Orthopaedic Surgery - Turf Toe

Basics

Turf toe is a:

Hyperextension sprain of the first metatarsophalangeal joint.

It involves injury to the:

Plantar capsuloligamentous complex

of the great toe MTP joint.

Historical Background

The term:

Turf toe

was introduced in 1976 after the injury was recognized frequently in collegiate football players competing on:

Artificial turf

while wearing relatively:

Flexible footwear.

Anatomy

The first MTP joint is stabilized by several plantar structures, including the:

Plantar plate

Joint capsule

Sesamoid complex

Flexor hallucis brevis

and surrounding:

Collateral ligaments.

Functional Importance

The first MTP joint is essential for:

Push-off

during walking, running, jumping, and:

Cutting maneuvers.

Injury can therefore significantly impair:

Athletic performance.

Classification

Turf toe is commonly divided into:

Grade I

Grade II

and

Grade III injuries

according to the severity of capsuloligamentous disruption and clinical instability.

Grade I

Grade I represents a:

Mild sprain or stretching injury

of the plantar capsuloligamentous complex.

Typical findings include:

Localized plantar or medial tenderness

Minimal swelling

and

No significant ecchymosis.

Joint stability is generally:

Preserved.

Grade II

Grade II represents a:

Partial tear

of the plantar capsuloligamentous complex.

Typical findings include:

More diffuse tenderness

Mild to moderate swelling

and

Mild to moderate ecchymosis.

There is usually greater pain with:

Great-toe motion

and temporary loss of:

Athletic participation.

Grade III

Grade III represents a:

Complete or severe capsuloligamentous disruption.

Typical findings include:

Severe diffuse tenderness

Marked swelling

Moderate to severe ecchymosis

and

Painful or restricted motion.

There may be:

Gross MTP instability

and significant loss of:

Push-off strength.

Epidemiology

Turf toe is particularly associated with:

Football

and other sports requiring repeated:

Acceleration

Cutting

and

Forefoot loading.

Incidence

Historical studies have reported a high prevalence among:

Professional football players.

One older series reported that approximately:

45% of professional football players

had experienced turf toe at some point.

Playing Surface

Historical series have reported that a large proportion of cases occurred on:

Artificial turf.

One report found approximately:

83%

of cases associated with synthetic playing surfaces.

Collegiate Football

An incidence of approximately:

0.062 injuries per 1,000 athlete exposures

has been reported in NCAA football players in one study.

Rates vary according to:

Sport

Surface

Position

and

Study methodology.

Risk Factors

Important risk factors include:

Artificial turf

Flexible footwear

Repeated cutting maneuvers

Previous turf toe injury

and high-intensity:

Game participation.

Competition Versus Practice

The injury is more commonly reported during:

Live competition

than during:

Practice

or preseason and postseason activities.

Athlete Characteristics

Risk may increase with:

Older age

and

More years of participation in the sport.

Football Positions

In football, positions requiring frequent acceleration and cutting may be particularly affected, including:

Running backs

Quarterbacks

and

Receivers.

Pathophysiology

The classic mechanism is forced:

Hyperextension of the first MTP joint.

Plantar Injury

As the great toe is forcibly dorsiflexed, the:

Plantar capsule

and

Plantar plate

are placed under excessive tension.

Tear Pattern

MRI studies commonly demonstrate tearing of the plantar structures:

Distal to the sesamoids.

Severity

The injury may range from:

Microscopic stretching

to

Partial tearing

or

Complete disruption.

Etiology

Turf toe was historically uncommon before widespread use of:

Artificial playing surfaces

and very:

Flexible athletic shoes.

Mechanism in Sports

A common mechanism occurs when an athlete’s:

Forefoot is fixed against the playing surface

while the heel is forced upward, producing:

Excessive dorsiflexion of the great toe.

Associated Conditions

Turf toe may occur with:

Sesamoid fracture

Diastasis of a bipartite sesamoid

Articular injury of the metatarsal head

or

Acute traumatic hallux valgus.

Sesamoid Injury

Because the sesamoids are incorporated into the plantar complex, severe hyperextension may produce:

Fracture

or

Separation of a bipartite sesamoid.

Chondral Injury

The metatarsal head may sustain:

Articular cartilage injury

or

Impaction damage.

Diagnosis

Diagnosis is based on:

Mechanism

Physical examination

and

Imaging.

Signs and Symptoms

Patients typically report:

Pain beneath the first MTP joint

after a hyperextension injury.

Swelling

There may be:

Localized or diffuse swelling

around the:

First MTP joint.

Ecchymosis

Bruising on the plantar or medial side of the joint suggests a more significant:

Capsuloligamentous injury.

Push-Off Weakness

Patients may complain of difficulty with:

Push-off

during:

Walking

Running

or

Jumping.

Physical Examination

Inspect the first MTP joint for:

Swelling

Ecchymosis

Deformity

and evidence of:

Instability.

