- Email: [email protected]
Management of Athletic Turf Toe Using Biologics
Management of Athletic Turf Toe Using Biologics$ Aaron V. Mares, MD, Ryan Schreiter, DO, Carola F. van Eck, MD, PhD, Robert Blanc, MS, LAT, ATC, and Volker Musahl, MD Turf toe is a common injury in a variety of different athletes, especially those involved in contact sports played on rigid surfaces. It is caused by a hyperextension injury to the hallux metatarsophalangeal joint resulting in attenuation or tearing of the plantar capsular ligamentous complex. Treatment generally consists of nonoperative measures such as rest, ice, nonsteroidal anti-inflammatory drugs, taping, a stiff-sole shoe, walking boot, or casting. There has been a recent increase in the use of biologics, such as platelet-rich plasma and autologous conditioned plasma for the treatment of a variety of orthopaedic conditions. This study reports on 2 cases of turf toe treated with a combination of Toradol and autologous conditioned plasma. These case presentations are followed by a literature review on the use of biologics in the treatment of sports injuries. Oper Tech Orthop ]:]]]-]]] C 2016 Elsevier Inc. All rights reserved. KEYWORDS Turf Toe, MTP Sprain, PRP, ACP, Toradol, Ketorolac
Introduction
T
urf toe is a common injury in a variety of different athletes, especially those involved in contact sports played on rigid surfaces.1,2 It is caused by a hyperextension injury to the plantar plate and sesamoid complex of the hallux metatarsophalangeal (MTP) joint. This usually occurs when the forefoot is fixed on the ground and the hallux MTP joint is positioned in hyperextension, with axial load applied to the heel. This then results in attenuation or tearing of the plantar capsular ligamentous complex, most commonly off the proximal phalanx. It can be an isolated injury, or occur in combination with a sesamoid fracture, proximal migration of the sesamoid, chondral injury to the MTP joint, or stress fracture of the
Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA. $ The authors did not receive any outside funding or grants directly related to the research presented in this article. The authors state that this article is an original work only submitted to this journal. The authors hold the rights to all the material presented in this article. All authors contributed to the preparation of this work. *Address reprint requests to Aaron V. Mares, MD, UPMC Center for Sports Medicine, 3200 S Water St, Pittsburgh, PA 15203 E-mail: [email protected]
http://dx.doi.org/10.1053/j.oto.2015.12.006 1048-6666//& 2016 Elsevier Inc. All rights reserved.
proximal phalanx. It can be a devastating injury to the professional athlete. The athlete would usually present with sudden onset of pain, stiffness, and swelling at the MTP joint, as well as the inability to push off and reduced agility. Physical examination may show plantar swelling and ecchymosis, inability to hyperextend the MTP joint, positive vertical Lachman test, varus or valgus instability, and an altered gait with a shorter time spent after heel rise. It is therefore often a diagnosis made based on clinical findings, rather than on imaging. Ultrasound can be used to confirm the diagnosis (Fig.). Radiographs can be obtained if there is concern for associated injuries and should then include weight-baring anteroposterior, lateral and oblique views of the foot, as well as sesamoid axial and forced dorsiflexion views.3 If radiographs are negative and there is concern for a stress fracture, a bone scan or magnetic resonance imaging can be considered.3 Turf toe can be graded as grade I: a sprain of the plantar plate, grade II: a partial tear of the plantar plate or grade III: a complete tear of the plantar plate. Treatment generally consists of nonoperative measures such as rest, icing, nonsteroidal antiinflammatory drugs (NSAIDS), taping, a stiff-soled shoe, walking boot, or casting.1 This can be followed by physical therapy to work on progressive motion once the injury is stable. Surgery is only indicated when patients fail conservative 1
A.V. Mares et al.
2
Figure Ultrasound of a normal first MTP joint. (Color version of figure is available online.)
management and can include repair of the plantar capsular ligamentous complex, repair or excision of the sesamoid, removal of loose bodies from the MTP joint, and abductor hallucis transfer if the plantar plate of flexor tendons cannot be restored.1 Hallux rigidus, claw-toe, or cock-up toe deformity with interphalangeal joint flexion contracture are potential late complications.1,4 There has been a recent increase in the use of biologics, such as platelet-rich plasma (PRP) and autologous conditioned plasma (ACP) for the treatment of a variety of orthopaedic conditions. PRP is concentrated blood plasma enriched with platelets. PRP contains and releases several different growth factors and other cytokines that are thought to aid in healing of bone and soft tissue.5 ACP is a specific kind of PRP. Unlike other kinds of PRP types, ACP is distinguished by a low concentration of white blood cells such as neutrophil granulocytes that can be detrimental to the healing process when present in high concentrations.5-7 This study reports on 2 cases of turf toe treated with a combination of Toradol (Toradol [Ketorolac], Roche Pharmaceuticals, Dee Why, Australia) and ACP, followed by a review of literature on the treatment of sports injuries using biologics.
