Introduction
- Stephen Gould, MD, MPH
- Kenneth J. Mroczek, MD
Epidemiology
- •
The term turf toe first appeared in literature in 1976 as reported by Bowers and Martin to describe plantar capsuloligamentous sprain of the first metatarsophalangeal (MTP) joint related to hard artificial surfaces and insubstantial footwear.
Age and Sex
- •
There are no age or sex predilections for this injury.
- •
Mechanism of injury, playing surface, and individual biomechanics are predisposing factors to the injury.
Sport and Position
- •
Football players (running backs, wide receivers, defensive backs, offensive linemen, tight ends) have a higher incidence of turf toe injury but the injury is also seen in other sports/activities such as soccer and dance.
- •
Forty-five percent of professional football players surveyed reported suffering from turf toe.
- •
Turf toe can cause significant functional disability.
- •
Coker et al. reported a series of injuries in University of Arkansas football players. The authors described the severity of turf toe injury in terms of lost playing time and delayed return to play, even when compared with more common, but debilitating injuries.
- •
Hallux metatarsophalangeal joint sprains occur in other sporting activities such as dance (modern and classical) and beach volleyball. “Sand Toe” is the term used to describe this injury in beach volleyball.
Pathophysiology
Intrinsic Factors
- •
Major contributors
- •
Increased ankle dorsiflexion
- •
Mean ankle dorsiflexion of the uninjured side in injured players was 13.33° compared with 7.87° in uninjured players.
- •
- •
Flattening of the first MTP
- •
Foot pronation
- •
- •
Minor contributors
- •
Decreased first metatarsophalangeal dorsiflexion is associated with turf toe injury (40.6 ± 15.1° in football players with turf toe versus 48.4 ± 12.8° in football players without history of turf toe)
- •
Hallux degenerative joint disease
- •
Prior first MTP joint injury
- •
Pes planus
- •
Athlete’s weight
- •
Number of years in professional football
- •
5.2 years for injured versus 3.0 for controls
- •
- •
Extrinsic Factors
- •
Playing surface
- •
Artificial turf and playing surfaces. The introduction of these manufactured surfaces in the mid-1960s resulted in a loss of shock-absorbing characteristics compared with grass turf.
- •
Eighty-three percent of patients report initial injury on an artificial surface.
- •
- •
Footwear
- •
The forces the halluces experience are compounded by the friction between athletic shoe and turf.
- •
Lighter, more flexible shoes with increased toe box flexibility and decreased number of cleats in the shoe provide greater agility but offer less protection to the halluces from impact.
- •
Traumatic Factors
- •
The most common mechanism of injury, accounting for 85% of injuries, results from forced hyperdorsiflexion at the first MTP. This occurs when the forefoot is planted and the heel rises from the ground. If this stress causes the hallux to dorsiflex beyond its biomechanical limits, damage to the capsule at the neck of the first MTP will occur. This is because the joint capsule attachment is weaker at this site than at the proximal phalanx.
- •
The biomechanics of this injury results from distal traction on the medial and lateral sesamoids during forced hyperextension. This transfers the mechanical load to the dorsal aspect of the metatarsal head. This stress can cause partial or complete disruption of the plantar plate. Injury to the plantar plate results in impaction of the articular surfaces of the proximal phalanx to the metatarsal head during extension of the MTP. This is the most severe form of injury to the soft tissues of the first MTP.
- •
Eighty-five percent of turf toe injuries result from hyperextension of the first metatarsophalangeal joint. Less common mechanisms of injury include plantar flexion injury to the first MTP joint, and varus or valgus stress injuries. Hyperplantarflexion injuries are more commonly seen in dance and beach volleyball ( Figure 45-1 ).
FIGURE 45-1
Loading mechanisms that can result in turf toe injury.
- •
Various football positions are susceptible to this injury.
- •
Offensive linemen when pushing off from a stance, can hyperextend the first MTP.
- •
Running backs and receivers may be also be injured if tackled from behind, with their forefoot planted on the ground, if another player falls onto their leg causing hyperextension at the first MTP ( Figure 45-2 ).
FIGURE 45-2
Forced dorsiflexionflexion injury in football.
(Redrawn from Rodeo SA, O’Brien S, Warren RF, Barnes R, Wickiewicz TL, Dillingham MF: Turf-toe: An analysis of metatarsophalangeal joint sprains in professional football players. Am J Sports Med 18(3):280–285, 1990.)
- •
Essentially, any activity that results in forced hyperdorsiflexion on the great toe can result in damage to the first MTP. Additional examples include forced dorsiflexion due to tackling or due to impact of the first MTP against the toe box of the shoe during rapid deceleration.
