What is Turf Toe?


instagram-iconsfacebooktwitter  Click to follow

By Meggie Morley, DPT

During Game 3 of the Clipper’s series against the Utah Jazz, Blake Griffin suffered an injury to his toe that would rule him out for the remainder of the playoffs. He recently underwent surgery to treat his injury, which was reported as an injury to the plantar plate of his big toe. This injury is also known as turf toe, and even though it may seem like a small injury it can greatly affect the ability to participate in sports, recreational activities and even walking.

Toe Anatomy

Turf toe typically refers to an injury to the big toe. The big toe is comprised of two bones, known as the distal and proximal phalange. The proximal phalange attaches to the metatarsal bone in the foot, forming the metatarsal phalangeal joint (MTP). Underneath the MTP is the plantar plate, a small sesamoid bone, and various ligaments and muscle attachments.   Turf toe 2

Mechanics of Injury

Turf toe typically occurs when the first toe is hyperextended. In other words, when the toes are planted on the ground and the rest of the foot is lifting off the ground. This position places strain on the bottom of the MTP joint, causing damage to the plantar plate and surrounding structures. This injury occurs commonly on turf due to the harder surface, which can cause the toes to be stuck in place. The symptoms of turf toe include pain, tenderness, bruising, stiffness and swelling at the joint.  Parents should watch for avoidance behaviors and painful gait patterns in their children.

Ligament Sprain Grade

Grade I: The ligament is stretched and there may be small tears

Grade II: Large tear, but the tear doesn’t completely go through the ligament

Grade III: Complete rupture of the ligament

Recovery time depends on the grade of the sprain, and in the case of complete tears surgery may be necessary. For any turf toe injury, rest is required in order to allow for healing.  Bracing, splinting and taping are often used for weight bearing tolerance so it is important to prevent adhesions in the injured structures. Passive ROM can be initiated within a few days of Grade I and II injuries along with non-impact activities. Grade III injuries require immobilization but even if surgery is needed, ROM can be performed at 5-7 days post op.  Make sure to see a PT and find out what you can be doing throughout all phases of recovery.

FullSizeRender 9Blog Post written by Meggie Morley, DPT.  At the time of posting Meggie was in her final clinical rotation with me at Catz Physical Therapy Institute.

References

1. Stanley, Laura. Physical Therapist’s Guide to Turf Toe. Retrieved from http://www.moveforwardpt.com/symptomsconditionsdetail.aspx?cid=6db543a6-7a53-4dcd-8141-3137c4391f07

2. McCormick JJ, Anderson RB. Turf toe: anatomy, diagnosis, and treatment. Sports Health. 2010; 2(6):487–494.

3. Garguilo, C. (2015). Foot and Ankle Orthopedics (Power Point slides). Retrieved from https://courseworks.columbia.edu/access/content/group/PHYTM8610_081_2015_2/Lectures/Ankle/Camtasia%20Foot%20and%20Ankle%20Lectures/Camtasia%20Lecture%20Foot%20Ankle%20Disorders%20Handout%202015%20Section%203.pdf

What are Shin Splints?

IMG_9771

instagram-iconsfacebooktwitter Follow Chris Butler Sports PT

By Michael Joseph, DPT Student

Definition and Risk Factors:

Medial Tibial Stress Syndrome (MTSS), better known as shin splints, is a common athletic injury caused by repetitive stress to the tibia. MTSS is more prevalent in activities involving a great deal of running and jumping, like distance running, sprinting, basketball, tennis, gymnastics, and dancing; it is also common in military personnel. MTSS can be caused by many factors stressing the tibia, including: periostitis (inflammation of connective tissue surrounding bone), periosteal remodeling, tendinopathy, and dysfunction of muscles surrounding the tibia, like the tibialis posterior, tibialis anterior, flexor digitorum longus, and soleus muscles. Risk factors for MTSS include flat feet and/or over-pronation, repetitive running and jumping, excessive hip range of motion, smaller calf girth, and a body mass index above 20.2.

Symptoms:

Symptoms include pain of the middle and lower thirds of the medial shin. Individuals may experience pain during and/or after physical activity. During the early onset of MTSS, symptoms may be felt at the beginning of exercise, but may subside as activity continues. As MTSS progresses, pain may be felt throughout exercise and may linger afterwards.