He had full strength with great toe flexion, but did demonstrate weakness—graded 4 out of 5—with extension, secondary to pain. Examination under fluoroscopy demonstrated no instability or fracture. This pain caused an abnormal gait and difficulty competing at a high level of football. He was diagnosed with a first MTP sprain consistent with a grade II “turf toe.” He was initially treated with rest via a controlled ankle walking boot, modalities including laser treatment and cryotherapy, NSAID's as well as a carbon fiber plate. He was held from full-contact practice during the first week postinjury based on pain. He was evaluated for running ability and pain control and played the next game with moderate pain. A week postinjury, he was still symptomatic and he received an ultrasound guided-corticosteroid injection. This resulted in minimal improvement of pain. At 2 weeks postinjury, he was given an intra-articular injection of ACP in combination with 10 mg of Toradol. This was followed by a rest period of 48 hours. Thereafter, he was progressed from linear sprint drills to noncontact position-specific drills that included cutting and pivoting, and then to full-contact drills. Pain level guided his progression. He was able to return to play for the remainder of the season without pain and did not have recurrence of symptoms.
Case 1 A 19-year-old man, division I college football running back presented to the training room after a game with the chief complaint of left great toe pain. The pain started after taking off running from a football 3-point stance. He stated the pain was affecting his ability to push off from a static position. A thorough examination showed full range of motion in the ankle, foot, and all toes without any laxity of ligament structures. There was a mild valgus deformity to the first metatarsophalangeal joint. No ecchymosis or erythema was present. There was mild-to-moderate swelling to the first MTP joint with tenderness to palpation over the dorsal and plantar aspect of the joint. A vertical Lachman test of the MTP showed mild laxity. There was no pain on palpation of either the medial or lateral sesamoid, or the flexor hallucis longus tendon.
Case 2 An 18-year-old man, division I college football running back presented to the training room, following a football game, with the chief complaint of first MTP joint pain. Owing to his position on the football field, he had been exposed to repetitive hyperextension with a loading force. He recalled a specific injury where he had his foot planted and pushed off to do a lateral movement. He had mild swelling at the plantar aspect of the MTP joint without any hallux valgus deformity. There was no pain to palpation of either the medial or lateral sesamoid bones, or the flexor hallucis longus tendon. A vertical Lachman test showed a mild laxity of the MTP joint. His gait also showed a shortened interval of plantar flexion while walking. He had pain with active and passive range of motion of the MTP joint.
Managing athletic turf toe Ultrasound and fluoroscopy immediately following the game demonstrated minimal joint effusion and no instability or fracture. He was diagnosed with a grade II turf toe. Less than 48 hours after initial presentation to the medical staff, he was treated with an intra-articular injection of ACP with 10 mg Toradol. He tolerated this procedure well. The athlete rested for 48 hours after the injection. After 48 hours, he was pain free and had no return of symptoms during the week's practice. He returned to play in full-contact football 1 week after presenting with the injury and has remained asymptomatic for the remainder of the season. In this study, the 2 cases of turf toe were treated with ACP in combination with Toradol. The treatment of turf toe generally consists of nonoperative strategies that can include rest, ice and elevation. Taping, a hard-soled shoe, cam walker boot, or even a short period of casting can be used to provide temporary immobilization of the first MTP joint as the plantar plate heals.1 This is generally followed by physical therapy to work on progressive motion once the injury is stable.1 Cortisone injections have been used, but lack scientific evidence for this specific diagnosis. Surgical management is usually reserved for those patient who have failed all conservative treatment options.4 The most commonly employed surgical treatment strategies are repair of the plantar capsular ligamentous complex or reconstruction using an abductor hallucis transfer; repair or excision of the associated injured sesamoid, and debridement and removal of loose bodies from the MTP joint.1,4 These surgical techniques have been shown to allow athletes to return to play and efficiently reach their preinjury level of participation.4 On evaluation of existing literature, there were no studies on the treatment of turf toe with an injection of Toradol, ACP, PRP, or any combination of these. There is evidence for the use of all of these treatments for several other sports injuries.