- •
Classic Pathological Findings
- •
While initially used to describe only a sprain or strain of the soft tissue support structures of the first MTP, the term turf toe has come to designate a spectrum of injuries from sprains to frank dorsal dislocation of the toe.
- •
Clanton et al developed a classification system to describe the severity of turf toe injuries. This system remains utilized today to help dictate treatment and return to play.
- •
Grade I injuries: least severe; strain of the capsuloligamentous complex without loss of its functional integrity.
- •
Grade II injuries are more severe and represent partial thickness tearing of the plantar plate and capsular structures.
- •
Grade III injuries are the most severe. This grade of injury may be used to describe either chronic effects of a disrupted capsule, or to describe an acute injury with complete disruption of the capsuloligamentous complex. With this grade of injury, the plantar plate may be completely avulsed from the metatarsal neck, resulting in impaction of the metatarsal head during full extension of the joint.
- •
Clinical Presentation
History
- •
Typical presentation includes great toe pain in an athlete whose sport exposes him or her to hyperextension of the toe on a hard surface. Football players, soccer players, and dancers, among others may suffer from this injury.
- •
The patient may complain of pain, swelling, and tenderness of the plantar aspect of the MTP, as well as inability to push off with the great toe.
Physical Examination
Key Elements of Exam
- •
Observe for general deformity of the toe, presence of swelling and ecchymosis (ecchymosis indicates fracture or disruption of tendon/ligament).
- •
Palpate joint structures including dorsal metatarsal head and neck, dorsal aspect of the proximal phalanx, and the sesamoids to assess integrity and presence of tenderness to palpation.
- •
Stress tests
- •
Abduction stress test: assesses medial collateral ligament, medial capsule, abductor halluces
- •
Adduction stress test: assesses lateral collateral ligament, lateral capsule, and adductor halluces
- •
Lachman-type maneuver to assess plantar plate
- •
Flexor hallucis brevis strength and integrity assessment
- •
Abnormal Findings
- •
Grade I: Plantar or medial tenderness to palpation; minimal to no swelling; minimal or no ecchymosis
- •
Grade II: Diffuse tenderness to palpation; moderate swelling and ecchymosis; painful and restricted range of motion. Symptoms may progress and athletes can lose up to 2 weeks of play.
- •
Grade III: Severe tenderness to palpation; marked swelling and ecchymosis, and restricted range of motion. The patient usually will avoid weight bearing due to pain. Athletes can miss up to 6 weeks or more of play. Hallux plantarflexion weakness or frank instability of hallux MTP can occur.
Pertinent Normal Findings
- •
Grade 1: no visible bruising. There is little change in the range of motion and the patient can continue to bear weight.
Imaging
Grade I
- •
Radiographs are normal. An MRI may demonstrate mild soft tissue edema surrounding the capsule; however, all components of the capsule remain intact.
Grade II
- •
Radiographs are typically normal. An MRI will show adjacent soft tissue edema. Partial thickness disruption may be seen as fluid signal intensity extending partially through the plantar plate and capsular structures. The sesamoid bones typically remain in normal position.
Grade III
- •
Radiographs are abnormal and may demonstrate an associated capsular avulsion, compression fracture; sesamoid fracture, diastasis, or proximal migration. Comparison films with the contralateral foot or preinjury radiographs may be helpful in detecting sesamoid abnormalities.
- •
A small fleck of bone might be found avulsed from the proximal phalanx or the sesamoid, suggesting a capsular disruption.
- •
An MRI will also demonstrate these findings and can also reveal the extent of injury to each component of the capsuloligamentous structure ( Figure 45-3 ), including the plantar plate, collateral ligaments, as well as the flexor and extensor tendons.
FIGURE 45-3
Anatomy of the capsuloligamentous structures.
(Redrawn from Rodeo SA, O’Brien S, Warren RF, Barnes R, Wickiewicz TL, Dillingham MF: Turf-toe: An analysis of metatarsophalangeal joint sprains in professional football players. Am J Sports Med 18(3):280–285, 1990.)
- •
An MRI can also assess the integrity of the articular surface of the MTP joint.
General Imaging
- •
Comparison radiographs of the contralateral foot are mandatory as patients with a rupture of the plantar plate will have proximal migration of one or both sesamoids.
- •
Forced dorsiflexion lateral radiographs should be obtained if there is clinical suspicion for a plantar plate disruption. If there is a complete disruption of the MTP joint complex, the sesamoids will not track distally with the hallux extension and will appear to be located proximally.
- •
An MRI is useful for both soft-tissue injury and osseous damage. T2-weighted images will identify subtle injuries. An MRI is recommended for all grade II or III injures to help guide the treatment plan and return to play.