Diagnosis:

A thorough physical therapy subjective and objective exam is usually sufficient to diagnose MTSS. However, patients may require further imaging or work up to rule out pathologies like stress fractures, exertional compartment syndrome, or peripheral vascular disease.

Management of Shin Splints:

Acute Phase:

The goal of physical therapy in the acute phase is to reduce pain and inflammation. This can be done through stretching, manual therapy of the injured tissue, taping, icing, and rest. For many athletes prolonged rest from their sport is not ideal. MTSS management may require “relative” rest, meaning their activity level may need to be adjusted but not stopped completely. This depends on the activity and severity of the pathology.

Subacute Phase:

The goal of physical therapy in the subacute phase is to modify training regimens and correct biomechanical abnormalities. According to Galbraith et al, reducing weekly training frequency and intensity by 50% will likely improve symptoms without completely stopping training. However, this depends on each patient’s case and may need to be adjusted. Training can also be augmented with low impact exercises, like swimming or cycling, to help maintain strength and cardiovascular endurance.


Create a Physical Change in Your Body and Movement

Another treatment of MTSS is to strengthen the arch of the foot and hip, and increase core stability; this will help to improve jumping and landing mechanics, as well as single leg stability. Specifically, strengthening the tibialis posterior and intrinsic foot musculature will help increase arch support and prevent excessive pronation. Improving hip extensor and abductor strength can help improve lower extremity mechanics. Stretching and eccentric strengthening of the calf has also been shown to be beneficial by decreasing muscle fatigue with running and jumping.

Changing running biomechanics may also be beneficial. A study from Leiberman et al, found that heel first strike during initial contact, when running, creates an impact transient equal to nearly three times the individual’s body weight. Not only is this incredibly inefficient, but this creates a large force traveling directly up through the tibia with each step. The impact transient with forefoot first strike during initial contact is seven times lower than with a heel strike. This evidence suggests forefoot running is more efficient and less injurious. 

FullSizeRender 15Blog Post written by Michael Joseph, DPT Student at Mount Saint Mary’s University. Michael is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

Sources:

  1. Budde, Kari Brown. Physical Therapist’s Guide to Shin Splints (Medial Tibial Stress Syndrome). http://www.moveforwardpt.com. Accessed May 11, 2017.
  2. Galbraith, R. Michael, Lavelle, Mark E. Medial tibial stress syndrome: conservative treatment options. Curr Rev Musculoskelet Med. 2009 Sep; 2(3):127-133.
  3. Lieberman, Daniel E., Venkadesan, Madhusudhan, Werbel, William A., Daoud, Adam I., D’Andrea, Susan, Davis, Irene S., Mang’Eni, Robert Ojiambo, Pitsiladis, Yannis. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 2010 Jan; 463:531-535.
  4. Moen, Maarten Hendrik, Holtslag, Lenoor, Bakker, Eric, Barten, Carl, Weir, Adam, Tol, Johannes L., Backx, Frank. The treatment of medial tibial stress syndrome in athletes; a randomized clinical trial. Sports Med Arthrosc Rehabil Ther Technol. 2012 Mar; 4(12).

What is a Bone Bruise?

IMG_8389

instagram-iconsfacebooktwitter

By Meggie Morley, DPT Student

The term “bone bruise” can give the impression that it is not a very serious injury, when in reality a bone bruise is one step below a fracture of the bone. FullSizeRender 10A bone bruise occurs when several trabeculae in the bone are broken, whereas a fracture occurs when all the trabeculae in one area have broken.  Trabecular bone is also known as spongey bone.

Bone Structure

A typical bone in the body is comprised of cortical bone, cancellous bone and bone marrow. Cortical bone accounts for roughly 80% of bone structure in the adult human skeleton. The outer layer of cortical bone is the periosteum and the inner layer of cortical bone is the endosteum. Cancellous bone is often referred to a trabecular bone. It is found at the end of long bones and contains a dense network of fibers and blood vessels.

Three Types of Bone Bruises

  1. Subperiosteal hematoma: A bruise that occurs due to an impact on the periosteum that leads to pooling of blood in the region
  2. Intraosseous Bruising: The bruise occurs in the bone marrow and is due to high impact stress on the bone.
  3. Subchondral Bruise: This bruise is bleeding between cartilage and bone such as in a joint.

