Updated: 7/31/2017

Turf Toe

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Introduction
  • Hyperextention injury to plantar plate and sesamoid complex of the hallux metatarsophalangeal (MTP) joint 
  • Epidemiology
    • demographics
      • more prevalent in contact athletic sports played on rigid surfaces
  • 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)
  • Prognosis
    • can be a devastating injury to the professional athlete
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
      • 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
 

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