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Turf Toe

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Other Names

  • Turf Toe
  • First Metatarsophalangeal Joint Sprain

Background

  • This page refers to 'turf toe', general term that applies to a spectrum of injuries affecting the first Metatarsophalangeal Joint (MTPJ) complex[1]

History

  • First described by Bowers and Martin as a sprain of the plantar soft tissue support of the 1st MTPJ[2]
  • The term turf toe was described in a 1970s study of the University of West Virginia football team[3]

Epidemiology

  • Incidence
    • Among NCAA football players, 0.062 per 1000 athlete-exposures[4]

Pathophysiology

Illustrations of the most commonly described mechanism for turf toe injury: (A) axial load on a dorsiflexed great toe and (B) landing on another object, such as another player’s foot, causing hyperdorsiflexion of the great toe.[4]
  • Definition
    • 'Turf Toe' is a broad term referring to damage to the 1st MTPJ Complex
    • This can include hallux plantar capsule, plantar muscles, sesamoid complex

Etiology

  • 1st MTPJ
    • Bears more than double the load of the lesser toes
    • Peak plantar pressures occur beneath the first MTPJ during functions essential to athletic performance
    • Examples include running, jumping, and cutting
  • In American football the majority of injuries come from[4]
    • Contact with the playing surface (35.4%)
    • Contact with another player (32.7%)

Mechanism of Injury

  • Hyperdorsiflexion
    • Hyperdorsiflexion of the first MTP through a planted hallux represents about 85% of cases
    • The structures most commonly affected are the glenosesamoid apparatus and the plantar ligaments[5]
    • Disruption of the volar capsule proximal to the sesamoids, dorsal translation or dislocation of the hallux
    • In severe cases, retraction of the sesamoids[6]
    • Resultant instability can damage the joint surface and subchondral bone
    • This occurs due to unrestrained proximal phalanx eccentrically loads the dorsal articular surface of the metatarsal head
  • Forceful valgus stress + Hyperdorsiflexion
    • Can create the so-called "medial variant" injury
    • The medial plantar ligaments and tibial sesamoid complex are injured
    • This produces an unbalanced pull of the adductor halluces through the base of the proximal phalanx
    • Subsequently, the patient will develop progressive hallux valgus[7]
    • Chronic metatarsus primus elevation can eccentrically load the MTP, over time producing a dorsally based hallux rigidus[7]

Associated Conditions

  • Sesamoid Fracture
  • Proximal migration of sesamoid
  • Stress fracture of proximal phalanx
  • Osteochondral injuries
  • Bone contusions
  • Loose bodies
  • Degenerative changes
  • Acute traumatic hallux valgus with medial collateral ligament involvement[8]
  • Varus or valgus injuries to hallux MTP

Pathoanatomy

  • 1st Metatarsophalangeal Joint
    • Hinged ball and socket formed by articulation of the 1st Metatarsal and proximal Phalanx
    • Due to the shallow concavity of the base of the proximal phalanx, this articulation is relatively unstable
    • Supported by an additional 9 ligaments, 3 tendons, and two Sesamoids

Risk Factors

  • Sports
    • Football
      • Quarterback, running back most common
  • Training Factors
    • Among football players, risk is 14x higher during games than practice[4]
    • Increased rate on artificial surfaces compared to natural grass

Differential Diagnosis


Clinical Features

  • History
    • Patients report pain or stiffness at the joint, typically on the plantar surface
    • Reduced push-off strength and agility during play[9]
    • In more chronic cases, 1st MTP pain worsens with activity and subsides with rest.
  • Physical Exam: Physical Exam Foot
    • Early/ acute exam is more helpful in localizing injured structures
    • Swelling and ecchymosis are not always present, which can make diagnosis challenging
    • Palpate: collateral ligaments, dorsal capsule, and tibial and fibular sesamoids
    • Dorsal or medial joint line tenderness may be present
    • Decreased resistance to passive dorsiflexion indicates injury to the plantar plate
    • Limitations of the MTP in active flexion and extension could indicate damage to the flexor or extensor tendon insertions
    • Dynamic instability: Compromised FHB, tested by resisted plantarflexion of the MTP with the IP joint held in extension
    • Inability to hyperextend the hallux MTP joint without significant pain
    • Inability to push off with the big toe
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Foot
    • Views: weight-bearing anteroposterior, forced dorsiflexion lateral, and axial
  • Lateral and medial 40° oblique
    • Can help visualize the lateral and medial sesamoids
  • Comparison radiographs of the contralateral uninjured foot
    • Should be obtained to assess for proximal migration of the sesamoids[10]
    • A 3-mm increase in distance from sesamoids to the proximal phalanx is predictive of severe injury to the plantar plate[11]

