The term “turf toe” was initially described by Bowers in 1976 as a sprain of the plantar capsule–ligament of the great toe metatarsophalangeal (MTP) joint. It occurs secondary to a forceful hyperextension of the first MTP joint. Injury to the plantar plate of the great toe leads to pain with push-off and reduced agility. It can be a devastating injury in the elite athlete but also a nuisance in the general population.
Turf toe is most commonly sustained as a result of forceful hyperextension of the first MTP joint. Turf toe can occur during many sports such as basketball, soccer, and gymnastics, but it is most commonly described in football, and the prevalence is far greater in athletes who play on an artificial field since it is more rigid than a natural grass field. This injury was prevalent on the astroturf (short-pile) fields of the past because it was a much less compliant surface and placed more strain on the players' feet. Modern (high-pile) turf behaves in a way more similar to natural turf, and the prevalence of the injury has decreased.
The first MTP is a ginglymi arthrodial joint, which functions as a hinge and a sliding joint. The shallow articulation between the convex metatarsal head and the concave base of the proximal phalanx articular surface results in little bony stability. Therefore, it relies on the complex attachments of the capsule, ligaments, and musculotendinous structures surrounding the joint. The plantar plate is the strongest stabilizer of the first MTP joint and is composed of a thickening of the joint capsule. It attaches to the transverse head of the adductor hallucis, the flexor tendon sheath, and the deep, transverse intermetatarsal ligament. The classification system is composed of the degree of injury to the plantar plate:
The patient will commonly complain of pain and swelling of the first metatarsophalangeal joint. The patient may also complain of antalgic gait and pain, especially with foot flat to toe-off during the gait cycle. The patient may or may not describe an inciting event of an acute forceful hyperextension of the first MTP. There have also been reports of subacute to the chronic development of turf toe.
A physical exam should consist of inspection, palpation, ROM, muscle strength testing, and special testing.
Initial imaging studies should be limited to AP, lateral, and axial sesamoid weight-bearing radiographs to assess for fracture or dislocation. Bilateral radiographs should be obtained to assess the migration of sesamoid bone for migration or fracture. Radiographs should be normal, but there may be noted soft tissue swelling.
MRI without contrast should be performed to evaluate for soft tissue pathology. MRI can evaluate for a plantar plate or surrounding soft tissue injury. It can also assess the articular surface of the joint. If this becomes a chronic process, there may be a degenerative change of the joint, potentially leading to hallux rigidus or a traumatic bunion. T2 MRI sequences will best identify acute inflammatory changes.
Turf toe is diagnosed depending on physical exam and imaging findings. It is graded on a scale of 1 to 3 according to the Anderson classification system.
Regardless of the grade, initial treatment for most injuries should consist of basic RICE principles (rest, ice, compression, and elevation). A stiff sole shoe or rocker bottom sole can also help limit motion. For more severe injuries, a controlled ankle motion (CAM) boot or walking cast can help minimize motion at the joint to allow the plantar plate to heal. Once the injury is stable, it is important to begin progressive motion.
Grade 1 injuries typically take a week or 2 to heal before a patient returns to play as tolerated.
Grade 2 injuries typical recovery time is 4 to 6 weeks. The patient may require taping when they return to play as tolerated. Taping for these injuries, once the swelling has abated in the acute phase, should focus on resisting hyperextension of the MTP joint. Corticosteroid and/or anesthetic injections are not advised for this injury.
Grade 3 injuries are more severe but usually respond to conservative treatment, albeit of longer duration. Immobilization in a CAM boot or short-leg walking cast for 4 to 6 weeks may be enough time for the healing process to begin. Progressive, gentle range of motion should follow initial immobilization with continued protected ambulation with modified shoe wear or inserts like a carbon-fiber, foot-plate extension, commonly used for hallux rigidus. Progression of activity should be as tolerated. It is expected that this injury will take 6 to 12 months to heal.
If the patient fails conservative management, surgical repair is an option. Characteristics of injuries that could benefit from surgical intervention are large capsular avulsion with unstable joint, diastasis or retraction of sesamoids, vertical instability, traumatic hallux valgus deformity, chondral injury, intra-articular loose body, sesamoid fracture, and failed conservative treatment.
Medial plantar incision: Identify the plantar medial digital nerve and protect; identify and assess soft tissue injury.
Joint synovitis or osteochondral defects often require debridement or cheilectomy. If the plantar plate or flexor tendons cannot be restored, abductor hallucis transfer may be required.