Local Toradol Injection in Orthopaedic Sports Injuries Toradol (generic name: Ketorolac) is an NSAID pain reliever. It is the only NSAID that is available for oral, intravenous and intramuscular use. When given intramuscularly, it is a very potent analgesic that starts working within 10 minutes with a peak at 45 minutes.8 Toradol effects neutrophil aggregation, migration, release of lysosomal enzymes, oxidative phosphorylation, and chemotaxis.9,10 In addition it reduces prostaglandin levels that decreases the sensitivity of afferent nerve receptors involved in pain generation.8 The effectiveness of NSAIDS on soft-tissue injuries is controversial. Most clinical studies demonstrate improvements in pain and earlier return to play.11,12 However, these improvements are usually small.11,12 Regarding ligament healing there is contradictory evidence as well. Animal studies have shown both positive and negative results.13-15 Clinical studies have shown a benefit for certain injuries such as ankle sprains.11,16 However, these studies involved oral NSAIDS, not a local injection such as in the case reports presented in this article. The effect of NSAIDs on muscle healing has been studied as well. An inflammatory response is necessary for muscle healing
3 as muscle injury results in tissue necrosis and hematoma formation.17 Animal studies have shown improved muscle contractile force and load to failure with NSAID treatment, but also a delay in collagen deposition and muscle regeneration.18,19 In clinical studies NSAIDS have shown improved pain, muscle strength recovery, and return to play. In high doses, they prevented heterotopic ossification and myositis ossificans.11,12,20 NSAIDS should be avoided in the setting of an acute or stress fracture because of the potential increased risk for nonunion.21-23 Toradol is popular for use in athletes, specifically in the National Football League (NFL). A survey of medical personal in the NFL indicated that greater than 90% of them had used intramuscular Toradol in the pregame setting.24 An average of 15 players per team received an injection up to once a week.24 Some of the reported complications were gastrointestinal symptoms, soreness, and muscle injuries, but no major complications such as renal failure or bleeding were seen.24 The theoretical increased bleeding risk with Toradol is a legitimate concern, especially in contact sports. Small increases in bleeding potential can have major consequences on injuries such as head trauma, spinal, and blunt visceral injuries. Although there is no evidence to suggest a local injection can cause a systematically increased bleeding potential, this has to be considered before injecting an athlete.8
Biologics in Orthopaedic Sports Medicine The use of platelet concentrates such are PRP and ACP for the treatment of a variety of sports injuries has been popularized over the last few years. Platelet concentrates for topical use are blood extracts obtained after processing of a whole blood sample by centrifugation.5 The objective of this process is to discard the blood components that are not useful and keep those which have therapeutic applications such as the fibrinogen, fibrin, platelets, growth factors, cytokines, and leukocytes.5-7 Cytokines such as platelet-derived growth factor-β, transforming growth factor-β, bone morphogenetic proteins, insulin-like growth factor-1, vascular endothelial growth factor, and fibroblast growth factor have been shown to play a role in the healing process and may aid the bodys natural ability to heal bony and soft-tissue injuries.25 As these material are tissues themselves, they are not considered pharmaceuticals. The goal of the injection of platelet concentrates is to stimulate, improve of accelerate healing.26 Although there are no specific reports in literature regarding the use of PRP, ACP, or other biologics in the treatment of turf toe, positive outcomes have been reported for a variety of other sports injuries such as rotator cuff tears, ulnar collateral ligament injuries, lateral epicondylitis (tennis elbow), hamstring injuries, Achilles tendon pathology, and even osteoarthritis. For rotator cuff tears, the evidence for the use of PRP is conflicting. A study that compared conventional arthroscopic rotator cuff repair with a repair augmented with PRP and found a greater than 50% decrease in retear rate in the PRP group as well an improvement in overall shoulder function.27 However, this study is contrasted by 2 studies that found no difference in functional outcomes with the addition of PRP.28,29
A.V. Mares et al.
4 PRP was also studied as an alternative to surgical management in the treatment of ulnar collateral ligament injuries in throwing athletes. In a study involving 34 athletes, 30 of these had returned to play at an average of 12 weeks and all of them had a significant improvement in functional outcome measures.30 However, no control group was available for comparison.30 Overall, 2 double-blind randomized studies from the same group evaluated the effect of PRP in the treatment of lateral epicondylitis. Their control group received a cortisone injection. They found that PRP was more effective in reducing pain and improving function and disability scores. Positive effects also lasted longer in the PRP group than the cortisone group.31,32 Other authors have reported similar findings after comparing PRP to a local anesthetic.33 Limited quality research exists regarding the treatment of hamstring injuries with PRP. The most compelling study is an NFL case series where players were injected with PRP within 24-48 hours after an acute hamstring injury and achieved an earlier return to play of 3-5 days.34 Several uncontrolled prospective and small retrospective studies have reported good outcomes of ultrasound guided PRP injection for Achilles tendinopathy.35-37 One of them even reporting 78% of patients had experienced clinical improvement and had avoided surgical intervention at 6-month followup.35 However, only 1 group performed a randomized controlled clinical trial comparing PRP to placebo injection followed by a rehabilitation protocol involving eccentric exercises. They failed to show any significant differences between the groups for patient satisfaction, return to sports and tendon structural reorganization both at 6 months and 1-year follow-up.38,39 A large number of studies have investigated the effectiveness of PRP in the treatment of knee osteoarthritis.40-43 All of these have shown improved pain and function. However, when compared with viscous supplement injection, there was no significant difference.40-43 There was a clear benefit of PRP for the subgroup of younger patients with less degenerative changes.40-43 The treatment algorithm for turf toe generally starts with a period of ice, rest and elevation. If this fails to provide relief, immobilization in the form of taping, stiff-soled shoes, a walking boot, or casting can be attempted, followed by physical therapy. If the patient is still symptomatic, 1 or more cortisone injections into the MTP joint can be tried. Once these treatment options have been exhausted, surgical treatment is often considered, followed by a period or rest and rehabilitation. However, this study describes a single injection of Toradol and ACP for the management of turf toe, shortly after the injury occurs. In the 2 cases that were presented, this resulted in fast pain relief and return to sports without the recurrence of symptoms. The present study hereby challenges the current treatment regimens. This is particularly important, as turf toe is generally an injury that occurs in athletes for whom time to return to play is a very important outcome. Of course future research needs to be performed to further validate this novel treatment.