Range of Motion

Assess:

Dorsiflexion

and

Plantarflexion

of the first MTP joint.

Compare the injured side with the:

Contralateral foot.

Hyperextension Pain

Pain with passive:

MTP dorsiflexion

is a common finding.

Plantar Tenderness

Palpate the:

Plantar plate

Sesamoids

and surrounding:

Capsule.

Great-Toe Lachman Test

A:

Great-toe Lachman test

or sagittal-plane drawer test can assess:

MTP instability.

Technique

The proximal phalanx is translated relative to the:

First metatarsal head.

Increased translation or loss of a firm endpoint suggests:

Plantar plate insufficiency.

Imaging

Weight-Bearing Radiographs

Initial imaging should include:

Weight-bearing foot radiographs

when tolerated.

Radiographic Findings

Radiographs may demonstrate:

Capsular avulsion fracture

Sesamoid fracture

Metatarsal head impaction

Proximal sesamoid migration

or

Diastasis of a bipartite sesamoid.

Sesamoid Position

Proximal migration of the sesamoid complex may indicate substantial disruption of the:

Plantar plate.

Dorsiflexion Stress View

A:

Dorsiflexion lateral stress radiograph

may help evaluate plantar complex integrity.

Sesamoid-to-Phalanx Relationship

The distance between the:

Distal sesamoid

and

Base of the proximal phalanx

should remain relatively constant as the MTP joint moves from:

Plantarflexion to dorsiflexion.

Abnormal change may suggest:

Plantar plate disruption.

MRI

MRI is particularly useful in:

Grade II

and

Grade III injuries

or when plain radiographs show:

Abnormal findings.

MRI Assessment

MRI can evaluate:

Plantar plate injury

Capsular disruption

Sesamoid injury

and

Chondral damage.

Differential Diagnosis

Important alternatives include:

Sesamoiditis

Bipartite sesamoid diastasis

Sesamoid fracture

Sesamoid stress fracture

Sesamoid osteonecrosis

Traumatic hallux valgus

First MTP osteochondral injury

Hallux fracture

and

MTP dislocation.

Treatment

Treatment depends on:

Injury grade

Instability

Associated injuries

and the patient’s:

Athletic demands.

Initial Measures

Acute treatment includes:

Rest

Ice

Compression

and

Elevation.

Grade I Treatment

Grade I injuries can usually be managed with:

Symptomatic treatment

and protection against:

Excessive dorsiflexion.

Footwear

A:

Stiff-soled shoe

or

Rigid insert

can reduce painful first-MTP motion.

Taping

The hallux may be taped to limit:

Hyperdorsiflexion.

Athletic Participation

Some athletes with mild Grade I injuries may continue participation as symptoms permit with:

Protective taping and stiff footwear.

Grade II Treatment

Grade II injuries usually require a period of:

Reduced activity

and often:

Walking-boot immobilization.

Crutches

Crutches may be used when:

Weight bearing is painful.

Immobilization

A:

Walking boot

helps protect the plantar complex while reducing stress across the:

First MTP joint.

Return to Play

Historical return-to-play estimates for Grade II injury are approximately:

3–14 days

although more significant injuries may require:

Longer recovery.

Grade III Treatment

Grade III injuries generally require more prolonged:

Immobilization

and careful evaluation for:

Surgical indications.

Nonoperative Grade III Treatment

Selected stable injuries may be treated with:

Boot or cast immobilization

followed by carefully controlled:

Range of motion.

Surgical Grade III Injury

Surgery may be considered when there is:

Gross instability

Complete plantar plate disruption

Persistent pain

or marked loss of:

Push-off strength.

Early Motion

Once the injury is sufficiently stable, gentle motion is encouraged to reduce the risk of:

MTP stiffness.

Physical Therapy

Therapy may include:

Active range of motion

Passive range of motion

Strengthening

and gradual:

Gait retraining.

Return to Sport

Return should be based on resolution of:

Pain

Swelling

Instability

and restoration of:

Push-off strength.

Surgery

Operative treatment is uncommon but appropriate for selected:

Severe injuries.

Indications

Potential indications include:

Grade III injury with gross instability

Persistent pain after appropriate conservative treatment

Persistent loss of push-off strength

and significant associated:

Sesamoid or chondral injury.

Plantar Plate Repair

Complete disruption of the plantar structures may be treated with:

Direct plantar plate repair.

Sesamoid Fracture

A displaced or symptomatic sesamoid fracture may require:

Internal fixation

or selected:

Sesamoidectomy.

Sesamoid Preservation

When possible, preservation of the sesamoid is desirable because the sesamoid complex contributes to:

Flexor hallucis brevis function

and

Great-toe biomechanics.

Abductor Hallucis Transfer

Selected severe medial plantar complex injuries may require:

Abductor hallucis transfer

as part of reconstruction.

Postoperative Care

Postoperative rehabilitation is:

Gradual

because excessive early dorsiflexion may stress the:

Repair.

