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Turf Toe Injury

The term turf toe is used to describe a sprain of the first MTP joint, it’s a hyperextention injury to plantar plate and sesamoid complex of the hallux MTP joint.

Turf toe injury is more common in football, baseball, and soccer players.

hallux anatomy
Hallux Anatomy

Mechanism of Injury

The mechanism injury of the turf toe can also involve hyperflexion and varus and valgus stresses of the first MTP joint. With forced hyperflexion of the hallux, tearing of the plantar plate and collateral ligaments can occur.

In the more severe injury, the capsule can actually tear off from the metatarsal head.

A fracture of the sesamoids can also occur, and posterior (dorsal) dislocation of the first MTP joint is possible.

turf toe injury mechanism
Mechanism of Injury

Turf Toe Grades

Clanton and Ford have classified the severity of turf toe injury into 3 grades:

  1. Grade I: a minor stretch injury to the soft tissue restraints with little pain, swelling, or disability.
  2. Grade II: a partial tear of the capsuloligamentous structures with moderate pain, swelling, ecchymosis, and disability.
  3. Grade III: a complete tear of the plantar plate with severe swelling, pain, ecchymosis, and inability to bear weight normally.
DescriptionTreatment
Grade ICapsular strainStiff insole, turf toe taping,
Immediate return to play.
Grade IIPartial capsular tearNo athletic activity for 2 weeks, stiff insole,
Return to play if painless 60-degree dorsiflexion present.
Grade IIIComplete tear of the plantar plateSuperior results demonstrated with operative repair of the plantar plate over conservative care
Turf Toe Grades & Treatment

Clinical Findings

Clinically, patients with turf toe present with a swollen, stiff, and red, first MTP joint. They may have a history of a single dorsiflexion injury or multiple injuries to the great toe.

The joint may be tender, both plantarly and posteriorly (dorsally). Players may have a limp and be unable to run or jump because of pain.

Turf toe typically develops into a chronic injury and long term results include decreased first MTP joint motion, impaired push-off, and hallux rigidus. Fifty percent of athletes will have persistent symptoms 5 years later.

Radiographic Imaging

Radiographic views include:

  1. weightbearing AP,
  2. Lateral view,
  3. oblique view.
  4. sesamoid axial views.

Radiographic findings may include:

  1. Increased the sesamoid-to-joint distance.
  2. Medial sesamoid may be displaced proximally.
  3. A sesamoid fracture

Bone scan is indicated if persistent pain, swelling, weak toe push-off with negative x-ray findings. It may show increased signal at 1st MTP joint.

MRI will show disruption of volar plate.

Turf Toe Treatment

The treatment for turf toe in the acute phase is rest, ice, a compressive dressing, and elevation, and NSAIDs are often prescribed.

The Turf Toe tapping is done with multiple loops of tape placed over the posterior (dorsal) aspect of the hallucal proximal phalanx and criss-crossed under the ball of the foot plantarly to limit dorsiflexion.

Turf Toe tapping
Turf Toe Tapping

Occasionally, a forefoot steel plate is used.

Turf Toe Physical Therapy

Turf Toe Physical Therapy treatment varies for each of the three grades of injury:

For Grade I injuries, taping in slight plantar flexion is used to restrict movement and provide compression, while rehabilitation can begin after 3 to 5 days. Gentle passive plantarflexion and gradually increasing strengthening exercises are introduced, along with distraction and dorsal and proximal sliding of the proximal phalanx on the first metatarsal to restore normal range of motion (ROM) and strength. Non-weight bearing athletic activities like bicycling, pool therapy, and elliptical training can be done, and stiff-soled shoes are recommended.

For Grade II injuries, at least 2 weeks of recovery are needed before returning to activity, and the focus of treatment is on reducing pain and increasing range of motion. Passive joint mobilizations are used if the athlete can tolerate it, and rehabilitation begins only after pain and swelling have been reduced. Toe protectors or orthotics are used to protect the toe, and active exercises like toe crunches, towel curling, sand bucket exercises, and short foot exercises are introduced. Pulsed ultrasound or ionophoresis can help manage inflammation and promote soft tissue healing. The athlete can progress to higher impact activities as progress is made.

