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
QUESTIONS 1 of 3 1 2 3 Previous Next (OBQ18.111) A collegiate soccer player presents as a referral to your office after sustaining an injury to the right foot, which he describes as hyperdorsiflexion of the toes. The patient notes worsening pain at the toe-off phase of gait. Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. Pain is worsened with passive toe extension. An AP radiograph is shown in FIgure A. An MRI is performed and selected cuts are shown in Figures B and C. What is this patients diagnosis? QID: 213007 FIGURES: A B C Type & Select Correct Answer 1 FHL tendon tear 5% (95/1815) 2 FHB tendon tear 9% (157/1815) 3 Medial sesamoid fracture 7% (132/1815) 4 Rupture of the plantar plate 76% (1380/1815) 5 Metatarsal head fracture 2% (32/1815) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
All Videos (2) Podcasts (1) Login to View Community Videos Login to View Community Videos 2019 Orthopaedic Summit Evolving Techniques He Is Playing With Nonoperative Treatment - Michael Coughlin, MD Foot & Ankle - Turf Toe D 12/15/2020 127 views 0.0 (0) Login to View Community Videos Login to View Community Videos 2019 Orthopaedic Summit Evolving Techniques He Is Out! Bite The Bullet, He Needs Long Term Function: Be The Hated Person - Robert Anderson, MD Robert Anderson Foot & Ankle - Turf Toe D 12/15/2020 104 views 0.0 (0) Foot & Ankle⎪Turf Toe Team Orthobullets 4 Foot & Ankle - Turf Toe Listen Now 12:45 min 10/15/2019 407 plays 5.0 (4)