#873 Can collateral toe ligaments be surgically repaired? - DOC

#873 Can collateral toe ligaments be surgically repaired?

Should I have surgery to repair the collateral ligaments in my toe if I am a runner? Well, that is a great question and that is what we’re talking about today on the Doc On The Run Podcast.

 

 

This morning, I was on a consulting call for a second opinion for a runner who had a couple of different injuries in his foot and one of them he had was injury to the collateral ligaments in one of his toes and he feels like the toe is weak and unstable. And then it is going to be a problem if he runs.

He was asking me, “Well, can we surgically repair these?” Well, it is really simple. When you look at the toe, in the toe, you basically have a couple of bones, right? So, here is the couple of toes, and let us say there is a second toe, so, big toe over here. There is a second toe. You have three bones. You have the distal phalanx bone. You have the intermediate phalanx bone and then you have the proximal phalanx and those line up with the metatarsal that goes across top of your foot.

The collateral ligaments, what are they, where are they? Well, they are little ligaments on the side, and they are on the lateral side outside. So, you have them here and here, and here, and here. What do they do? They keep the toe straight, right? So, if you cut this one, the toe is going to tilt that way. If you cut that one, that part of the toe is going to tilt that way.

Can you fix them surgically? Well, good question. Here is how that works. If you look at this, so let us say this is the tail from the side, what you have is the distal phalanx bone that is this one and then you have the intermediate phalanx bone here. Then you have the proximal phalanx. So, let us say for simplicity of our illustration, that you have ruptured or torn the collateral ligament here. That is torn, it is ripped,  it is ripped apart. Let us say this one is still intact. The idea is, could we go in, make a surgical incision on the side of the toe and fix this? Well, the short answer is, yes, technically speaking, we could.

We could go in and make an incision on the side of the toe, it would have to go from there to about there. And then we have to open it up by pulling it apart, so we could actually see the collateral ligaments in there. Then we would have to do something to fix it. Most people would do something like just sew it up. So, you stitch it together, put it in a whole bunch of suture, stitch it together. It wouldn’t be that messy, but you get the idea.

The other way is to put in a couple of bone anchors. Now, why would you not want to do this? Well, the first thing is that if you think of the toe, as a box, right, you have the toenail here and you have the bone in the middle, well, you have nerves, you have four of them at each corner of the toe. So, when you make this big incision and you have a nerve running through here and you have a nerve running through here on the side, well, when we go in and make that big incision, sometimes when with the toe that small, sometimes when we put in the stitches to close the skin, we catch one of the nerves.

If we go in and we sew up the toe from the side and we get a nerve entrapment, where some of the suture wraps around the nerve or from just the tissue dissection where we actually spread the tissue apart so that we can see in there to actually sew it up. If you get scar tissue between those tissue planes and it causes entanglement or tension or tethering or strangulation of the nerve, that causes pain. So, if the toe is not really painful, even if it is slightly unstable, it is not actually causing problems for you for running., this is super risky.

The truth is, is that many times if you tell a doctor,  my toes are unstable, can you sew one of these up, they would say, well, I am not going to do that, but I will go in if you have torn this one here. What I will do is go in and fuse this bone. I will remove the cartilage, I will either put a pin in it or put like a tiny little screw that goes through the bone in this way, and from the end of the toe. We are doing an incision on top, to do it and why would they do that? Because they don’t want to be near the nerves. They don’t want to get a nerve entrapment. The goal is to get back to running. If your toe is stable, it is rock solid, and it looks totally normal other than the scar on the side that you can not really see but you have pain running, that is not a success. That is what we call a failure. A surgical misadventure.  You do not want one of those if you are a runner.

Too much risk of chronic pain, logistically, virtually impossible without risk because  you can get too many issues and of course you can always get a scar when the toes rub together that causes you pain later just because you have a thick scar. So, can the collateral toe ligaments be repaired? Yes. Should you do it? Probably not. But if your doctor says so and you believe that story, that is between you and your doctor.

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