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 login to view 1 more bullet tendons login to view 4 more bullets ligaments login to view 2 more bullets plantar plate login to view 2 more bullets 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 login to view 1 more bullet technique login to view 4 more bullets physiotherapy login to view 1 more bullet Operative surgical repair indications (usually Grade III injuries) login to view 6 more bullets technique login to view 5 more bullets outcomes login to view 3 more bullets 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