PFATS Articles

Rare Foot Disorders in the National Football League: Rehabilitation and Associated Care of a Great Toe Metatarsal Osteotomy with Medial Release

Reggie Barnes, MS, ATC
Director of Rehabilitation/Associate Athletic Trainer
Seattle Seahawks Football Club

Introduction

Occasionally, the treatment and rehabilitation for injuries in the National Football League (NFL) are so rare that few medical staff members have experience in managing the injury. Often, management of these rare injuries is based solely on the knowledge of the treating medical staff and orthopedic surgeons. This is the case of an NFL linebacker who underwent successful rehabilitation of a right great toe osteotomy with a medial release. Historically, professional athletes undergo this procedure just before retirement and, at best, resume “normal” levels of athletic activity. However, in this situation, surgical intervention quickly became the only alternative for a successful outcome. To date, this is the first documented case that resulted in full participation within the NFL.

History:

In October, the athlete’s injury was initially diagnosed as a typical moderate-to-severe turf toe injury. After two weeks of rehabilitation, the athlete returned to practice and competed in that week’s game. During the game, the injury was re-aggravated causing the athlete to withdraw from competition. Two months later after exhausting all other treatment options, the athlete underwent surgery utilizing a new technique for correcting abnormal metatarsal alignment.

Anatomical Review:

The bony structure of the great toe consists of the first metatarsocuneiform joint, first metatarsal, first metatarsophalangeal joint, the first proximal and distal phalanges and the sesamoid bones. Associated bony landmarks include the first cuneiform, navicular, talus and second metatarsophalangeal joint. Movement is provided by the flexor hallicus longus and brevis, extensor hallicus longus and brevis, the abductor hallicus and the adductor hallicus. Vascular and nervous innervations are supplied through the dorsal pedal artery and medial dorsal cutaneous nerve, respectively.

Definition and Mechanism of Injury:

Osteotomy procedures are performed in order to correct a bunion deformity and involves cutting the bone to shorten, lengthen, or change its alignment. Other injuries associated with a bunion deformity include severe arthritis and chondromalacia of the joint cartilage. These cases often result in limited range of motion of the first MTP joint. While bunion deformities are traditionally hereditary, they can be exacerbated with a “turf toe” type injury or sprain of the first MTP joint. In our athlete’s case, his pre-existing bunion was aggravated by a moderate to severe sprain of his first MTP joint.

Evaluation and Assessment:

Our team of orthopedic physicians first assessed the athlete’s range of motion, strength, stability, and point tenderness of the forefoot and first MTP joint concluded in a diagnoses of a sprain to the first MTP joint. The athlete was referred to a foot and ankle orthopedic surgeon to further confirm the diagnosis. After undergoing X-Ray and MRI studies, the X-Ray films revealed a laterally deformed first metatarsal and metatarsophalangeal joint, in addition to a build up of bony tissue along the distal medial articular surface of the first metatarsal. Although the sesamoids were normal, MRI films revealed inflammation along the medial border of the MTP joint, with moderate ligamentous damage.

Pre-surgery Treatment:

In their respected time frames, the treatment therapy included:

Use of a short walking boot and crutches immediately following surgery in order to maximize healing
Application of traditional modalities - Rest, Ice, Compression, Elevation (RICE) and monitored use of Non-Steroidal Anti-inflammatory Drugs (NSAIDs)
Use of interferential current electrical stim, ultrasound, infrared therapy, contrast bath and iontophoresis
Implementation of progressive resistive exercises

Towel slides, towel scrunches, single leg balancing, ankle tubing, marble pick ups, and pool jogging

Application of light joint mobilizations (as soon as tolerated and the athlete could maintain ankle mobility on the BAPS board)
Use of a foam roller to mobilize the IT band and peroneal muscles
Implementation of corrective measures including:

A bunion pad to provide comfort
A toe spacer to alleviate pain along the medial border of the MTP joint
A nighttime bunion splint to decrease symptomatic pain and increase strength and range of motion

Implementation of custom orthotics and a carbon fiber insole (for fortified rigidity in the athletes walking and training shoes)

Over the course of this treatment and rehabilitation, the athlete had improved clinical exams but did not feel a noticeable improvement. Daily living activities also proved to be difficult. After exhausting all options surgery was suggested as the next step in treatment. However, due to the unpredictable and unproven nature of this surgery in a professional football player, it was not strongly recommended. There simply wasn’t enough literature to support this type of surgery for an NFL player aspiring to return to full functional activity on an active roster. After many discussions and opinions from foot and ankle specialists local and nationwide, we determined that an invasive intervention was the only corrective measure that might provide relief. The primary goal was to attempt to restore comfortable activities of daily living with a secondary objective of achieving a return to the playing field.

