Taking A Closer Look At A Complex Case Of Turf Toe After A Soccer Injury

I recently heard via email from a mother of a 16-year-old female soccer player with the potential to play in college. Her daughter suffered a soccer-related injury in September 2018 and sought additional advice on her daughter’s behalf. 

Her daughter’s original diagnosis was that of an anterior talofibular ligament injury, likely a tear according to the original orthopedic surgeon. The patient’s treatment included casting, then a walking boot and several months of physical therapy. Her doctor cleared her to play in January 2019. However, after a few games, she continued to have pain and swelling in the ankle. She stopped playing, went back to physical therapy and again achieved clearance to play in April 2019. 

At that same time, she began to develop pain in the ball of her foot, which continued for several months until magnetic resonance imaging (MRI) revealed turf toe in June 2019. Her doctor put her in a boot for several weeks and she went through a few more months of physical therapy before returning to play in August 2019. However, the patient’s pain returned in October 2019 after playing back-to-back games of 90 minutes each. Throughout this entire time, she continued to have pain and swelling in her previously injured ankle as well as foot pain.

In November 2019, the patient underwent a modified Brostrom procedure with a different orthopedic surgeon to address three torn ligaments. Two of the ligaments were repaired with anchors and the other ligament was a primary reconstruction repair. She had immediate pain in the ball of the foot when she began weightbearing postoperatively. Her surgeon had hoped that rest after surgery would help the ball of foot pain and prescribed physical therapy for both the ankle and foot during January and February 2020. 

The patient and mother sought an additional opinion from a podiatrist in March 2020 for the continued foot pain. This podiatrist took X-rays, (negative for fracture or abnormality of the sesamoids) diagnosed sesamoiditis and made custom orthotics. At this time, the COVID-19 pandemic hit and the patient was unable to follow up for several weeks. 

Yet another opinion from a foot and ankle orthopedist revealed similar X-ray findings but a MRI showed no abnormality of the sesamoids. The MRI did show very subtle bone marrow edema of the head of the second metatarsal with surrounding soft tissue edema extending into the first interspace and around the lateral sesamoid, which the radiologist attributed to chronic stresses or repetitive trauma. There was no evidence of fracture or osteomyelitis, and no soft tissue fluid collection. 

I was glad the patient had this MRI as many patients have irregular sesamoids on X-ray, never get an MRI and often undergo a sesamoidectomy due to chronic pain. Swelling around the lateral sesamoid from turf toe (grade 2 or 3 tearing of the lateral collateral ligament) can appear like a sesamoid fracture. I did find it confusing that this MRI did not document turf toe but maybe the injury was a severe stage 1 or mild stage 2. If one was basing treatment on the MRI only, this should all be healed by now.

The foot and ankle orthopedist put her on a Medrol dose pack, showed her how to tape her toe and told her to wear her boot for a few weeks to relieve some of the pain. She did not feel any benefit from the Medrol dose pack. 

The original podiatrist then reopened the practice and modified her orthotics, recommended against the walking boot due to concern for muscle atrophy and recommended stretching three times daily and ice due to tight hamstrings and calves. She is currently back in physical therapy, wearing a Merrell hiking shoe for more support, taping the toe and using a J pad (dancer’s pad). I recommended that the patient talk to her podiatrist about possibly filing down her cleat right beneath the ball of the foot and that she purchase turf shoes for training and play when outdoor cleats are not necessary. 

Dancer’s padding is a must in cases such as hers, as I will often use it on the orthotic and on the foot. One typically needs ¼ inch of sesamoid float to take the pressure off so it might be worthwhile to see how much the orthotic will accomplish. I feel it is time for this patient to get at least five of the following things that work for her: taping, orthotics, dancer’s pads, Cluffy wedges, icing, contrast soaks and stable shoes. Perhaps a Hoka One One shoe may alleviate some stress via the rocker design. 

The podiatrist plans on seeing this patient back in a few weeks to determine her pain level. Her mother relates that if her daughter isn’t getting much relief, the treating podiatrist may consider a cortisone shot and that if conservative treatment for a few more months is not successful, he may recommend a lateral sesamoidectomy. The podiatrist shared that this is a last resort option but noted the patient could recover well from such a procedure and potentially return to soccer four months later. 

Whoa! Based on the information at hand, I disagree. There is no problem documented in the lateral sesamoid. Injecting cortisone into a chronic turf toe may or may not be okay. Turf toe, which I think is the working diagnosis for the aforementioned patient, is a tear or stretch of the ligaments. It can make the joint unstable and I do not know if she is already naturally lax. The patient may consider an arthrogram with the injection of dye into the joint although this test is rare. If a Lachman test for turf toe is part of her record, I recommend finding out those results. As of now, I am convinced the patient has ligament instability due to turf toe.

Dr. Blake is in practice at the Center for Sports Medicine, which is affiliated with St. Francis Memorial Hospital in San Francisco. He is a past president of the American Academy of Podiatric Sports Medicine. Dr. Blake is the author of the recently published book, “The Inverted Orthotic Technique: A Process Of Foot Stabilization For Pronated Feet,” which is available at www.bookbaby.com. 

Editor’s note: This blog originally appeared at www.drblakeshealingsole.com. It is adapted with permission from the author.