Continuing Education Activity

Bowers initially described the term turf toe in 1976 as a sprain of the plantar capsule ligament of the great toe metatarsophalangeal (MTP) joint. It occurs secondary to forceful hyperextension of the first MTP joint. Injury to the plantar plate of the great toe leads to pain with push-off and reduced agility. It can be a devastating injury in the elite athlete and a nuisance in the general population. This activity reviews the evaluation and management of turf toe and highlights interprofessional team members' role in collaborating to provide well-coordinated care and enhance patient outcomes.

Objectives:

• Describe the pathophysiology of turf toe.
• Review the presentation of turf toe.
• Summarize the treatment options for turf toe.
• Explain modalities to improve care coordination among interprofessional team members in order to improve outcomes for patients affected by turf toe.

Introduction

The term “turf toe” was initially described by Bowers in 1976 as a sprain of the plantar capsule–ligament of the great toe metatarsophalangeal (MTP) joint. It occurs secondary to a forceful hyperextension of the first MTP joint. Injury to the plantar plate of the great toe leads to pain with push-off and reduced agility. It can be a devastating injury in the elite athlete but also a nuisance in the general population.[1][2][3][4][5]

Etiology

Turf toe is most commonly sustained as a result of forceful hyperextension of the first MTP joint. Turf toe can occur during many sports such as basketball, soccer, and gymnastics, but it is most commonly described in football, and the prevalence is far greater in athletes who play on an artificial field since it is more rigid than a natural grass field. This injury was prevalent on the astroturf (short-pile) fields of the past because it was a much less compliant surface and placed more strain on the players' feet. Modern (high-pile) turf behaves in a way more similar to natural turf, and the prevalence of the injury has decreased.

Pathophysiology

The first MTP is a ginglymi arthrodial joint, which functions as a hinge and a sliding joint. The shallow articulation between the convex metatarsal head and the concave base of the proximal phalanx articular surface results in little bony stability. Therefore, it relies on the complex attachments of the capsule, ligaments, and musculotendinous structures surrounding the joint. The plantar plate is the strongest stabilizer of the first MTP joint and is composed of a thickening of the joint capsule. It attaches to the transverse head of the adductor hallucis, the flexor tendon sheath, and the deep, transverse intermetatarsal ligament. The classification system is composed of the degree of injury to the plantar plate:

• Grade I injury is a sprain of the plantar plate.
• Grade II is a partial tear of the plantar plate.
• Grade III is a complete tear of the plantar plate

History and Physical

The patient will commonly complain of pain and swelling of the first metatarsophalangeal joint. The patient may also complain of antalgic gait and pain, especially with foot flat to toe-off during the gait cycle. The patient may or may not describe an inciting event of an acute forceful hyperextension of the first MTP. There have also been reports of subacute to the chronic development of turf toe.

A physical exam should consist of inspection, palpation, ROM, muscle strength testing, and special testing.

• Inspection: There may be swelling and ecchymosis of the first MTP.  The examiner should evaluate the patient's gait pattern and note an antalgic gait, especially with the patient favoring toe-off. The patient will find it difficult to perform toe raises on the affected side.  The examiner should also note any obvious deformities of the joint, including dislocation, hallux valgus, or hallux varus deformities.

• Palpation: There should be point tenderness over the plantar aspect of the first MTP. There can also be tenderness over the medial and lateral or dorsal joint. Examiner should compare the location of the sesamoid bone to the unaffected side to assess proximal migration.  

• ROM: Examiners should evaluate passive and active ROM. The patient will complain of pain with extension of the first MTP with passive ROM. The patient will complain of pain with active flexion of the first MTP.

• Muscle strength: Examiners can have patient flex toes or extend toe against resistance. Abduction can also be performed.

• Special testing: Examiner can perform a valgus and varus stress test of the first MTP joint to assess medial and lateral stability. Vertical Lachman test will test the degree of vertical translation of the proximal phalanx compared to the metatarsal; it is important to compare this to the contralateral side. A positive test has more laxity than the contralateral side.

• To perform vertical Lachman, the examiner should neutralize the metatarsal head in one hand and the base of the proximal phalanx in the other; the maneuver is one of pure vertical translation at the joint. Normally a competent plantar plate will not allow for any vertical translation, but normal variations of soft tissue compliance make it important to compare the affected toe to the unaffected side.

