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Updated: Oct 27 2023

Turf Toe

  • summary
    • Turf Toe is a hyperextension injury to the plantar plate and sesamoid complex of the big toe metatarsophalangeal joint that most commonly occurs in contact athletic sports.
    • Diagnosis is made clinically with the inability to hyperextend the hallux MTP joint without significant pain and the inability to push off with the big toe. A vertical Lachman test will show greater laxity compared to the contralateral side.
    • Treatment is rest, NSAIDs, taping, stiff-sole shoe, or walking boot in the majority of cases. Surgical repair is indicated for patients with progressive and persistent symptoms who fail nonoperative management. 
  • Epidemiology
    • Demographics
      • more prevalent in contact athletic sports played on rigid surfaces
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • forefoot is fixed to the ground
        • hallux MTP joint positioned in hyper-extension
        • axial load is applied to the heel
        • combination of force and joint positioning causes attenuation or tearing of the plantar capsular-ligamentous complex
      • pathoanatomy
        • tear to capsular-ligamentous-seasmoid complex
        • tear occurs off the proximal phalanx, not the metatarsal
    • Associated injuries
      • varus, valgus injuries to hallux MTP
      • sesamoid fracture
      • proximal migration of sesamoid
      • cartilaginous injury or loose body in hallux MTP joint
      • stress fracture of proximal phalanx
      • hallux rigidus (late sequelae)
  • Classification
    • Grade I
      • sprain of plantar plate
    • Grade II
      • partial tear of plantar plate
    • Grade III
      • complete tear of plantar plate
  • Anatomy
    • Hallux metatarsophalangeal (MTP) joint
      • stabilized by
        • osseous structures
          • articulation between MT and proximal phalanx
        • tendons
          • flexor hallucis brevis
            • contains tibial and fibular seasmoids
          • abductor hallucis attaches to medial sesamoid
          • adductor hallucis attaches to lateral sesamoid
        • ligaments
          • medial and lateral collateral ligaments
          • intermetatarsal ligament
        • plantar plate
          • composed of the joint capsule
          • attaches to the transverse head of adductor hallucis, flexor tendon sheath and deep transverse intermetatarsal ligament
  • Presentation
    • History
      • circumstances of injury
        • mechanism of injury consistent with hyper-extension and axial loading of hallux MTP
        • type of athletic shoe and surface
    • Symptoms
      • primary symptoms
        • acute pain
        • stiffness
        • swelling
      • defining characteristics
        • inability to push-off
        • reduced agility
    • Physical exam
      • inspection
        • plantar swelling and ecchymosis
        • alignment of hallux MTP joint
      • motion
        • active and passive range of motion
        • inability to hyperextend the joint without significant symptoms
        • vertical Lachman test (positive if greater laxity compared to contralateral side)
        • varus/valgus instability
      • gait
        • shorten time spent after heel rise
  • Imaging
    • Radiographs
      • recommended views
        • weightbearing AP, lat, oblique foot
      • additional views
        • sesamoid axial views
        • forced dorsiflexion view
      • findings
        • comparison of the sesamoid-to-joint distances
        • medial sesamoid may be displaced proximally
        • may show a sesamoid fracture
        • often does not show a dislocation of the great toe MTP joint because it is concentrically located on both radiographs
    • Bone scan
      • indications
        • negative radiograph with persistent pain, swelling, weak toe push-off
      • findings
        • increased signal at 1st MTP joint
        • stress fracture of the proximal phalanx
    • MRI
      • indications
        • positive bone scan
        • hyperdorsiflexion injury with exam findings consistent with a plantar plate rupture
        • abnormal radiographs
        • persistent pain, swelling, weak toe push-off
        • not recommended routinely
      • findings
        • will show disruption of volar plate
        • used to rule out stress fracture of the proximal phalanx
  • Treatment
    • Nonoperative
      • rest, NSAIDS, taping, stiff-sole shoe or walking boot
        • indications
          • nonoperative modalities indicated in most injuries (Grade I-III)
        • technique
          • early icing and rest
          • taping not indicated in acute phase due to vascular compromise with swelling
          • stiff-sole shoe or rocker bottom sole to limit motion
          • more severe injuries may require walker boot or short leg cast for 2-6 weeks
        • physiotherapy
          • progressive motion once the injury is stable
    • Operative
      • surgical repair
        • indications (usually Grade III injuries)
          • failed conservative treatment
          • retraction of sesamoids
          • fracture of sesamoids with diastasis
          • traumatic bunions
          • loose fragments in the joint
          • hallux toe deformity
        • technique
          • medial plantar incision
          • repair or excision of sesamoid depending on fragmentation
          • headless screw or suture repair of sesamoid fracture
          • joint synovitis or osteochondral defect often requires debridement or cheilectomy
          • abductor hallucis transfer may be required if plantar plate or flexor tendons cannot be restored
        • outcomes
          • immediate post-operative non-weight bearing
          • progressive ROM and physiotherapy
          • expected return to sport 3-4 months
  • Complications
    • Hallux rigidus
      • a late sequela
      • treat with cheilectomy versus arthrodesis, depending on severity
    • Proximal phalanx stress fracture
      • may be overlooked
  • Prognosis
    • Can be a devastating injury to the professional athlete
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