Symptoms of Bone Bruises

  • Pain and tenderness in the region of injury
  • Swelling in the region of injury
  • Skin discoloration in the region of injury

Bone bruises often occur with joint injuries, such as ankle sprains and ACL tears, therefore a bone bruise can also coincide with stiffness and swelling in the joint.

Diagnosis and Treatment

A bone bruise can only be diagnosed with a MRI, but an X-ray may be used to rule out a fracture. The first line of treatment is to rest and limit activity on the limb. Walking with an assistive device such as crutches is recommended for as long as weight bearing is painful. Physical therapy is also a beneficial treatment in order to maintain full joint mobility and strength during the healing process. Bone bruises often take several months to heal, and possibly longer if the bruise is larger. A study by Boks et al found that the average healing time of a bone bruise was actually 42.1 weeks after a traumatic knee injury. 

  When Steelers QB Ben Roethlisberger suffered a bone bruise during the 2015 playoffs Dr. David Chao explained it like this, “Think of the bones in the knee being covered by articular cartilage like the dirt of the football field has grass on top.  If an elephant stomps on the grass the dirt underneath can be damaged/compressed.  In order to allow the grass (articular cartilage) to rejuvenate and heal, you can’t keep playing football on it.  The “keep off the grass” sign allows for a chance to heal.”

Overall, it is important to allow for bone bruises to heal for as long as needed to ensure that the bone does suffer further damage.

FullSizeRender 9 Blog Post written by Meggie Morley, DPT Student at Columbia University. Meggie is currently in her final Clinical Rotation with me at Catz Physical Therapy Institute.

Sources

  1.  Janice Polandit, 5 Things You Need to Know About a Bone Bruise, 2011; http://www.livestrong.com/article/5521-need-bone-bruise/ Grades of recommendation F
  2. Jelić Đ, Mašulović D. Bone bruise of the knee associated with the lesions of anterior cruciate ligament and menisci on magnetic resonance imaging. Vojnosanitetski pregled. 2011;68(9):762-6.
  3. https://www.saintlukeshealthsystem.org/health-library/bone-bruise
  4. Boks SS, Vroegindeweij D, Koes BW, Bernsen RM, Hunink MM, Bierma-Zeinstra SM. MRI follow-up of posttraumatic bone bruises of the knee in general practice. American Journal of Roentgenology. 2007 Sep;189(3):556-62.
  5. Bone Photo Credit click here

Femoral Acetabular Impingement: Kira

fullsizerender-7

Early in the year I had a hip injury and I couldn’t dance for a few months. Thanks to Chris and Catz I am back dancing with my team and am headed with them to compete at USA Nationals in a few weeks.

-Kira

ACL Reconstruction: Kyle

img_7116

Thank you so much for helping me through my recovery. Lacrosse tryouts went well and I made the varsity team again, and I have been back to playing lacrosse cobrassince just before the new year. My knee feels excellent, and if not back to full health it is at least 99%.  It is crazy to me to think that about 8 months ago I was barely able to crutch around and couldn’t do a leg lift, and I can’t believe how far I’ve come. In addition to making varsity, I have been coaching and attended a tournament, and I really cannot stress enough how good it feels after so long away from the sport. I have loyolaattached pictures of me in a tournament last weekend, and I hope they show how helpful you were in my recovery. Thank you so much, I could not have done it without you and hopefully I can find a time to swing by CATZ soon to say thanks in person.

Sincerely,
Kyle

 

Ankle Fracture Post-op: Maya

When I broke my ankle last summer during early training for club soccer season, I was devastated. After surgery and with 2 screws in my ankles, I was told that I would miss most of the season. Being an athlete is so much a part of who crown-cityI am and what I do that having to sit out practice after practice and game after game was absolutely terrible.

The turning point for me was when I started PT with Chris. Chris understood that it was not just about rehabbing my broken ankle but about strengthening and conditioning my whole body so that when my ankle was healed I would be ready to go back to sports. PT with Chris helped me recover faster and for that I am very thankful!img_7117

– Maya

 

Pitching Elbow Stress Fracture: Brennan


“Thank you Chris for sharing your knowledge about the mental game and how to keep good arm care! Couldn’t be anymore excited or feel any stronger for my up coming season.”

-Brennan