The Dynasty Doctor: Turf Toe

This installment of The Dynasty Doctor will address Eddie Lacy and his mysterious toe injury. We will review turf toe injuries and delve deeper into why Lacy may have had a toe fusion.

Turf toe injuries sound trivial, but can be quite debilitating. The hallux, or “big toe,” is important for athletes to push off on their feet, or change directions in twisting motions. It might sound crazy that a toe injury could shelve an athlete for several games or even impact their careers, but there are several reasons why this injury is a pain, for athletes and fantasy football owners alike.

The first step in learning about turf toe injuries is to understand anatomy of the big toe. Using the diagram below as a reference, the big toe is composed of three important bones, the distal phalanx (red), proximal phalanx (green), and metatarsal bone (yellow).

The proximal phalanx (green) and metatarsal bone (yellow) form the metatarsophalangeal joint (MTPJ), and this is the major joint impacted by turf toe injuries. The MTPJ is surrounded by ligaments on either side, a tough ligament below called the plantar plate, tendons from the flexor hallucis longus (FHL) and flexor hallucis brevis (FHB) below, and a few other tendons that are not important to discuss. These structures, called the Capsular Ligamentous Complex (CLC), support the MTPJ, and hold the proximal phalanx in the cavity of the metatarsal bone. This is important, as the cavity in the metatarsal bone holding the proximal phalanx is shallow and easily dislocated. The CLC helps to hold this joint together, and allows the big toe to flex and extend in a comfortable manner. Turf toe injuries result when any part of the CLC is sprained or torn.

Turf toe injuries arise most commonly when the big toe is planted in the ground, the foot is pushed down (plantar flexion), and a tackler falls on the raised heel, driving the big toe into the ground (see diagrams here). This position and force makes the toe dislocate upwards (dorsiflexion) to an extreme that injures the CLC, leading to turf toe. Less commonly, twisting forces can push the big toe inward, and damage the collateral ligaments on the sides, effectively bending the big toe inward. This is called hallux valgus, more commonly called a bunion. If this injury is not treated properly,  the joints of the big toe will not bend smoothly, and this leads to arthritic pain, joint deformity and reduced range of motion.

Severity of turf toe injuries are based on three grades. Here is a table that highlights the grading system for turf toe injuries, a description of damage done and expected recovery time:

Surgery is used for severe turf toe injuries in elite athletes, given the aggressive nature and physical toll their sport places on the big toe. It is estimated the big toe can absorb force as much as eight times the weight of an athlete.² Surgery allows for faster and durable recovery, as tears of the CLC can be more easily repaired while reducing build-up of scar tissue, compared to conservative (non-surgical) approaches. Fusion of the MTPJ is the extreme form of treatment, and can be quite effective at reducing pain. The problem with fusion of the MTPJ is it will impact mobility of the big toe and this can hinder an elite athlete. Turf toe injuries seem to be more common in recent years, and light-weight shoes might be contributing to it. Light-weight shoes make it easier for the big toe to move upwards, and this increases likelihood of a turf toe injury. This is also why turf toe injuries are often treated with a Morton’s extension plate, as it helps to prevent excessive upward movement of the toe (dorsiflexion) while playing football.

Turf toe injuries can be diagnosed on examination (tenderness with movement of the big toe), x-rays or MRI scans. The injury appears to be more common than first thought, as surveys have shown 45% of NFL athletes have experienced a turf toe injury, 83% occurring on artificial turf.³  Outcomes for elite football players with turf toe injuries are generally good. One author reported a small group of nineteen football players with turf toe injuries, nine treated surgically, and all but two returned to full athletic activity with documented stability of the big toe.⁴ Return to play following surgery can take as long as four months, but 6-12 months before orthotic plates in the foot are removed.¹ Residual pain can be an issue, and one article noted 50% of athletes can have persistent pain following treatment, most of which arose from delay in treatment.⁵ Turf toe injuries may reduce upward range of motion (dorsiflexion), but do not appear to impact downward range of motion (plantar flexion).⁶ Downward movement of the big toe is most important in generating explosive or twisting motion, so that is actually encouraging for Lacy.

Lacy suffered a turf toe injury in the 2011 season, and missed only one game from it. In fact, that was the only game he missed his last two years at Alabama. That Lacy only missed one game from his turf toe injury suggests it was more of a grade 2 variety.

The fact Lacy had a toe fusion is the most pressing question. One might think he had a severe turf toe injury given his need for surgery, but based on my research, it seems likely that he had the toe fusion for preventive purposes, not so much to treat the prior injury in 2011. Stating the obvious, I am not able to review his medical records, so I will try my best to piece this together based on available information. The Alabama team physician, Dr. Lyle Cain, has commented that Lacy’s toe fusion is not expected to be a problem, and he expects Lacy to have a “long, productive NFL career.”  Dr. Cain also said the toe fusion was done “to allow the ligament to work better”. The only joint fused was between the distal and proximal phalanges (red and green bones on the previous diagram). That is a critical distinction. The technical term for this is hallux interphalangeal joint arthrodesis, just in case you want to Google it. Note, the MTPJ was NOT fused. That is extremely important to understand. To test out this point, take your big toe at the tip, and bend it down. The first joint that bends is the interphalangeal joint (IPJ). Now, grab the bone behind the IPJ and bend it. The second joint that bends is the MTPJ. You can feel how the MTPJ is capable of flexing the big toe on its own, with or without the IPJ.

