High Yield Topics

Turf Toe

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Ovid: 5-Minute Sports Medicine Consult, The


Turf Toe
Matthew Pecci
Basics
Sprain of the 1st metatarsophalangeal (MTP) joint
Description
  • Hyperdorsiflexion of the 1st MTP joint, causing sprain of the supporting structures, most notably the plantarcapsuloligamentous complex
  • Historically, playing on artificial turf was felt to be a significant contributing factor, but in actuality, it is believed to be related more to the flexible shoe wear that is typically worn on these surfaces.
Epidemiology
  • 1st described in the 1970s
  • Incidence seems to have increased since the late 1960s, related to the more widespread use of artificial turf fields
  • Common in football, but also seen in soccer, basketball, tennis, volleyball, and wrestling
Risk Factors
  • Playing on hard surfaces such as artificial turf combined with shoes with flexible soles, which are commonly worn on these surfaces
  • Any condition that limits motion in 1st MTP joint can predispose to injury, such as baseline-poor MTP range of motion with dorsiflexion <60°, degenerative joint disease of the 1st MTP, hallux rigidus
  • Foot mechanical issues that place increased stress on MTP joint during the gait cycle may predispose to injury, such as poor ankle flexibility, pes planus, and overpronation.
  • The greater the years of sports participation, the greater the chance of sustaining a 1st MTP injury.
General Prevention
  • Careful choice of shoe wear, specifically use of stiff-soled shoes, especially when training or competing on hard surfaces such as artificial turf
  • During the preparticipation exam, identify those with a predisposition to injury, specifically those with limited 1st MTP joint motion (dorsiflexion <60°) or limited ankle flexibility
  • Those with prior injury or those with predisposing factor may benefit from a stiff orthotic or insole prophylactically.
Etiology
  • Most common mechanism is hyperextension of the 1st MTP joint, which injures the plantarcapsuloligamentous complex
  • During sports, this mechanism can occur with the foot in a position of push-off with the forefoot and 1st MTP joint dorsiflexed and the heel off the ground. If an axial force is applied to the foot at the heel, this can cause hyperdorsiflexion of the 1st MTP joint and injury.
  • If the hyperextension force is severe, it can lead to dorsal dislocation of the MTP joint and injury to the joint articular cartilage.
  • Less common mechanisms include hyperflexion and valgus type injuries.
Commonly Associated Conditions
Severe injuries can be associated with dorsal dislocation of the 1st MTP joint, articular cartilage injury, plantar plate rupture, and sesamoid fractures.
Diagnosis
History
  • Excessive dorsiflexion of 1st MTP, causing injury
  • Pain localized to 1st MTP and increases with range of motion and ambulation, particularly toeing off
  • Localized swelling
  • May describe ecchymosis
Physical Exam
  • Metatarsophalangeal (MTP) periarticular swelling
  • May have ecchymosis
  • MTP tenderness to palpation, commonly on the plantar aspect, but with more severe injuries can be present dorsally as well
  • Painful range of motion of MTP, particularly dorsiflexion
  • May have decreased range of motion
  • Difficulty weight bearing, may walk with everted foot to avoid toe-off
  • May have laxity of the ligamentous capsule or collateral ligaments, depending on mechanism of injury
  • May have positive Lachman test of toe with plantar plate rupture
  • Grading system:
    • Grade 1 sprain: Pain over plantar or medial aspect, no ecchymosis, minimal swelling, limited pain with weight-bearing
    • Grade 2 sprain: More intense and diffuse pain, pain with motion, ecchymosis, swelling, significant pain with weight-bearing
    • Grade 3 sprain: Severe pain with motion, considerable swelling and ecchymosis, restricted range of motion, inability to bear weight
Diagnostic Tests & Interpretation
Imaging
  • Anteroposterior, lateral, and oblique radiographic views to rule out associated fractures
  • Radiographs may show avulsion fracture of capsule or ligamentous complex.
  • If there is an associated metatarsal compression fracture, radiographs may show intra-articular loose bodies.
  • MRI may be performed if suspected plantar plate rupture or other soft tissue injury.
  • Bone scan may be useful to differentiate associated sesamoid fracture from a bipartite sesamoid.
Differential Diagnosis
  • Fracture of the 1st metatarsal or proximal phalanx
  • Sesamoiditis
  • Exacerbation of degenerative joint disease
  • Tendonitis of flexor or extensor hallucis tendons
  • Plantar plate rupture

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Treatment
  • Grade 1:
    • Ice
    • Elevation
    • NSAIDs
    • Taping of toe to limit dorsiflexion
    • Early controlled range of motion
    • May be allowed to continue sports participation if the pain is minimal when taped
  • Grade 2:
    • Treated similar to grade 1, except needs to refrain from activity until minimal pain, which may take 1–2 wks
    • May benefit from rigid-soled shoe or rigid forefoot orthotic when returns to play
  • Grade 3:
    • Treated similar to grade 2, except may need crutches for weight-bearing until walking produces little discomfort
    • Slow progressive return to participation when symptoms allow, which may take 4–8 wks
Medication
NSAIDs
Additional Treatment
Additional Therapies
Physical therapy referral for aggressive range of motion in chronic cases with limitations in motion
Surgery/Other Procedures
  • Surgery is rarely indicated acutely except in cases of significant fracture-dislocations or plantar plate injury.
  • Surgery is only considered in chronic cases with nonunion or osteonecrosis of a sesamoid fracture, persistent pain, restricted motion, or inability to return to sports participation.
Ongoing Care
More severe or recurrent cases may require a rigid-soled shoe or rigid forefoot orthotic when participating in sports.
Prognosis
Most cases can return to previous level of function with proper conservative treatment.
Complications
Chronic or severe cases can lead to significantly limited range of motion, which can predispose to recurrent injury, so early controlled range of motion is recommended after injury to minimize the risk of this complication.
Additional Reading
Allen LR, Flemming D, Sanders TG. Turf toe: ligamentous injury of the first metatarsophalangeal joint. Mil Med. 2004;169:xix–xxiv.
Clanton TO, Ford JJ. Turf toe injury. Clin Sports Med. 1994;13:731–741.
Crain JM, Phancao JP, Stidham K. MR imaging of turf toe. Magn Reson Imaging Clin N Am. 2008;16:93–103.
Kubitz ER. Athletic injuries of the first metatarsophal-angeal joint. J Am Podiatr Med Assoc. 2003;93:325–332.
Mullen JE, O'Malley MJ. Sprains–residual instability of subtalar, Lisfranc joints, and turf toe. Clin Sports Med. 2004;23:97–121.
Rodeo SA, O'Brien S, Warren RF, et al. Turf-toe: an analysis of metatarsophalangeal joint sprains in professional football players. Am J Sports Med. 1990;18:280–285.
Sammarco GJ. Turf toe. Instr Course Lect. 1993;42:207–212.
Watson TS, Anderson RB, Davis WH. Periarticular injuries to the hallux metatarsophalangeal joint in athletes. Foot Ankle Clin. 2000;5:687–713.
Codes
ICD9
845.12 Metatarsaophalangeal (joint) sprain
Clinical Pearls
  • Return to play:
    • An athlete typically must pass a functional progression for his/her given sport without pain to return to play. This progression typically begins when an athlete is pain free with ambulation and daily activity, which may take 1–8 wks, depending on the degree of initial injury.
  • Returning to participation too soon may delay full healing and can lead to chronic symptoms. This lack of healing can also cause loss of MTP motion, which can lead to recurrent injury.
  • Corticosteroid injections merely mask symptoms and do not hasten healing.


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