MRI

  • Useful to evaluate for
    • Identification of capsular disruption
    • Soft-tissue injury
    • Osseous or articular damage
  • Indications
    • All ambiguous and grade II/III injuries
  • Extremity surface coil[12]
    • When placed over the forefoot, reduces field of view
    • Improves signal-to-noise ratio and the spatial resolution
  • Structures
    • Plantar plate, hallux sesamoids: best visualized in sagittal, coronal plane
    • Lateral deep intermetatarsal ligament best seen in coronal plane
    • Maine collateral ligament, sesamoid ligaments best seen in axial-long and coronal short plane

Fluoroscopy

  • Useful to[13]
    • Assess the motion of sesamoids with dorsiflexion of the hallux
    • Evaluate instability in varying planes
    • Absent distal sesamoid excursion with great toe extension suggest plantar soft-tissue disruption[14]
    • Help differentiate between bipartite sesamoids (stable with range of motion), acute diastasis of a synchondrosis or fracture

CT

  • Evaluate for
    • Fracture fragments and margins
    • Sclerosis
    • Bony erosions

Bone Scintigraphy

  • Non-specific, not routinely used

Classification

Graade 1 Grade II Grade III
Definition Strain of capsuloligamentous complex Partial tear of plantar plate
with capsuloligamentous
complex strain but without
articular injury
Complete tear of plantar
plate and rupture of
capsuloligamentous
complex; sesamoid
fracture, bruising of
subchondral bone
Physical exam Tenderness, minimal swelling,
no visible ecchymosis, normal
range of hallux motion
Swelling, visible ecchymosis,
painful and sometimes
reduced range of motion,
or difficulty with weight
bearing
Very tender to palpation
diffusely, significant
swelling and ecchymosis,
restriction of joint motion
Diagnostic imaging Radiographs Radiographs; consider MRI in
ambiguous grade II injuries
Radiographs and MRI
Treatment RICE, ibuprofen, and Toradol for
pain management; consider
walking boot or casting for
4-6 weeks if significant
capsuloligamentous injury
Stable: nonoperative (see
grade I)
Unstable: operative
Operative

Management

Nonoperative

  • Indications
    • Grade I
    • Stable grade II (absent hallux valgus, negative lachman, <2 mm sesamoid migration)
  • Early PRICE Therapy
  • Immobilization
  • Physical Therapy
    • As pain subsides, begin gentle range of motion
    • Avoid hyperdorsiflexion

Operative

  • Indications
    • Unstable grade II
    • Grade III
    • Bipartite or fractured sesamoids with diastasis
    • Sesamoid retraction,
    • Traumatic hallux valgus
    • Large capsular avulsion with an unstable MTP
    • Vertical MTP instability (positive Lachman testing)
    • Loose body in the MTP joint
    • Chondral injury to the MTP joint surface,
    • Failed conservative treatment (unable to jog without pain after 3 weeks of rest)
  • Objective
    • Repair the anatomy
    • Restore stability of the MTP joint
  • Technique depends on specific injuries but includes
    • Medial plantar incision
    • Repair or excision of sesamoid depending on fragmentation
    • Headless screw or suture repair of sesamoid fracture
    • Joint synovitis or osteochondral defect often requires debridement or cheilectomy
    • Abductor hallucis transfer may be required if plantar plate or flexor tendons cannot be restored

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • General guidelines[1]
    • Consider when weight bearing is painless or nearly painless, athlete can produce normal plantar foot pressure
    • All players should achieve at least a 50°-60° arc of painless first MTP motion prior to return to play.
    • Consider player position when returning an athlete to play
    • Players in those positions that require more push-off/cutting may need to be held from play longer
  • Grade I
    • Return to competition as tolerated
    • Recommend taping great toe in plantarflexion ± orthotic to minimize MTP joint motion
  • Grade II
    • Walking boot with crutches for 2-4 weeks
    • Permitted return to play with preinjury level of performance in practice
  • Grade III
    • Require up to 8-16 weeks of recovery
    • Rehabilitation before competition to reduce stiffness and residual pain