For Grade III injuries, immobilization in plantar flexion for 8 weeks is required, and complete rehabilitation can take up to 6 months. The hallux MTP joint should return to a painless passive dorsiflexion motion of 50° to 60° before restarting sport activity. Physical therapy rehabilitation and prevention using toe protectors/orthotics are essential, but in some cases, surgical intervention may be necessary.

After turf toe injury, patient returns to normal activities is based on the initial severity:

  • Patients with Grade I sprains are usually allowed to return to sports as soon as symptoms allow, sometimes immediately.
  • Patients with Grade II sprains usually require 3–14 days, rest from athletic training.
  • Grade III sprains usually require crutches for a few days and up to 6 weeks, rest from sports participation.

A return to sports training too early after injury could result in prolonged disability. Return to play is indicated when the toe can be dorsiflexed 90 degrees.

Turf Toe Complications

  1. Hallux rigidus: a late sequela, treatment with cheilectomy versus arthrodesis, depending on severity
  2. Proximal phalanx stress fracture: may be overlooked.

Q&A for Patients

What is turf toe?

Turf toe is a sprain of the first metatarsophalangeal (MTP) joint in the foot, which is the joint that connects the big toe to the rest of the foot. It is often caused by hyperextension of the joint, and is common in sports like football, baseball, and soccer.

What are the symptoms of turf toe?

Symptoms of turf toe include pain, swelling, stiffness, and redness in the first MTP joint. The joint may be tender to the touch, and patients may have difficulty running or jumping due to pain. In more severe cases, patients may experience difficulty bearing weight on the foot.

How is turf toe diagnosed?

Diagnosis of turf toe is typically based on a physical examination, where the doctor will assess the patient’s range of motion and check for tenderness in the affected joint. X-rays may also be taken to rule out any other injuries, such as fractures or dislocations.

What is the treatment for turf toe?

Treatment for turf toe depends on the severity of the injury. In general, rest, ice, compression, and elevation (RICE) are recommended in the acute phase of injury, along with nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief. Turf toe tapping may also be used to limit dorsiflexion of the joint. Physical therapy is often recommended to help restore range of motion and strength, and in some cases, surgical intervention may be necessary.

How long does it take to recover from turf toe?

Recovery time for turf toe varies depending on the severity of the injury. Grade I injuries may allow for a quick return to sports activities, while Grade III injuries may require up to 6 months of immobilization and rehabilitation before returning to normal activity.

What are the long-term complications of turf toe?

Long-term complications of turf toe may include decreased range of motion in the affected joint, impaired push-off, and the development of hallux rigidus, which is a condition that causes stiffness and pain in the big toe. In some cases, a stress fracture of the proximal phalanx may also occur. Treatment for these complications may involve cheilectomy or arthrodesis, depending on severity.

How can I prevent turf toe?

To help prevent turf toe, it is important to wear appropriate footwear for your sport, with stiff-soled shoes that limit the motion of the big toe. Toe protectors or orthotics may also be recommended to provide additional support. It is also important to warm up properly before engaging in sports activities, and to avoid overuse or repetitive stress on the joint.

References

  1. Wedmore IS, Charette J: Emergency department evaluation and treatment of ankle and foot injuries. Emerg Med Clin North Am 18:86–114, 2000.
  2. Hockenbury RT. Forefoot problems in athletes. Med Sci Sports Exerc. 1999 Jul;31(7 Suppl):S448-58. doi: 10.1097/00005768-199907001-00006. PMID: 10416546.
  3. Sammarco GJ: Turf toe. Instr Course Lect 42:207–212, 1993.
  4. Omey ML, Micheli LJ. Foot and ankle problems in the young athlete. Med Sci Sports Exerc. 1999 Jul;31(7 Suppl):S470-86. doi: 10.1097/00005768-199907001-00008. PMID: 10416548.
  5. Glasoe WM, Yack HJ, Saltzman CL: Anatomy and biomechanics of the first ray. Phys Ther 79:854–859, 1999.
  6. Garrick JG. Characterization of the Patient Population in a Sports Medicine Facility. Phys Sportsmed. 1985 Oct;13(10):73-6. doi: 10.1080/00913847.1985.11708901. PMID: 27409750.
  7. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
  8. Millers Review of Orthopaedics -7th Edition Book.
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