Conclusion The use of biologics such as PRP and ACP in the treatment of sports injuries is gaining popularity. Several studies have shown good results for specific conditions such as rotator cuff tears, ulnar collateral ligament injuries, lateral epicondylitis, hamstring and Achilles tendon injuries, and osteoarthritis. Although there are no studies specifically on the treatment of turf toe with ACP, the 2 cases presented in this article showed promising results, specifically regarding return to play. Welldesigned clinical trials are needed to determine the appropriate indications and possible limitations and adverse effects of biologics for the treatment of sports injuries such as turf toe.
References 1. Mason LW, Molloy AP: Turf toe and disorders of the sesamoid complex. Clin Sports Med 34:725-739, 2015 2. George E, Harris AH, Dragoo JL, et al: Incidence and risk factors for turf toe injuries in intercollegiate football: Data from the national collegiate athletic association injury surveillance system. Foot Ankle Int 35:108-115, 2014 3. Schein AJ, Skalski MR, Patel DB, et al: Turf toe and sesamoiditis: What the radiologist needs to know. Clin Imaging 39:380-389, 2015 4. McCormick JJ, Anderson RB: The great toe: Failed turf toe, chronic turf toe, and complicated sesamoid injuries. Foot Ankle Clin 14:135-150, 2009 5. Dohan Ehrenfest DM, Andia I, Zumstein MA, et al: Classification of platelet concentrates (platelet-rich plasma-PRP, platelet-rich fibrin-PRF) for topical and infiltrative use in orthopedic and sports medicine: Current consensus, clinical implications and perspectives. Muscles Ligaments Tendons J 4:3-9, 2014 6. Mazzocca AD, McCarthy MB, Chowaniec DM, et al: Platelet-rich plasma differs according to preparation method and human variability. J Bone Joint Surg Am 94:308-316, 2012 7. Sundman EA, Cole BJ, Fortier LA: Growth factor and catabolic cytokine concentrations are influenced by the cellular composition of platelet-rich plasma. Am J Sports Med 39:2135-2140, 2011 8. Nepple JJ, Matava MJ: Soft tissue injections in the athlete. Sports Health 1:396-404, 2009 9. Buckwalter JA: Pharmacological treatment of soft-tissue injuries. J Bone Joint Surg Am 77:1902-1914, 1995 10. Ekman EF, Koman LA: Acute pain following musculoskeletal injuries and orthopaedic surgery: Mechanisms and management. Instr Course Lect 54:21-33, 2005 11. Mehallo CJ, Drezner JA, Bytomski JR: Practical management: Nonsteroidal antiinflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med 16:170-174, 2006 12. Weiler JM: Medical modifiers of sports injury. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in sports soft-tissue injury. Clin Sports Med 11:625-644, 1992 13. Dahners LE, Gilbert JA, Lester GE, et al: The effect of a nonsteroidal antiinflammatory drug on the healing of ligaments. Am J Sports Med 16:641-646, 1988 14. Elder CL, Dahners LE, Weinhold PS: A cyclooxygenase-2 inhibitor impairs ligament healing in the rat. Am J Sports Med 29:801-805, 2001 15. Hanson CA, Weinhold PS, Afshari HM, et al: The effect of analgesic agents on the healing rat medial collateral ligament. Am J Sports Med 33: 674-679, 2005 16. Slatyer MA, Hensley MJ, Lopert R: A randomized controlled trial of piroxicam in the management of acute ankle sprain in Australian Regular Army recruits. The Kapooka Ankle Sprain Study. Am J Sports Med 25:544-553, 1997 17. Jarvinen TA, Jarvinen TL, Kaariainen M, et al: Muscle injuries: Biology and treatment. Am J Sports Med 33:745-764, 2005
Managing athletic turf toe 18. Almekinders LC, Gilbert JA: Healing of experimental muscle strains and the effects of nonsteroidal antiinflammatory medication. Am J Sports Med 14:303-308, 1986 19. Obremsky WT, Seaber AV, Ribbeck BM, et al: Biomechanical and histologic assessment of a controlled muscle strain injury treated with piroxicam. Am J Sports Med 22:558-561, 1994 20. Pritchett JW: Ketorolac prophylaxis against heterotopic ossification after hip replacement. Clin Orthop Relat Res 314:162-165, 1995 21. Gerstenfeld LC, Al-Ghawas M, Alkhiary YM, et al: Selective and nonselective cyclooxygenase-2 inhibitors and experimental fracture-healing. Reversibility of effects after short-term treatment. J Bone Joint Surg Am 89:114-125, 2007 22. Simon AM, Manigrasso MB, O'Connor JP: Cyclo-oxygenase 2 function is essential for bone fracture healing. J Bone Miner Res 17:963-976, 2002 23. Zhang X, Schwarz EM, Young DA, et al: Cyclooxygenase-2 regulates mesenchymal cell differentiation into the osteoblast lineage and is critically involved in bone repair. J Clin Invest 109:1405-1415, 2002 24. Powell ET, Tokish JM, Hawkins RJ: Toradol use in the athletic population. Curr Sports Med Rep 1:191, 2002 25. Anz AW, Hackel JG, Nilssen EC, et al: Application of biologics in the treatment of the rotator