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.

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 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.

	Description	Treatment
Grade I	Capsular strain	Stiff insole, turf toe taping, Immediate return to play.
Grade II	Partial capsular tear	No athletic activity for 2 weeks, stiff insole, Return to play if painless 60-degree dorsiflexion present.
Grade III	Complete tear of the plantar plate	Superior results demonstrated with operative repair of the plantar plate over conservative care

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.

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

References

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