do see a little space right here.

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So that may have cleared up a

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series of confusions for you.

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There's a little more simpler anatomy present.

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We have two sesamoids connected

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by an intrasesamoid ligament.

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Got a nice little tunnel for

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the flexor hallucis longus.

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But it's time to talk about the oft

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forgotten, neglected flexor hallucis brevis.

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It's this.

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It has a head or an attachment on each sesamoid.

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There is the attachment to the medial sesamoid.

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It should be a black line.

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There's the tendon.

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It should continue right there.

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It's swollen.

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There's something there

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alright, but it's not normal.

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Let's go over to the other sesamoid.

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The healthier sesamoid.

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There's the tendon.

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There's the normal flexor hallucis brevis.

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Now let's go back to the abnormal one.

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Right here, there's the swollen one.

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Swollen, sick flexor hallucis.

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Healthy flexor hallucis.

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But we're not done yet.

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Because this patient has the

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entity known as turf toe.

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So let's look at the plantar plate.

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Beneath the flexor hallucis longus,

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that goes in the sesamoid tunnel,

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is an area of capsular condensation.

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It looks a little better over here.

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You can just barely see it.

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I'm gonna put up all the sagittals,

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and especially the high resolution one.

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Let's look at the high resolution one,

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and we'll get our orientation here,

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and we'll go over to the good side.

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This is the good side, where we see

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a linear structure, right there.

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I'm gonna blow it up and make it bigger,

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because this is challenging stuff.

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There it is.

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Now let's go to the medial side.

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Oh, look at what's happening.

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Our plate is not reaching all the way

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to the base of the bone and cartilage.

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It's squiggling up like a ball.

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Now that plate has an attachment to the sesamoid.

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If the sesamoid is no longer

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anchored, guess what happens?

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The flexor hallucis brevis,

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which is this muscle right here.

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Let's go to it.

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The swollen brevis.

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There it is.

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Still attached.

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It's going to pull the sesamoid back.

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And without the capsule to keep it

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in place, it migrates proximally.

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Let's have a look.

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Let's go across and see if the

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sesamoids are in the same place.

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So let's go to the good sesamoid.

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Good sesamoid.

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Now let's go to the bad sesamoid.

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Bad sesamoid.

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And you might appreciate there's a little

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more space, and this is a little more

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proximal, than its counterpart here.

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This is a little bit closer.

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This one's a little bit further.

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And there's no plate.

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So the plantar plate is ruptured laterally.

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There's some plate that's present medially.

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The next thing you might want to do is say,

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"Okay, what percentage of the plate is torn?"

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And when I say percentage, I mean this.

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I mean from side to side.

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So let's get that big toe back up there again.

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I'm talking medial to lateral.

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Sorry, I gotta get my pen working.

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Medial to lateral.

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I want to know if 50% or more, from here to here,

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or from here to here, or 50% in

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the middle, If it's more than 50%,

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those patients usually end up at surgery.

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If it's less than 50%, they end up

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with conservative management.

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So the thing to do is to scroll on your

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high resolution, thin section, 3D image,

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which is on your left, from side to side,

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and see how much plates you got.

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You got a squiggly, wiggly plate here,

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and now it comes back right in the midline.

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There it is, right there.

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157 00:06:35,505 --> 00:06:37,215 Now you might say, well, it's not attaching.

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Yes it is.

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That's cartilage.

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It's attaching to cartilage.

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There is a little space there.

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Let's keep looking.

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Let's keep looking.

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The plate's still there.

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The plate's still there.

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The plate is still right there.

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It is preserved for the entire

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lateral half of the great toe.

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Let's go to the medial half.

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We're at the level of the crista, this bump.

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Now let's go medial to the crista.

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Sick, retracted, wavy plate.

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Let's keep going.

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Sick plate disappearing.

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The plate is completely gone.

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So 50% is gone, 50% is present.

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We treated him conservatively.

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He got better.

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He played the following season at a high level.

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This was a non-surgical one right on the border.

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That's Turf Toe.