cuff, meniscus, cartilage, and osteoarthritis. J Am Acad Orthop Surg 22:68-79, 2014 26. Williams PN, Moran G, Bradley JP, et al: Platelet-rich plasma and other cellular strategies in orthopedic surgery. Curr Rev Musculoskelet Med 8:32-39, 2015 27. Jo CH, Kim JE, Yoon KS, et al: Does platelet-rich plasma accelerate recovery after rotator cuff repair? A prospective cohort study. Am J Sports Med 39:2082-2090, 2011 28. Bergeson AG, Tashjian RZ, Greis PE, et al: Effects of platelet-rich fibrin matrix on repair integrity of at-risk rotator cuff tears. Am J Sports Med 40:286-293, 2012 29. Rodeo SA, Delos D, Williams RJ, et al: The effect of platelet-rich fibrin matrix on rotator cuff tendon healing: A prospective, randomized clinical study. Am J Sports Med 40:1234-1241, 2012 30. Podesta L, Crow SA, Volkmer D, et al: Treatment of partial ulnar collateral ligament tears in the elbow with platelet-rich plasma. Am J Sports Med 41:1689-1694, 2013 31. Peerbooms JC, Sluimer J, Bruijn DJ, et al: Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: Platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med 38:255-262, 2010
5 32. Gosens T, Peerbooms JC, van Laar W, et al: Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: A double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med 39:1200-1208, 2011 33. Mishra A, Pavelko T: Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med 34:1774-1778, 2006 34. Mejia MA, Bradley JP: The effects of platelet-rich plasma on muscle: Basic science and clinical application. Oper Tech Sports Med 19:149-153, 2011 35. Murawski CD, Smyth NA, Newman H, et al: A single platelet-rich plasma injection for chronic midsubstance achilles tendinopathy: A retrospective preliminary analysis. Foot Ankle Spec 7:372-376, 2014 36. Ferrero G, Fabbro E, Orlandi D, et al: Ultrasound-guided injection of platelet-rich plasma in chronic Achilles and patellar tendinopathy. J Ultrasound 15:260-266, 2012 37. Owens Jr. RF, Ginnetti J, Conti SF, et al: Clinical and magnetic resonance imaging outcomes following platelet rich plasma injection for chronic midsubstance Achilles tendinopathy. Foot Ankle Int 32:1032-1039, 2011 38. de Vos RJ, Weir A, van Schie HT, et al: Platelet-rich plasma injection for chronic Achilles tendinopathy: A randomized controlled trial. J Am Med Assoc 303:144-149, 2010 39. de Jonge S, de Vos RJ, Weir A, et al: One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: A double-blind randomized placebo-controlled trial. Am J Sports Med 39:1623-1629, 2011 40. Filardo G, Kon E, Roffi A, et al: Platelet-rich plasma: Why intra-articular? A systematic review of preclinical studies and clinical evidence on PRP for joint degeneration. Knee Surg Sports Traumatol Arthrosc 23:2459-2474, 2015 41. Filardo G, Kon E, Pereira Ruiz MT, et al: Platelet-rich plasma intra-articular injections for cartilage degeneration and osteoarthritis: Single- versus double-spinning approach. Knee Surg Sports Traumatol Arthrosc 20:2082-2091, 2012 42. Kon E, Mandelbaum B, Buda R, et al: Platelet-rich plasma intra-articular injection versus hyaluronic acid viscosupplementation as treatments for cartilage pathology: From early degeneration to osteoarthritis. Arthroscopy 27:1490-1501, 2011 43. Patel S, Dhillon MS, Aggarwal S, et al: Treatment with platelet-rich plasma is more effective than placebo for knee osteoarthritis: A prospective, double-blind, randomized trial. Am J Sports Med 41:356-364, 2013
Introduction
T
urf toe is a common injury in a variety of different athletes, especially those involved in contact sports played on rigid surfaces.1,2 It is caused by a hyperextension injury to the plantar plate and sesamoid complex of the hallux metatarsophalangeal (MTP) joint. This usually occurs when the forefoot is fixed on the ground and the hallux MTP joint is positioned in hyperextension, with axial load applied to the heel. This then results in attenuation or tearing of the plantar capsular ligamentous complex, most commonly off the proximal phalanx. It can be an isolated injury, or occur in combination with a sesamoid fracture, proximal migration of the sesamoid, chondral injury to the MTP joint, or stress fracture of the
Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA. $ The authors did not receive any outside funding or grants directly related to the research presented in this article. The authors state that this article is an original work only submitted to this journal. The authors hold the rights to all the material presented in this article. All authors contributed to the preparation of this work. *Address reprint requests to Aaron V. Mares, MD, UPMC Center for Sports Medicine, 3200 S Water St, Pittsburgh, PA 15203 E-mail: [email protected]
http://dx.doi.org/10.1053/j.oto.2015.12.006 1048-6666//& 2016 Elsevier Inc. All rights reserved.
