The Toe That Lost the Super Bowl

The Problem During the Game

Everyone knows Achilles’ story of vulnerability but the Great toe joint (aka 1st MPJ, big toe joint, piggy that goes to market) may be the real weak link in the foot.

The big toe joint has retired a long list of elite and pro athletes. Deion Sanders, Jack Lambert (old school), and Shaq are just a few. So if you think this is a minor problem I dare you to call anyone of these guys a wimp to their face.

The next on the list may be Patrick Mahomes. There was a definite change in play from the AFC championship game.  His passing accuracy was not the same and his mobility, Patrick’s major weapon, was lost. He was not just a step slow but 2-3 steps slow – for him. His romps to the sidelines for first downs were few and his ability to protect himself and get out of the pocket were significantly affected.

So what can go wrong with the great toe to make it less than great?

I have no insider info or tips but I do see a lot of these injuries and this is what it looks like to me. There was a unilateral short stride and restricted toe off. I did not get a good view but it looked like he had a modified shoe to protect motion of the great toe joint. This is a classic parent of a hallux Limitus deformity (a.k.a. “turf toe” or Hallux Rigidus) with an OCD (osteochondral defect). In other words a really stiff toe that has a divot taken out of the cartilage on the first metatarsal head.

turf toe

Injury Facts

Normal motion for this joint is 70-80 degrees of upward motion. Downward motion is not critical unless you are going off a diving board or on a gymnastic beam. An acute injury can occur when the forefoot is planted and the rear-foot continues to move up. The 1st MPJ is forced past its limits. There can also be limited motion from inherited mechanics.   Less motion would then be needed to produce damage. I would expect to see a lot of stiff big toe joints at a Mahomes family reunion.

This injury would be like moving your index finger so far back that it touches your hand- OUCH! We are not talking about a dislocated finger that can be buddy taped. There is 4-6 x body weight of force placed on the toe with every step. That is why he would wear a modified cleat to limited forefoot motion. A combination of the toe and shoe would definitely limit his mobility to get away from a 280 lb defender.

The pain involved with this injury is not just distracting but consuming with every step. Players at this level are tough but 30% of attention is now on pain and not reading the lineman. Things get missed like weak side blitzes.

Most likely his joint was injected with a local anesthetic and steroid. The NFL does not restrict or ban the use of local anesthetics. This is a fairly common practice in elite and pro sports. The most common meds provide 2-4 hours of numbness. This would get a player only through warm up and maybe the beginning of the game. I’m not sure that this could be repeated during the game. This is a very difficult joint to inject on the field or even at halftime. There is a new local anesthetic we use in surgery that last up to 72 hours- obviously not used.

The first concern with a turf toe injury is soft tissue damage. The real deal is if there is cartilage or bone damage. A bone contusion is something that will resolve in time. If a divot is taken out of the cartilage there will be long term consequences that are not forgiving.

It was rumored that Patrick will have surgery in the off season. The big Ifs – If it is a Turf toe or Hallux Limitus then a joint clean up procedure will be considered. This involves removing or repairing the OCD (osteochondral defect). The good news is that this procedure has a relatively quick recovery. The bad news is that replacement cartilage is not the same quality as the original equipment. The joint will eventually develop arthritis. The clock starts ticking because the life of the joint is going to be shortened and there will never be normal motion.

The chances of using a joint implant is not really an option. It is not a good idea to put these in a non-active person and a horrendous idea to use them in an elite athlete. (That is my editorial comment for the day…DON”T get me started on great toe implants!

I had no skin in this Super Bowl but I think everyone wanted all the players to be at their best. We can appreciate that athletes at this level are in the 99 percentile in every category that makes a great player. (Okay, except in the good judgment category after watching some of the penalties). The big wild card for these athletes is avoiding an unrecoverable injury that could cut a career short. How many potential Hall of Famers never get past three years in the NFL? I enjoy watching Patrick at his best and I hope that he can rise again and stay there long enough to be “One of the Greats”. I also do not want to diminish the players on the opposite side of the line or detract from their incredible efforts.

Enough about the athletes…and on to the Heroes. I applaud the NFL for using health care workers to fill the stands. These were truly the toughest people at the Super Bowl. These people are in the 99 percentile of compassion, commitment, selflessness, and toughness. I am sure all of them would exchange a toe injury instead of the memory of the carnage they have witnessed!)


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