A. J. Green is out with a toe injury that is being described as “a little bit more than turf toe” by the Bengals.
Lets start by saying that “turf toe” is awful. “Turf toe” is just a quick term used to describe a Metatarsophalangeal joint (MTP joint) strain/sprain injury. Without making it complicated, an MTP sprain/strain is very much like any other joint sprain/strain injury that we have talked about in the past, in terms of the science. The injury is graded as a 1, 2, or 3; with 1 – indicating over stretching with swelling and pain; 2 – indicating small tears to the structures as well as pain, swelling and possibly some instability and loss of strength; and 3 – indicating a complete tear. The grade on Green’s toe has not been publicized, but I think it is safe to say that it is beyond a grade 1, as he is seeing multiple specialist and likely to miss the game this week. It is also safe to say it is not a grade 3 as this would have caused a more definite time-table for his return and may have required surgery. Therefore, I come to the conclusion that we are dealing with a grade 2 sprain/strain injury for his big toe.
While I say that this is still a sprain/strain injury similar to those that occur at other joints such as your knee or ankle, the difference with “turf toe” is that the joint and its ligaments/tendons are small enough to make adding support very difficult, but important enough to hinder almost everything you do on a football field.
The Plantar plate in figure 1 actually represents the ligament in this area while the Flexor hallucis represents the tendon in this area. This is why we can consider this a sprain/strain injury, (remember sprains are for ligaments and strains are for muscle and tendon) as in most cases both of these structures are suffering as well as the actual joint. If you put your hand on the ball of your foot on your big toe side and go forward just a little until you hit the crease that separates the ball from your toe, you can feel the area that is irritated with this injury. If you then stand up and walk, you will notice how much bend and push-off you get from that joint. Hopefully from doing this you can somewhat appreciate how this injury can make walking painful and difficult, but now imagine running at the speeds of an A.J. Green.
The functional issue comes down to push-off (Illustrated in figure 2) which is powered at the MTP joint and by the Flexor Hallucis Longus which crosses the joint. Most of us don’t think about walking as a sequence or pattern, but it is. In short, we do a number of things during walking that we take for granted and one of the crucial stages of gait (walking) is pushing off of the balls of our feet and toes to allow our foot to propel off the ground into a swing forward motion to take a step. Without this action, your walking would be dysfunctional and you would either be walking with a limp or with an assistive device like a cane or a walker. Running is just a faster and more forceful version of walking; and this same push-off is essential. In theory, these freaky fast athletes are creating more force in a shorter amount of time during their push-off as compared to the non athletic population. This may be a gift and a curse as the force that their talent produces on their joint, ligaments and tendons is not alway supported by these structures. I believe this is why the most elite, most talented athletes are at higher risk for injury. Similar to the cars driven in Nascar being at higher risk for malfunction, these athletes are built better than the norm; they receive more attention than the norm; but just like those cars they are pushed to the limit and therefore repairs are needed often.
Sticking with the car analogy, A.J. has a busted tire and unfortunately he does not have the option to switch tires. Similar to most other sprain/strain injuries, he should be looking at about a 3-6 weeks to heal. His attempts to play through the injury have already failed and if he comes back too quick again, he may risk missing the rest of the season or at least under performing for the rest of the season.
One of the most important things to understand with this injury is that healing occurs in stages. While with knee or ankle sprain/strain injuries, I have supported athletes returning early; when it comes to this injury, an early return could spell disaster. The 3 stages of healing are inflammation, repair and remodeling. With those knee and ankle injuries, it is not always essential to get to the remodeling phase before the player returns to play, as the injured structure can be still healing while I send the player out with a tape job or a very supportive brace that will replace the function of the injured structure. In the case of turf toe, I need the entire healing process to run its course as bracing or stabilizing the joint is not an effective option at this level of athleticism as it takes away the push-off that makes A.J. Green the fast and explosive receiver that he is. One of the hardest things to manage with this injury is that the mechanism of injury occurs during a motion that IS supposed to happen, although not to the degree of force and range that is encountered during the injury. When you compare this to other ligament or tendon injuries that occur during motions that are not supposed to happen at all, you can see why stabilizing or bracing against those motions is a more straight forward approach. “Turf toe” gives us the unique task of limiting a joint movement to a very precise range that optimizes performance but prevents injury.
If this all sounds confusing then use this analogy:
Problem: You want to stop eating potato chips.
Option A: stop eating them by simply not buying any at all.
Option B: stop eating them by buying a bag of chips but stopping at 5 chips per day(for the sake of this analogy, lets say that eating 6 or 7 would cause an all out disaster in your body)
I think most of us would choose option A as an easier and more realistic option as stopping at 5 chips with an entire bag in front of you is tough (or maybe its just me). The point is, in order to play on a “turf toe” injury you would be asking the ligaments and tendons of the MTP joint to do the same thing that option B ask you to do. Your toe would have to extend to just the perfect point (5 chips) and then stop before crossing the threshold of stretching and irritating the ligaments, tendons, and joint (6 or 7 chips). With a knee sprain to a ligament like the MCL, I can use option A by simply using a brace with extra medial support to stop the knee from receiving valgus force (outer to inner) on the knee which in turn would significantly protect the MCL from receiving any motion that would stress the area (0 chips). I give this analogy to simply say that managing this injury while the athlete continues to play is very difficult and likely unsuccessful, similar to option B with the chips. Therefore, A.J. Green is likely on the option A path, which means not playing at all.
The NFL has all types of interventions to help Green heal at an optimal rate, but if I am the Bengals, I expect him out for at least a month.
What You Need To Know
Two Hall of Famers come to mind when I think of “turf toe”. Jonathan Ogden the hall of fame Offensive tackle went out with turf toe, but athletically that doesn’t quite relate to A.J. Green. However, the second, who in my opinion is the greatest athlete of all time (on the football field) was also chased out of the game because of his toe–Deion Sanders a.k.a. “Prime Time”. Now, Sanders was near the end of his career anyway, but my guess is that before the “turf toe” Deion was still in the top ten in regards to speed in the league and still a top defensive back. The injury simply took him out after failed conservative management followed by a failed surgical attempt. I say all of this to say that even though it is a toe injury, it is a very serious threat to a receiver that relies on his athleticism.
I do not see a risk of Green retiring from this injury, but I do think that after trying to play through this injury he will have a healthier respect for the injury and sit out for a good while. I would be surprised if Green played before week 10 and even when he returns, I expect he will be rusty. Keep in mind that resting this injury stops him from nearly all weight bearing activity on that foot which is a very big deal. So for fantasy owners, I am expecting that A.J. Green will not be his normal self until deep into the season and barely ready for fantasy playoffs. With that said, I would trade him now! There is a good chance that this story will look scarier to your fantasy league after all the Doctors visits are done and A.J. starts missing practices and games; and then you may have a hard time trading him. If you trade him now, there is a good chance that many devalue the significance of this injury and give you good return for him. If it had been a little earlier in the season, I might say keep him but I just don’t think anyone is worth a roster spot if they can not produce for 4 weeks or more, as we know it doesn’t take much to fall out of playoff contention. A.J. Green will be of no use to you in week 11 or 12 if you are already mathematically out of the playoffs. In any case, the roster move is your choice; but the chances of a productive A.J. Green before week 10 at the Browns is slim.