Begin gentle passive motion at 7 to 10 days with a physical therapist, then be non-weight bearing in removable splint or boot with hallux protected for 4 weeks. At 4 weeks, increase active motion and allow ambulation in the boot. The patient should wear a modified shoe at 2 months and return to contact activity with protection from excessive dorsiflexion at 3 to 4 months. Expect 6 to 12 months for a full recovery.
The outlook for turf-toe recovery is commensurate with the grade of the injury. More severe injuries require additional recovery time. Some cases will result in incomplete recovery resulting in joint stiffness or an arthritic toe. Prevention of re-injury is paramount to avoiding long-term sequelae.
Complications of turf toe can include the following:
Acute complications can include infections, scar formation secondary to hypertrophy, and plantar nerve neuroma development.
Patients need to understand the factors that can increase the risk of a turf toe injury, including competing on artificial turf and shoes with excessively flexible soles. The athlete must understand that their athletic footwear must be supportive and appropriate to the surface on which they compete. They should receive instruction on flexibility and strengthening exercises for the ankle and foot to increase their ability to withstand the stresses that accompany their athletic activities.
A relatively common injury pattern is suspected in athletes playing contact sports on more rigid surfaces with shoe wear that allows first MTP hyperextension. Early diagnosis and immobilization is key to quick healing and recovery. Avoid steroid injection into the plantar plate.
Diagnosis and management of tor turf are made by an interprofessional team that includes a sports physician, orthopedic surgeon, podiatrist, nurse practitioner, radiologist, and an emergency department physician. The initial treatment is conservative, but most severe injuries require some type of surgery. The symptoms often take months to subside. The majority of patients have a good outcome, but future protection of the toe is highly recommended to prevent a recurrence.
|||Nery C,Fonseca LF,Gonçalves JP,Mansur N,Lemos A,Maringolo L,Fonseca LF, First MTP joint instability - Expanding the concept of [PubMed PMID: 30509556]|
|||Clough TM,Majeed H, Turf Toe Injury - Current Concepts and an Updated Review of Literature. Foot and ankle clinics. 2018 Dec; [PubMed PMID: 30414661]|
|||Salat P,Le V,Veljkovic A,Cresswell ME, Imaging in Foot and Ankle Instability. Foot and ankle clinics. 2018 Dec; [PubMed PMID: 30414649]|
|||Ashimolowo T,Dunham G,Sharp JW,Porrino J, Turf Toe: An Update and Comprehensive Review. Radiologic clinics of North America. 2018 Nov; [PubMed PMID: 30322486]|
|||Najefi AA,Jeyaseelan L,Welck M, Turf toe: A clinical update. EFORT open reviews. 2018 Sep; [PubMed PMID: 30305934]|
|||De Maeseneer M,Moyson N,Lenchik L,Cattrysse E,Scafoglieri A,Roose R,Shahabpour M, MR imaging-anatomical correlation of the metatarsophalangeal joint of the hallux: Ligaments, tendons, and muscles. European journal of radiology. 2018 Sep; [PubMed PMID: 30150036]|
|||Edenfield KM,Michaudet C,Nicolette GW,Carek PJ, Foot and Ankle Conditions: Midfoot and Forefoot Conditions. FP essentials. 2018 Feb; [PubMed PMID: 29381043]|
|||Reissig J,Bitterman A,Lee S, Common Foot and Ankle Injuries: What Not to Miss and How Best to Manage. The Journal of the American Osteopathic Association. 2017 Feb 1; [PubMed PMID: 28134962]|
|||York PJ,Wydra FB,Hunt KJ, Injuries to the great toe. Current reviews in musculoskeletal medicine. 2017 Mar; [PubMed PMID: 28124292]|
|||Nery C,Baumfeld D,Umans H,Yamada AF, MR Imaging of the Plantar Plate: Normal Anatomy, Turf Toe, and Other Injuries. Magnetic resonance imaging clinics of North America. 2017 Feb; [PubMed PMID: 27888844]|
|||Burr P,Choudhury P, Fine Motor Disability 2020 Jan; [PubMed PMID: 33085413]|
|||Aran F,Shamrock AG,Scott AT, Turf Toe 2020 Jan; [PubMed PMID: 29939587]|
|||Smith K,Waldrop N, Operative Outcomes of Grade 3 Turf Toe Injuries in Competitive Football Players. Foot [PubMed PMID: 29909648]|
|||Hong CC,Pearce CJ,Ballal MS,Calder JD, Management of sports injuries of the foot and ankle: An update. The bone [PubMed PMID: 27694582]|