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Turf Toe
From WikiSM
Contents
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
- Football
- 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
- Fractures & Osseous Disease
- Traumatic/ Acute
- Stress Fractures
- Other Osseous
- Dislocations & Subluxations
- Muscle and Tendon Injuries
- Ligament Injuries
- Plantar Fasciopathy (Plantar Fasciitis)
- Turf Toe
- Plantar Plate Tear
- Spring Ligament Injury
- Neuropathies
- Mortons Neuroma
- Tarsal Tunnel Syndrome
- Joggers Foot (Medial Plantar Nerve)
- Baxters Neuropathy (Lateral Plantar Nerve)
- Arthropathies
- Hallux Rigidus (1st MTPJ OA)
- Gout
- Toenail
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Freibergs Disease (Avascular Necrosis of the Metatarsal Head)
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
- Lachman Test Toe: stabilize the first metatarsal, apply dorsal to plantar translation to proximal phalanx
- Valgus Stress Test Toe:
- Varus Stress Test Toe:
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
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
- Early immobilization with Cast Shoe, Posterior Short Leg Splint, Short Leg Cast
- Follow with 4-6 weeks protected weight bearing in Short Walking Boot
- If concern about capsuloligamentous injury with negative instability testing, consider Short Leg Cast with toe in slight plantar flexion
- This will allow for healing of the plantar soft tissue, decreasing long term morbidity
- 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
- 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
- Internal
- External
- Sports Medicine Review Foot Pain: https://www.sportsmedreview.com/by-joint/foot/
References
- ↑ 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
- ↑ Bowers KD Jr, Martin RB. Turf-toe: a shoe surface related football injury. Med Sci Sports. 1976;8:81-83.
- ↑ 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
- ↑ 4.0 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.
- ↑ 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
- ↑ 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
- ↑ 7.0 7.1 Hsu AR, Anderson RB. Foot and ankle injuries in American football. Am J Orthop (Belle Mead NJ). 2016;45:358-367.
- ↑ 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
- ↑ 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
- ↑ 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.
- ↑ 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
- ↑ 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
- ↑ Anderson RB. Turf toe injuries of the hallux metatarsophalangeal joint. Tech Foot Ankle Surg. 2002;1:102-111. doi:10.1097/00132587-200212000-00004
- ↑ McCormick JJ, Anderson RB. Turf toe: anatomy, diagnosis, and treatment. Sports Health. 2010;2:487-494. doi:10.1177/1941738110386681
- ↑ 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
- ↑ 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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