proximal phalanx. It can be a devastating injury to the professional athlete. The athlete would usually present with sudden onset of pain, stiffness, and swelling at the MTP joint, as well as the inability to push off and reduced agility. Physical examination may show plantar swelling and ecchymosis, inability to hyperextend the MTP joint, positive vertical Lachman test, varus or valgus instability, and an altered gait with a shorter time spent after heel rise. It is therefore often a diagnosis made based on clinical findings, rather than on imaging. Ultrasound can be used to confirm the diagnosis (Fig.). Radiographs can be obtained if there is concern for associated injuries and should then include weight-baring anteroposterior, lateral and oblique views of the foot, as well as sesamoid axial and forced dorsiflexion views.3 If radiographs are negative and there is concern for a stress fracture, a bone scan or magnetic resonance imaging can be considered.3 Turf toe can be graded as grade I: a sprain of the plantar plate, grade II: a partial tear of the plantar plate or grade III: a complete tear of the plantar plate. Treatment generally consists of nonoperative measures such as rest, icing, nonsteroidal antiinflammatory drugs (NSAIDS), taping, a stiff-soled shoe, walking boot, or casting.1 This can be followed by physical therapy to work on progressive motion once the injury is stable. Surgery is only indicated when patients fail conservative 1
A.V. Mares et al.
2
Figure Ultrasound of a normal first MTP joint. (Color version of figure is available online.)
management and can include repair of the plantar capsular ligamentous complex, repair or excision of the sesamoid, removal of loose bodies from the MTP joint, and abductor hallucis transfer if the plantar plate of flexor tendons cannot be restored.1 Hallux rigidus, claw-toe, or cock-up toe deformity with interphalangeal joint flexion contracture are potential late complications.1,4 There has been a recent increase in the use of biologics, such as platelet-rich plasma (PRP) and autologous conditioned plasma (ACP) for the treatment of a variety of orthopaedic conditions. PRP is concentrated blood plasma enriched with platelets. PRP contains and releases several different growth factors and other cytokines that are thought to aid in healing of bone and soft tissue.5 ACP is a specific kind of PRP. Unlike other kinds of PRP types, ACP is distinguished by a low concentration of white blood cells such as neutrophil granulocytes that can be detrimental to the healing process when present in high concentrations.5-7 This study reports on 2 cases of turf toe treated with a combination of Toradol (Toradol [Ketorolac], Roche Pharmaceuticals, Dee Why, Australia) and ACP, followed by a review of literature on the treatment of sports injuries using biologics.
He had full strength with great toe flexion, but did demonstrate weakness—graded 4 out of 5—with extension, secondary to pain. Examination under fluoroscopy demonstrated no instability or fracture. This pain caused an abnormal gait and difficulty competing at a high level of football. He was diagnosed with a first MTP sprain consistent with a grade II “turf toe.” He was initially treated with rest via a controlled ankle walking boot, modalities including laser treatment and cryotherapy, NSAID's as well as a carbon fiber plate. He was held from full-contact practice during the first week postinjury based on pain. He was evaluated for running ability and pain control and played the next game with moderate pain. A week postinjury, he was still symptomatic and he received an ultrasound guided-corticosteroid injection. This resulted in minimal improvement of pain. At 2 weeks postinjury, he was given an intra-articular injection of ACP in combination with 10 mg of Toradol. This was followed by a rest period of 48 hours. Thereafter, he was progressed from linear sprint drills to noncontact position-specific drills that included cutting and pivoting, and then to full-contact drills. Pain level guided his progression. He was able to return to play for the remainder of the season without pain and did not have recurrence of symptoms.