The surgical procedure for our athlete utilized a newly developed tool called the Biplane Chevron Cutting Guide. This tool is essentially a template that ensures a piece of the bone is cut perfectly and properly removed in order to successfully correct the lateral deformity of the MTP joint.

The six steps involved with this procedure include:

Medial release which requires the cutting away of the medial eminence of the first MTP joint. This release reveals a clear view of the malalignment to be corrected.
Placement and proper alignment of the cutting guide. A guide wire is drilled into the center of the first metatarsal to anchor the cutting guide.
A cut is made (based on the template of the cutting guide) and the template is fully inserted in the first metatarsal head. The guide wire is left in place to act as a lever to spread the bone once it has been cut.
A final cut is made along the now inserted template using a medical grade, fine toothed surgical saw.
A 2 mm wedge of bone is removed from the first metatarsal head.
A 3 to 4 mm medial shift of the first metatarsal head is held in place with orthosorb sutures.

Before and after Surgery X-Rays

Rehabilitation

As with any rehabilitation program, execution and attention to detail is essential. The development of the rehabilitation protocol for this procedure provided a challenging yet very rewarding experience for the medical staff and the involved athlete. There were many variables to take into consideration, requiring the practitioner to constantly consider the risks versus the rewards.

After two post operative weeks in a cast and non-weight bearing on crutches, the rehabilitation went as follows:

Weeks 2 to 6

Facilitate healing, protection and light conditioning

Continue crutch use and walking boot for non-weight bearing activities
Wear splint to ensure alignment and maintain surgical correction
Initiate light conditioning
- Upper body lift
- Stationary bike
- Non-weight bearing aquatic therapy exercises
Facilitate Active Release Techniques® to lower extremity musculature
- Prevent the build up of scar tissue around the subcutaneous nerve innervations around the incision sites

Weeks 6 and 7

Initiate ROM and joint mobility of MTP joint and ankle

Continue use of walking boot and crutches
Start passive range of motion of first MTP joint and joint mobilization of foot and ankle
Begin exercises
- BAPS board level 1, sitting
- Towel stretch to increase calf flexibility

Utilize foam Roller to mobilize Illiotibial band
Ensure strength of thigh musculature and cardiovascular maintenance

Weeks 8 to 10

Initiate weight bearing exercises and begin running progression

Towel scrunches
Marble pick ups
Calf raises on shuttle
Rice bucket resistance
Single leg balance
Ankle tubing (All planes)
Leg press
Squats
Stairmaster for conditioning
Running Progression

Shallow end pool jogging (Week 8)
Jog on trampoline (Week 9)
Run on treadmill (Week 9)
In-line running on field (Week 10)

Weeks 10 to 16 proved the most pivotal in the rehabilitation program as the surgery could have either failed at this point. Extreme caution was taken during the strength and running progression phases. Special attention was paid to gait patterns and any changes along the kinetic chain, from the great toe up to the hip and low back.

Weeks 10 to 16 and Return to Activity

Continue in-line running and progress to change of direction running and functional activity

Resume normal weight room lower body lifting
Begin functional activity

Position specific skill patterns
Jump rope
Plyometric bounding

Conclusion

The athlete in this case presentation went on to sign with another NFL team and participate fully on the active roster with little to no rippling effects or additional treatment. During rehabilitation, the athlete reported minimal discomfort at most, once the strengthening phase began. As mentioned earlier, engineering rehabilitation protocols for new surgical procedures can be challenging. Attention to detail, a strong effort from the athlete and the support of a knowledgeable medical staff is a formula for any rehabilitation program to be successful.

The Seattle Seahawks medical staff is comprised of the following:

Sam Ramsden, ATC - Head Athletic Trainer
Reggie Barnes, MS, ATC - Assoc. Athletic Trainer
Donald Rich, MS, ATC - Assist. Athletic Trainer
Ed Khalfayan, MD - Orthopedic Surgeon
Stan Herring, MD – Physiatrist & Spine Specialist
Mike McAdam, MD – Orthopedic Surgeon
Brad Shoup, MD – Internal Medicine
**Pepper Toomey, MD – Orthopedic Surgeon, specializing in the foot and ankle
- Special consultant for this case

Resources

¹ Torkki, M., et al (2001). Surgery vs. Orthosis vs. Watchful Waiting for Hallux Valgus: A Randomized Controlled Trial. Journal of the American Medical Assoc. 285: 2474-2480.
²Hoppenfeld, S. (1976). Physical Examination of the Spine and Extremities. Norwalk, CT: Prentice-Hall.
³Hetman, J. & Meyer, K (2005). The Distal Metatarsal Osteotomy for the Treatment of Hallux Valgus. Clinics in Podiatric Medicine. 22, 143-167.