Differential Diagnosis
- •
Gout: differentiated by associated erythema and warmth of joint; no ecchymosis present; severe pain and restriction of motion
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First metatarsal stress fracture: differentiated by lack of erythema/ecchymosis; point tenderness and indolent course
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Soft tissue mass (bursitis, granuloma, Morton neuroma): differentiated by minimal pain with palpation; lack of skin findings
Treatment
Nonoperative Management
- •
Immobilization, cryotherapy, NSAIDS
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Nonsurgical treatment options involve limiting the range of motion of the first MTP
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Taping of the toe
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Orthotics or “turf toe plate” in the shoe
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Rocker sole shoe
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- •
Walking boot and crutches as needed
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Long-term immobilization in boot or cast
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Steroid injection is controversial; some authors believe it may predispose to further soft tissue damage.
Guidelines for Choosing Among Nonoperative Treatments
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Grade I: The prognosis for full recovery is good and the patient can usually continue to play with only mild discomfort. Grade I injuries may be treated with taping of the toe and the use of a stiff insole in the shoe. Grade II: Treatment of grade II injuries is usually conservative with pain control, elevation, rest, and icing of the joint. Motion of the joint may be permitted in several days as symptoms permit. Walking boot and crutches as needed; may need taping on return to play.
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Grade III: The athlete will lose a minimum of 4 to 6 weeks of playing time, and treatment may require prolonged immobilization or surgery.
Surgical Indications
Relative
- •
Large capsular avulsion with unstable joint
- •
Diastasis of bipartite sesamoid
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Diastasis of sesamoid fracture
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Retraction of sesamoid(s)
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Traumatic hallux valgus deformity
- •
Vertical instability (positive Lachman test)
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Loose body
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Chondral injury
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Failed conservative treatment
Absolute
- •
Irreducible joint dislocation
Aspects of History, Demographics, or Exam Findings that Affect Choice of Treatment
- •
Grade I injury, or sprain of the capsuloligamentous structures, allows athletes to return to competition as tolerated. Taping in slight plantarflexion to diminish motion at the first MTP may alleviate symptoms. In addition, athletes can use orthotics or turf toe plates to minimize hallux MTP extension.
- •
Grade II injuries, or partial plantar capsular ligamentous rupture, will generally result in loss of playing time of at least 2 weeks. These injuries are treated with a similar regimen of relative immobilization of the first MTP, similar to that used for grade I injuries. Some authors further advocate a 2-week period of non–weight-bearing.
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Grade III injury, or complete plantar capsular ligamentous rupture, can have a prolonged recovery time. With these injuries, a 4- to 8-week period of immobilization followed by rehabilitation is appropriate before return to play.
Aspects of Clinical Decision Making When Surgery Is Indicated
- •
Conservative treatment with immobilization, cryotherapy, and NSAIDS is usually successful, so operative management is rarely considered in acute injury.
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However, operative intervention is required in the acute setting in the case of irreducible joint dislocation.
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If conservative measures fail, surgical intervention should be considered. This is especially true if the patients suffer loss of performance, such as loss of push-off strength.
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Because of the infrequency with which these injuries are surgically repaired, some authors recommend that they should be referred to a foot and ankle specialist.
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Consideration should be given to surgical repair of the ruptured capsuloligamentous complex (Grade III) in collegiate and professional athletes, particularly football players.
Evidence
Multiple-Choice Questions
- QUESTION 1.
What biomechanical factor predisposes an athlete to a turf toe injury?
- A.
Decreased ankle dorsiflexion
- B.
Increased ankle dorsiflexion
- C.
High arches
- D.
Prior anterior talofibular ligament injury
- A.
- QUESTION 2.
The most common mechanism of injury to the first metatarsal ligaments is
- A.
hyperplantarflexion.
- B.
hyperextension/hyperdorsiflexion.
- C.
varus stress.
- D.
valgus stress.
- A.
- QUESTION 3.
Which grade of injury represents partial thickness tearing of the plantar plate and capsular structures?
- A.
Grade 1
- B.
Grade 2
- C.
Grade 3
- D.
Grade 4
- A.
- QUESTION 4.
Which of the following is not an indication for surgical repair?
- A.
Vertical instability
- B.
Loose body
- C.
Partial tear of the capsuloligamentous complex
- D.
Chondral injury
- A.
- QUESTION 5.
If treated conservatively, Grade 3 injuries are usually treated with immobilization for what period of time?
- A.
1 week
- B.
2 weeks
- C.
3 weeks
- D.
4 or more weeks
- A.
Answer Key
- QUESTION 1.
Correct answer: A (see Pathophysiology, Major Contributors )
- QUESTION 2.
Correct answer: B (see Pathophysiology ; Mechanism of Injury)
- QUESTION 3.
Correct answer: B (see Clinical Presentation )
- QUESTION 4.
Correct answer: C (see Treatment ; Surgical Indications )
- QUESTION 5.
Correct answer: D (see Treatment )
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