Turf Toe

Introduction

Injury to plantar plate and sesamoid complex of the MTP joint of the great toe
- tear occurs off the proximal phalanx, not the MT
- sesamoids may displace proximally or fracture depending on the energy of the injury
Mechanism & pathophysiology
- hyperextension of the great toe MTP joint
  - hyperextension compounded by axial loading of the posterior hindfoot
  - occurs in collision and contact sports when athlete pushes off to accelerate
Associated injuries
- sesamoid fracture
- stress fracture of proximal phalanx
- hallux rigidus (late sequelae)
Prognosis
- can be a devastating injury to the professional athlete

Presentation

Symptoms
- pain, stiffness, and swelling of the MTP joint
Physical exam
- inability to hyperextend the joint without significant symptoms

Imaging

Radiographs
- often does not show a dislocation of the great toe MTP joint because it is concentrically located on both radiographs
- may show a sesamoid fracture
- medial sesamoid may be displaced proximally
MRI
- will show disruption of volar plate
- used to rule out stress fracture of the proximal phalanx
Bone scan
- if symptoms persist, obtain a bone scan to look for a stress fracture of the proximal phalanx

Treatment

Nonoperative
- rest, stiff-sole shoe or walking boot
  - indications
    - nonoperative modalities indicated in most injury patterns
  - technique
    - early icing
    - stiff-sole shoe or rocker bottom sole to limit motion
    - taping in plantar flexion
    - more severe injuries may require walker boot or short leg cast
  - therapy
    - progressive motion once the injury is stable
Operative
- surgical repair
  - indications (rarely necessary)
    - retraction of sesamoids
    - fracture of sesamoids with diastasis
    - traumatic bunions
    - loose fragments in the joint
  - technique
    - abductor hallucis transfer may be required if plantar plate or flexor tendons cannot be restored

Complications

Hallux rigidus
- a late sequela
- treat with cheilectomy versus arthrodesis, depending on severity
Proximal phalanx stress fracture
- may be overlooked

TAG

(OBQ09.61) A 57-year-old man plays 45 holes of golf per week and has foot pain during the toe-off phase of gait. He notes the foot pain started 3 months ago after walking up a hill and falling forward on some wet grass. Your exam shows skin callosities dorsally at the 2nd PIP joint and plantarly at the 2nd MT head. Radiographs show a hyperextension deformity of the 2nd proximal phalanx in relation to the metatarsal. All of the following are true about this patient's condition EXCEPT. Topic

Review Topic

1. Symptomatic treatment initially includes extradepth shoes, metatarsal pads, and well-padded liners
2. The MTP drawer test will likely show laxity at the MTP joint in the dorsal-plantar plane
3. Repeated MTP dorsiflexion weakens the plantar aponeurosis, plantar plate, and capsular stabilizers
4. Plantar callosities result from dorsal displacement of the fatty cushion underneath the metatarsal head
5. Condition is a result of repetitive stresses causing microfractures with subsequent compromised blood supply to the metatarsal subchondral bone

PREFERRED RESPONSE ▶

DISCUSSION: This patient's 2nd MTP hyperextension deformity is a result of a plantar plate rupture. Answer 5 describes the disease process of Freibergs Infraction and AVN of the subchondral bone of the metatarsal. The JAAOS article by Mizel describes lesser MTP joint conditions including MTP instability, subluxation, and dislocation. Patients with plantar plate ruptures have pain with toe-off as MTP dorsiflexion forces attenuate the plantar stabilizers and subsequently lead to the hyperextension of the proximal phalanx. A drawer test seen in Illustration A can demonstrate instability in the dorsal-plantar plane with plantar plate incompetence. The resulting MTP deformity leads to skin compromise at the PIP dorsally secondary to abutting the shoe box and the plantar metatarsal head due to dorsal migration of the plantar fatty cushion. Initial treatment includes off-loading the areas of increased pressure with metatarsal pads and relieving areas of high skin pressure with indepth shoes. Surgical options include resection of the metatarsal head to decompress the area and allow the fatty cushion to resume its normal position.

Illustrations: A

REFERENCES:

1. Mizel MS, Yodlowski ML. Disorders of the Lesser Metatarsophalangeal Joints. J Am Acad Orthop Surg. 1995 May;3(3):166-173. PMID:10790665 (Link to Abstract)

Question Authors:

Michael Hughes MD,

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Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Mizel MS, Yodlowski ML. Disorders of the Lesser Metatarsophalangeal Joints. J Am Acad Orthop Surg. 1995 May;3(3):166-173. PMID:10790665 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

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