The question is, why did Lacy need to fuse the IPJ at all? Turf toe injuries can occasionally result in ‘flexor muscle imbalance’ that occurs between the FHL and FHB. The FHL is a tendon that inserts on the proximal phalanx (green bone), whereas the FHB inserts behind it on the metatarsal bone (yellow bone). See the diagrams below:

A turf toe injury can make the FHB muscle not work as well, creating an imbalance between the FHL and FHB tendons. Over time, this can lead to arthritis, joint deformity and reduced range of motion in both the IPJ and MTPJ. This would be particularly disabling to an elite athlete like Lacy. But, if only the IPJ is fused, this will essentially eliminate the imbalance, as both the FHL and FHB tendons will now work to flex only the MTPJ. The IPJ fusion removes the extra joint, and that prevents ongoing damage to both joints that can occur if there is a discordance in their function. The FHL and FHB tendons still work fine, they just flex only the MTPJ. The entire purpose of fusing the IPJ is to prevent damage to the MTPJ, and that is a good thing for Lacy. It is not ideal that Lacy needs the IPJ fused, but he should be capable of returning to play without it significantly impacting his performance. In fact, Lacy did just that, having played the entire 2012 season after the fusion. Lacy denied having any pain at all, and not once consulted with his surgeon to manage pain. That is a very good sign, as that indicates chronic pain is not an issue from his previous turf toe injury. Lacy undoubtedly had his turf toe treated promptly and effectively, and this will reduce risk of long-term arthritic pain. The IPJ fusion should reduce risk of long-term damage to the MTPJ, and that will hopefully improve Lacy’s longevity. While playing on the toe fusion in 2012, he managed to rush for 1322 yards, 6.5 yards per carry (YPC), 17 touchdowns, 22 receptions for 189 yards receiving and two more touchdowns receiving. Lacy only had 204 carries in 2012, and had just 355 carries for his entire career at Alabama, yet averaged seven yards per carry. To put that into perspective, Ray Rice had 910 carries at Rutgers, and averaged 5.4 YPC.

Paranoia about the Steelers and Broncos passing on Lacy for medical reasons has been epically disseminated by the media, to a point where dynasty owners are convinced Lacy’s toe will fall off after one practice. Lacy has only missed one game in three years at Alabama, and that was from the turf toe injury, not the IPJ fusion. We are talking about a player who has played through a few injuries, but why is this an indictment on Lacy? If anything, Lacy has shown toughness in playing through pain, yet seems to get no credit for it. I have seen him drop to 1.09 in rookie drafts, and that is just way too much value to pass up. I put a lot of stock in NFL team evaluations of a player, so I do not take the Steelers and Broncos position on Lacy lightly. Still, NFL teams historically have passed on players for dubious reasons, such as Dan Marino dropping in the draft because of “drug issues” that were false. NFL scouts whiffed on Aaron Rodgers. Dez Bryant fell because of character issues. LeSean McCoy lasted until pick 53 as scouts thought he left college too early. Steven Jackson was an elite running back prospect but fell to pick 24 given concerns about a knee injury he suffered while playing at Oregon State. Frank Gore lasted until pick 65 from a history of knee injuries. The list goes on and on. My point is not to bash NFL scouts, but sometimes we need to take a chance on a productive player and look past the media hyperbole. I could understand dynasty owners passing on Lacy with the first pick, but if Lacy falls to the late first round of rookie drafts, that is crazy good value for dynasty owners. I would pick Lacy without hesitation at that point, and enjoy all those fantasy points that will be scored on one of the most prolific offenses in NFL history.

References

1. McCormick JJ and Anderson RB. The Great Toe: Failed Turf Toe, Chronic Turf Toe, and Complicated Sesamoid Injuries. Foot Ankle Clin N Am, 2009;14:135-150.
2. McCormick JJ and Anderson RB. Turf Toe: Anatomy, Diagnosis, and Treatment. Sports Health 2010;2(6):287-294.
3. Rodeo SA, O’Brien S, Warren RF, et al. Turf toe: An analysis of metatarsophalangeal joint sprains in professional football players. Am J Sports Med 1990;18(3):280-285.
4. Anderson R. Turf toe injuries of the hallux metatarsophalangeal joint. Techniques in Foot and Ankle Surgery 2002;1:102-111.
5. Clanton TO, Butler JE and Eggert A. Injuries to the metatarsophalangeal joints in athletes. Foot Ankle 1986;7(3):162-76.
6. Frimenko RE, Lievers WB, Coughlin MJ, et al. Etiology and Biomechanics of First Metatarsophalangeal Joint Sprains (turf toe) in Athletes. Critical Reviews in Biomedical Engineering 2012;40(1):43-61.

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Scott Peak

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