Case 1 A 19-year-old man, division I college football running back presented to the training room after a game with the chief complaint of left great toe pain. The pain started after taking off running from a football 3-point stance. He stated the pain was affecting his ability to push off from a static position. A thorough examination showed full range of motion in the ankle, foot, and all toes without any laxity of ligament structures. There was a mild valgus deformity to the first metatarsophalangeal joint. No ecchymosis or erythema was present. There was mild-to-moderate swelling to the first MTP joint with tenderness to palpation over the dorsal and plantar aspect of the joint. A vertical Lachman test of the MTP showed mild laxity. There was no pain on palpation of either the medial or lateral sesamoid, or the flexor hallucis longus tendon.
Case 2 An 18-year-old man, division I college football running back presented to the training room, following a football game, with the chief complaint of first MTP joint pain. Owing to his position on the football field, he had been exposed to repetitive hyperextension with a loading force. He recalled a specific injury where he had his foot planted and pushed off to do a lateral movement. He had mild swelling at the plantar aspect of the MTP joint without any hallux valgus deformity. There was no pain to palpation of either the medial or lateral sesamoid bones, or the flexor hallucis longus tendon. A vertical Lachman test showed a mild laxity of the MTP joint. His gait also showed a shortened interval of plantar flexion while walking. He had pain with active and passive range of motion of the MTP joint.
Managing athletic turf toe Ultrasound and fluoroscopy immediately following the game demonstrated minimal joint effusion and no instability or fracture. He was diagnosed with a grade II turf toe. Less than 48 hours after initial presentation to the medical staff, he was treated with an intra-articular injection of ACP with 10 mg Toradol. He tolerated this procedure well. The athlete rested for 48 hours after the injection. After 48 hours, he was pain free and had no return of symptoms during the week's practice. He returned to play in full-contact football 1 week after presenting with the injury and has remained asymptomatic for the remainder of the season. In this study, the 2 cases of turf toe were treated with ACP in combination with Toradol. The treatment of turf toe generally consists of nonoperative strategies that can include rest, ice and elevation. Taping, a hard-soled shoe, cam walker boot, or even a short period of casting can be used to provide temporary immobilization of the first MTP joint as the plantar plate heals.1 This is generally followed by physical therapy to work on progressive motion once the injury is stable.1 Cortisone injections have been used, but lack scientific evidence for this specific diagnosis. Surgical management is usually reserved for those patient who have failed all conservative treatment options.4 The most commonly employed surgical treatment strategies are repair of the plantar capsular ligamentous complex or reconstruction using an abductor hallucis transfer; repair or excision of the associated injured sesamoid, and debridement and removal of loose bodies from the MTP joint.1,4 These surgical techniques have been shown to allow athletes to return to play and efficiently reach their preinjury level of participation.4 On evaluation of existing literature, there were no studies on the treatment of turf toe with an injection of Toradol, ACP, PRP, or any combination of these. There is evidence for the use of all of these treatments for several other sports injuries.
Local Toradol Injection in Orthopaedic Sports Injuries Toradol (generic name: Ketorolac) is an NSAID pain reliever. It is the only NSAID that is available for oral, intravenous and intramuscular use. When given intramuscularly, it is a very potent analgesic that starts working within 10 minutes with a peak at 45 minutes.8 Toradol effects neutrophil aggregation, migration, release of lysosomal enzymes, oxidative phosphorylation, and chemotaxis.9,10 In addition it reduces prostaglandin levels that decreases the sensitivity of afferent nerve receptors involved in pain generation.8 The effectiveness of NSAIDS on soft-tissue injuries is controversial. Most clinical studies demonstrate improvements in pain and earlier return to play.11,12 However, these improvements are usually small.11,12 Regarding ligament healing there is contradictory evidence as well. Animal studies have shown both positive and negative results.13-15 Clinical studies have shown a benefit for certain injuries such as ankle sprains.11,16 However, these studies involved oral NSAIDS, not a local injection such as in the case reports presented in this article. The effect of NSAIDs on muscle healing has been studied as well. An inflammatory response is necessary for muscle healing
3 as muscle injury results in tissue necrosis and hematoma formation.17 Animal studies have shown improved muscle contractile force and load to failure with NSAID treatment, but also a delay in collagen deposition and muscle regeneration.18,19 In clinical studies NSAIDS have shown improved pain, muscle strength recovery, and return to play. In high doses, they prevented heterotopic ossification and myositis ossificans.11,12,20 NSAIDS should be avoided in the setting of an acute or stress fracture because of the potential increased risk for nonunion.21-23 Toradol is popular for use in athletes, specifically in the National Football League (NFL). A survey of medical personal in the NFL indicated that greater than 90% of them had used intramuscular Toradol in the pregame setting.24 An average of 15 players per team received an injection up to once a week.24 Some of the reported complications were gastrointestinal symptoms, soreness, and muscle injuries, but no major complications such as renal failure or bleeding were seen.24 The theoretical increased bleeding risk with Toradol is a legitimate concern, especially in contact sports. Small increases in bleeding potential can have major consequences on injuries such as head trauma, spinal, and blunt visceral injuries. Although there is no evidence to suggest a local injection can cause a systematically increased bleeding potential, this has to be considered before injecting an athlete.8