Non-Weight-Bearing

After major repair, patients may remain:

Non-weight-bearing

in a boot for approximately:

4 weeks.

Early Motion

Gentle passive range of motion may begin at approximately:

1 week

depending on the:

Repair.

Protective Footwear

A:

Stiff-soled shoe

may be introduced around:

6–8 weeks

when healing is satisfactory.

Return to Sport

Protected return to sport with limitation of excessive MTP dorsiflexion may begin around:

4 months

in selected patients.

Full Recovery

Complete recovery after severe operative injuries may require approximately:

6–12 months.

Follow-Up

Follow-up should monitor:

Pain

MTP motion

Joint stability

Sesamoid position

and

Push-off strength.

Prognosis

Most Grade I and Grade II injuries have a:

Good prognosis

with nonoperative treatment.

Historical Athletic Outcomes

In one historical series of 19 collegiate and professional athletes, 9 required surgery and:

7 returned to full athletic activity.

Nonoperative Series

Another historical series of 56 collegiate athletes, mostly football players on synthetic turf, found that:

53 returned to sport within approximately 3 weeks

after treatment with:

Stiff footwear

Orthotics

and

Taping.

Only one patient required:

Surgery.

Larger Collegiate Series

A study of 147 turf toe injuries in collegiate football players reported an average loss of approximately:

10 days of athletic participation.

Fewer than:

2%

required surgery.

These figures reflect specific athletic populations and should not be assumed for every:

Patient.

Complications

Complications may be:

Early

or

Delayed.

Medial Plantar Nerve Injury

An uncommon short-term complication is injury to the:

Medial plantar nerve.

Persistent Pain

Long-term symptoms may include:

Persistent pain during athletic activity.

Reduced Athletic Performance

Some athletes are unable to return fully to their previous level of:

Performance.

Restricted Motion

Chronic injury may result in:

Reduced first-MTP motion.

Hallux Valgus

Instability of the medial or plantar structures may contribute to:

Hallux valgus deformity.

Hallux Rigidus

Articular injury and chronic degeneration may eventually lead to:

Hallux rigidus.

Cock-Up Deformity

Severe plantar plate insufficiency may permit excessive:

MTP dorsiflexion

and contribute to a:

Cock-up deformity of the hallux.

Patient Monitoring

Management depends on:

Injury grade

and clinical response.

Grade I Monitoring

Grade I injuries are treated symptomatically with:

Taping

Stiff-soled footwear

or a:

Rigid insert.

Grade II Monitoring

Grade II injuries may require:

Walking-boot protection

RICE

and progressive:

Range-of-motion exercises.

Return to play may occur in approximately:

3–14 days

for uncomplicated injuries.

Grade III Monitoring

Grade III injuries generally require:

Walking-boot or cast immobilization

with carefully controlled:

MTP motion.

Dorsiflexion exercises may begin after approximately:

2–3 weeks

when appropriate, while avoiding:

Hyperdorsiflexion.

Grade III Return to Sport

Historical return-to-play estimates are approximately:

2–6 weeks

for selected nonoperative Grade III injuries, although complete severe tears often require considerably:

Longer rehabilitation.

Clinical Summary

Typical mechanism: Forced hyperextension of the first MTP joint, often when the forefoot is fixed and the heel rises.

Key pathology: Injury to the plantar plate and plantar capsuloligamentous complex, sometimes with sesamoid or chondral injury.

Key examination: Plantar tenderness, pain with MTP dorsiflexion, assessment of push-off strength, and the great-toe Lachman test for instability.

Imaging: Obtain weight-bearing radiographs; MRI is particularly useful for Grade II–III injuries or suspected plantar plate disruption.

Grade I: Mild sprain; treat with taping, stiff-soled footwear, and symptomatic care.

Grade II: Partial tear; commonly requires a walking boot, temporary activity restriction, and gradual rehabilitation.

Grade III: Complete or severe tear with instability; prolonged immobilization or surgical repair may be required.

Surgical indications: Gross instability, complete plantar plate disruption, persistent pain, loss of push-off strength, or significant associated sesamoid injury.

Major long-term concerns: Persistent pain, reduced athletic performance, stiffness, hallux valgus, hallux rigidus, and cock-up deformity.

Key Principle

Turf toe is a hyperextension injury of the first MTP joint that damages the plantar capsuloligamentous complex.

The severity ranges from a mild:

Grade I sprain

to a complete:

Grade III plantar plate disruption with instability.

Diagnosis depends on:

Mechanism, examination of MTP stability, weight-bearing radiographs, and MRI when indicated.

Most mild and moderate injuries respond to:

Protection from excessive dorsiflexion, stiff-soled footwear, taping, immobilization, and rehabilitation.

Severe unstable injuries may require:

Plantar plate repair or treatment of associated sesamoid injury.

Successful recovery depends on restoring:

Joint stability, motion, and effective great-toe push-off.