Epidemiology of Severe Foot Injuries in US Collegiate Athletes

Background: The effects of foot injuries on collegiate athletes in the United States are of interest because of the short 5-year eligibility period in the National Collegiate Athletic Association (NCAA). Purpose: To discuss the epidemiology of severe NCAA foot injuries sustained over 10 years in 25 sports. Study Design: Descriptive epidemiology study. Methods: We utilized the NCAA Injury Surveillance System, which prospectively collects deidentified injury data for collegiate athletes. Severe injuries were classified as season- or career-ending injuries, injuries with >30-day time loss, or injuries requiring operative treatment. Injury rates (IRs) were analyzed per 100,000 athlete-exposures. Results: Of 3607 total foot injuries, 18.71% (n = 675) were classified as severe, with an IR of 5.73 per 100,000 athletic-exposures. For all severe injuries, the operative rate was 24.3%, the season-ending rate 37.0%, and the career-ending rate 4.4%. The proportion of recurrent injuries was 13.9%. Men’s sports with the highest severe foot IRs were basketball (IR = 10.71), indoor track (IR = 7.16), and football (IR = 7.08). Women’s sports with the highest severe foot IRs were cross-country (IR = 17.15), gymnastics (IR = 14.76), and outdoor track (IR = 14.65). Among all severe foot injuries, the most common was a fifth metatarsal fracture. The highest contact/noncontact injury ratios were phalangeal fracture, turf toe, and Lisfranc injury. The severe injuries with the highest operative rates were Lisfranc injuries, fifth metatarsal fractures, and midfoot fractures. The severe injuries associated with the highest season-ending IRs were Lisfranc injury, midfoot fracture, and general metatarsal fractures. Severe flexor/extensor injuries had the highest career-ending IRs, followed by turf toe. Severe injuries with the highest median time loss were sesamoidal fractures, calcaneal fractures, and plantar fascial injuries. Conclusion: Of all collegiate foot injuries sustained over a 10-year period, 18.7% were characterized as severe, and 24.3% of severe injuries required surgery. Basketball was the men’s sport with the highest severe IR, and cross-country was the women’s sport with the highest severe IR. Overall, female athletes experienced slightly higher severe foot IRs as compared with male athletes.

Return to Play Following High-Grade Turf Toe Injuries in National Football League Athletes

Category: Sports; Midfoot/Forefoot; Trauma Introduction/Purpose: Return-to-play (RTP) rates of National Football League (NFL) athletes following surgical intervention for numerous foot and ankle injuries has been reported. To our knowledge, no studies have reported on RTP rates of NFL athletes after non-operative and operative treatment of high-grade turf toe injuries. The purpose of this study was to evaluate the RTP rates in NFL athletes who sustained high-grade turf to injuries. We hypothesized that NFL athletes requiring operative intervention for high-grade turf toe injuries would have lower RTP rates and longer recoveries than athletes treated non- operatively. Additionally, we hypothesized that regardless of treatment, NFL athletes would demonstrate equal productivity following RTP. Methods: Publicly available NFL injury data was reviewed to identify athletes who sustained high-grade turf toe injuries, as indicated by surgical intervention or missed playing time of 2 weeks or more. Athletes were excluded if RTP was prevented for reasons unrelated to the injury. Demographic and performance data was obtained including a player’s injury, date of injury, date of surgery, RTP, time to RTP, number and percentage of games played, and performance. Results: 53 NFL athletes were identified with high-grade turf toe injuries that met inclusion criteria. 28 of these athletes were treated non-operatively and 25 were treated with surgery. The overall RTP rate was 91%. Athletes who were treated non- operatively had a RTP rate of 100% while athletes who underwent surgery had a RTP rate of 80% (P = 0.011). The mean time to RTP for all athletes was 140.9+-111.9 days. The mean time to RTP for non-operatively treated patients was 75.8+-99.0 days, compared with 221.4+-81.6 days for operatively treated athletes (P = 0.002). In skill position athletes who achieved RTP, 78% treated non-operatively were able to return to their prior level of performance compared to only 27% for athletes treated surgically (P = 0.032). Conclusion: There is a significant difference in return to play following surgical versus non-operative management of high-grade turf toe injuries, with only 80% of athletes achieving return to play after surgery. No athletes were able to return the same season as surgery and the mean time to RTP following initiation of treatment was significantly shorter for players who underwent non- operative management. Postoperative performance was also significantly worse in players who underwent surgical intervention compared to non-operative management. This study provides important prognostic information to high level athletes in regards to recovery following high-grade turf toe injuries

Dynamic Imaging Evaluation in Turf Toe Injuries: A Prospective Protocol in 18 Patients

Category Sports; Trauma Introduction/Purpose: Turf Toe remains a diagnostic challenge for the orthopedic surgeon. A high index of suspicion is needed, in addition to adequate imaging strategies to characterize the broad spectrum of injuries involving this pathology. MRI imaging provides excellent static soft-tissue details and it has become widely used to determine the anatomical structures damaged. However, defining the stability of the 1st metatarsophalangeal (MTP) plantar plate complex is difficult without proper dynamic evaluation and this is crucial to define between conservative or operative management. Since there is no current consensus regarding the optimal imaging assessment to optimize turf toe diagnosis we present the results of an imaging protocol, including dynamic fluoroscopy and ultrasound (US), to enhance the identification of unstable Turf Toe injuries. Methods: A prospective imaging protocol consisting of bilateral comparative weightbearing x-rays, US examination, and mobilization under fluoroscopy was designed. The inclusion criterion was any patient with clinical findings consistent with plantar plate injury after forced hyperextension of the hallux. All studies were informed and performed by trained musculoskeletal radiologists. Location and symmetry of the sesamoids under the metatarsal, increased distal sesamoid-to-phalanx distance and proximal migration of one or both sesamoids were suggestive findings of unstable plantar plate rupture on weightbearing x-rays. Ultrasound examination was performed to address soft tissue injuries, characterize the magnitude of the plantar plate rupture and for dynamic/comparative stability assessment. A comparative dynamic fluoroscopic evaluation was performed to evaluate the behavior of the sesamoids under maximal dorsiflexion and plantarflexion of the hallux on the lateral view. MRI was also done in all of the patients with positive findings of instability. Results: Eighteen patients (11M/7F) were evaluated under suspicion of turf toe injury from August 2016 to November 2019. The mean age was 31 years old (range:14-50). Weightbearing X-rays were positive for sesamoid complex instability in one patient. Four patients (22,2%) had positive findings for instability in fluoroscopy and US. The agreement between US and fluoroscopy was excellent (kappa coefficient 1). Assuming fluoroscopy examination as the gold standard for instability, the US was highly effective at detecting unstable injuries (Sensitivity 100%, Specificity 100%, PPV 100%, NPV 100%). Four patients positive for instability received operative treatment. Conclusion: In our series, dynamic ultrasound and fluoroscopy allowed detection of 4/18 unstable turf toe injuries compared to Weightbearing X-rays that detected only one unstable injury. US examination is highly sensitive for instability being comparable to fluoroscopic examination. Dynamic testing, with either US or fluoroscopy, in turf toe may improve the diagnosis of severe injuries, leading to higher detection of patients requiring surgical stabilization of the plantar complex.