Biologics in Orthopaedic Sports Medicine The use of platelet concentrates such are PRP and ACP for the treatment of a variety of sports injuries has been popularized over the last few years. Platelet concentrates for topical use are blood extracts obtained after processing of a whole blood sample by centrifugation.5 The objective of this process is to discard the blood components that are not useful and keep those which have therapeutic applications such as the fibrinogen, fibrin, platelets, growth factors, cytokines, and leukocytes.5-7 Cytokines such as platelet-derived growth factor-β, transforming growth factor-β, bone morphogenetic proteins, insulin-like growth factor-1, vascular endothelial growth factor, and fibroblast growth factor have been shown to play a role in the healing process and may aid the bodys natural ability to heal bony and soft-tissue injuries.25 As these material are tissues themselves, they are not considered pharmaceuticals. The goal of the injection of platelet concentrates is to stimulate, improve of accelerate healing.26 Although there are no specific reports in literature regarding the use of PRP, ACP, or other biologics in the treatment of turf toe, positive outcomes have been reported for a variety of other sports injuries such as rotator cuff tears, ulnar collateral ligament injuries, lateral epicondylitis (tennis elbow), hamstring injuries, Achilles tendon pathology, and even osteoarthritis. For rotator cuff tears, the evidence for the use of PRP is conflicting. A study that compared conventional arthroscopic rotator cuff repair with a repair augmented with PRP and found a greater than 50% decrease in retear rate in the PRP group as well an improvement in overall shoulder function.27 However, this study is contrasted by 2 studies that found no difference in functional outcomes with the addition of PRP.28,29
A.V. Mares et al.
4 PRP was also studied as an alternative to surgical management in the treatment of ulnar collateral ligament injuries in throwing athletes. In a study involving 34 athletes, 30 of these had returned to play at an average of 12 weeks and all of them had a significant improvement in functional outcome measures.30 However, no control group was available for comparison.30 Overall, 2 double-blind randomized studies from the same group evaluated the effect of PRP in the treatment of lateral epicondylitis. Their control group received a cortisone injection. They found that PRP was more effective in reducing pain and improving function and disability scores. Positive effects also lasted longer in the PRP group than the cortisone group.31,32 Other authors have reported similar findings after comparing PRP to a local anesthetic.33 Limited quality research exists regarding the treatment of hamstring injuries with PRP. The most compelling study is an NFL case series where players were injected with PRP within 24-48 hours after an acute hamstring injury and achieved an earlier return to play of 3-5 days.34 Several uncontrolled prospective and small retrospective studies have reported good outcomes of ultrasound guided PRP injection for Achilles tendinopathy.35-37 One of them even reporting 78% of patients had experienced clinical improvement and had avoided surgical intervention at 6-month followup.35 However, only 1 group performed a randomized controlled clinical trial comparing PRP to placebo injection followed by a rehabilitation protocol involving eccentric exercises. They failed to show any significant differences between the groups for patient satisfaction, return to sports and tendon structural reorganization both at 6 months and 1-year follow-up.38,39 A large number of studies have investigated the effectiveness of PRP in the treatment of knee osteoarthritis.40-43 All of these have shown improved pain and function. However, when compared with viscous supplement injection, there was no significant difference.40-43 There was a clear benefit of PRP for the subgroup of younger patients with less degenerative changes.40-43 The treatment algorithm for turf toe generally starts with a period of ice, rest and elevation. If this fails to provide relief, immobilization in the form of taping, stiff-soled shoes, a walking boot, or casting can be attempted, followed by physical therapy. If the patient is still symptomatic, 1 or more cortisone injections into the MTP joint can be tried. Once these treatment options have been exhausted, surgical treatment is often considered, followed by a period or rest and rehabilitation. However, this study describes a single injection of Toradol and ACP for the management of turf toe, shortly after the injury occurs. In the 2 cases that were presented, this resulted in fast pain relief and return to sports without the recurrence of symptoms. The present study hereby challenges the current treatment regimens. This is particularly important, as turf toe is generally an injury that occurs in athletes for whom time to return to play is a very important outcome. Of course future research needs to be performed to further validate this novel treatment.
Conclusion The use of biologics such as PRP and ACP in the treatment of sports injuries is gaining popularity. Several studies have shown good results for specific conditions such as rotator cuff tears, ulnar collateral ligament injuries, lateral epicondylitis, hamstring and Achilles tendon injuries, and osteoarthritis. Although there are no studies specifically on the treatment of turf toe with ACP, the 2 cases presented in this article showed promising results, specifically regarding return to play. Welldesigned clinical trials are needed to determine the appropriate indications and possible limitations and adverse effects of biologics for the treatment of sports injuries such as turf toe.
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