Complications and Prognosis

Prognosis

  • Return to play
    • Hong et al: 78% of players return to pre injury level of play[15]
    • Clanton: 50% incidence of persistent symptoms at 5-year follow-up in 20 athletes diagnosed with turf toe[16]
  • Lost playing time
    • George et al found mean days lost due to injury of 10.1 days (7.9 to 12.4) among football players[4]

Complications

  • Joint stiffness and pain
  • Loss of push-off strength
  • Arthrosis and joint deformity
  • Decreased athletic performance
  • Hallux Rigidus
  • Proximal phalanx stress fracture

See Also


References

  1. 1.0 1.1 McCormick JJ, Anderson RB. The great toe: failed turf toe, chronic turf toe, and complicated sesamoid injuries. Foot Ankle Clin. 2009;14:135-150. doi:10.1016/j. fcl.2009.01.001
  2. Bowers KD Jr, Martin RB. Turf-toe: a shoe surface related football injury. Med Sci Sports. 1976;8:81-83.
  3. Coker TP, Arnold JA, Weber DL. Traumatic lesions of the metatarsophalangeal joint of the great toe in athletes. J Ark Med Soc. 1978;74:309-317. doi:10.1177/036354657800600604
  4. 4.0 4.1 4.2 4.3 4.4 George, Elizabeth, 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 international 35.2 (2014): 108-115.
  5. Rodeo SA, O’Brien S, Warren RF, Barnes R, Wickiewicz TL, Dillingham MF. Turftoe: an analysis of metatarsophalangeal joint sprains in professional football players. Am J Sports Med. 1990;18:280-285. doi:10.1177/036354659001800311
  6. Kadakia AR, Molloy A. Current concepts review: traumatic disorders of the first metatarsophalangeal joint and sesamoid complex. Foot Ankle Int. 2011;32:834-839. doi:10.3113/FAI.2011.0834
  7. 7.0 7.1 Hsu AR, Anderson RB. Foot and ankle injuries in American football. Am J Orthop (Belle Mead NJ). 2016;45:358-367.
  8. Covell DJ, Lareau CR, Anderson RB. Operative treatment of traumatic hallux valgus in elite athletes. Foot Ankle Int. 2017;38:590-595. doi:10.1177/1071100717697961
  9. Drakos MC, Fiore R, Murphy C, DiGiovanni CW. Plantar-plate disruptions: “The severe turf-toe injury.” Three cases in contact athletes. J Athl Train. 2015;50:553-560. doi:10.4085/1062-6050-49.6.05
  10. Graves SC, Prieskorn D, Mann RA. Posttraumatic proximal migration of the first metatarsophalangeal joint sesamoids: a report of four cases. Foot Ankle. 1991;12:117-122.
  11. Waldrop NE III, Zirker CA, Wijdicks CA, Laprade RF, Clanton TO. Radiographic evaluation of plantar plate injury. Foot Ankle Int. 2013;34:403-408. doi:10.1177/1071100712464953
  12. Schein AJ, Skalski MR, Patel DB, et al. Turf toe and sesamoiditis: what the radiologist needs to know. Clin Imaging. 2015;39:380- 389. doi:10.1016/j.clinimag.2014.11.011
  13. Anderson RB. Turf toe injuries of the hallux metatarsophalangeal joint. Tech Foot Ankle Surg. 2002;1:102-111. doi:10.1097/00132587-200212000-00004
  14. McCormick JJ, Anderson RB. Turf toe: anatomy, diagnosis, and treatment. Sports Health. 2010;2:487-494. doi:10.1177/1941738110386681
  15. Hong CC, Pearce CJ, Ballal MS, Calder JD. Management of sports injuries of the foot and ankle: an update. Bone Joint J. 2016;98-B:1299-1311. doi:10.1302/0301- 620X.98B10.37896
  16. Clanton TO, Ford JJ. Turf toe injury. Clin Sport Med. 1994;13:731-741.
Created by:
John Kiel on 26 June 2019 19:51:00
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Last edited:
4 October 2022 12:40:25
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