Evaluation

Initial imaging studies should be limited to AP, lateral, and axial sesamoid weight-bearing radiographs to assess for fracture or dislocation. Bilateral radiographs should be obtained to assess the migration of sesamoid bone for migration or fracture. Radiographs should be normal, but there may be noted soft tissue swelling.[6][7][8][9][10]

MRI without contrast should be performed to evaluate for soft tissue pathology. MRI can evaluate for a plantar plate or surrounding soft tissue injury. It can also assess the articular surface of the joint. If this becomes a chronic process, there may be a degenerative change of the joint, potentially leading to hallux rigidus or a traumatic bunion. T2 MRI sequences will best identify acute inflammatory changes.

Treatment / Management

Anderson Classification

Turf toe is diagnosed depending on physical exam and imaging findings. It is graded on a scale of 1 to 3 according to the Anderson classification system.

• Grade 1: Acute sprain without bony pathology or joint instability.  The patient will have normal ROM and should be able to weight bear.

• Grade 2: Partial tear of the plantar plate or joint capsule. The patient will have painful ROM, ecchymosis, swelling, and pain with weight-bearing.

• Grade 3: Complete tear with the loss of continuity of the plantar plate or capsule. Examiners may notice the migration of sesamoid bone on physical exam. There will be marked tenderness to palpation, decreased ROM, swelling, ecchymosis, and difficulty weight-bearing.

Treatment

Regardless of the grade, initial treatment for most injuries should consist of basic RICE principles (rest, ice, compression, and elevation). A stiff sole shoe or rocker bottom sole can also help limit motion. For more severe injuries, a controlled ankle motion (CAM) boot or walking cast can help minimize motion at the joint to allow the plantar plate to heal. Once the injury is stable, it is important to begin progressive motion.

Grade 1 injuries typically take a week or 2 to heal before a patient returns to play as tolerated. 

Grade 2 injuries typical recovery time is 4 to 6 weeks. The patient may require taping when they return to play as tolerated. Taping for these injuries, once the swelling has abated in the acute phase, should focus on resisting hyperextension of the MTP joint. Corticosteroid and/or anesthetic injections are not advised for this injury.

Grade 3 injuries are more severe but usually respond to conservative treatment, albeit of longer duration. Immobilization in a CAM boot or short-leg walking cast for 4 to 6 weeks may be enough time for the healing process to begin. Progressive, gentle range of motion should follow initial immobilization with continued protected ambulation with modified shoe wear or inserts like a carbon-fiber, foot-plate extension, commonly used for hallux rigidus. Progression of activity should be as tolerated. It is expected that this injury will take 6 to 12 months to heal.

If the patient fails conservative management, surgical repair is an option. Characteristics of injuries that could benefit from surgical intervention are large capsular avulsion with unstable joint, diastasis or retraction of sesamoids, vertical instability, traumatic hallux valgus deformity, chondral injury, intra-articular loose body, sesamoid fracture, and failed conservative treatment.

Surgical Technique

Medial plantar incision: Identify the plantar medial digital nerve and protect; identify and assess soft tissue injury.

• Assess FHL for longitudinal split tears
• Plantar plate tears are all distal ruptures. If there is enough distal stump, the surgeon may attempt a direct repair. If soft tissue is inadequate, use suture anchors or drill holes in the proximal phalanx to pass suture.
• If there is a sleeve avulsion from a sesamoid, the surgeon may drill in a hole in the distal sesamoid to pass the suture.
• With diastasis or fracture of the sesamoids, the surgeon may need to excise one or both poles and repair soft tissue defects. The surgeon may attempt repair of sesamoid fracture with a headless screw or suture repair.

Joint synovitis or osteochondral defects often require debridement or cheilectomy. If the plantar plate or flexor tendons cannot be restored, abductor hallucis transfer may be required.

Postoperative Management

Begin gentle passive motion at 7 to 10 days with a physical therapist, then be non-weight bearing in removable splint or boot with hallux protected for 4 weeks. At 4 weeks, increase active motion and allow ambulation in the boot. The patient should wear a modified shoe at 2 months and return to contact activity with protection from excessive dorsiflexion at 3 to 4 months. Expect 6 to 12 months for a full recovery.

Differential Diagnosis

• Hallux limitus

• Hallux rigidus

• Hallux valgus

• Reverse turf toe

• Soccer toe

Prognosis

The outlook for turf-toe recovery is commensurate with the grade of the injury. More severe injuries require additional recovery time. Some cases will result in incomplete recovery resulting in joint stiffness or an arthritic toe. Prevention of re-injury is paramount to avoiding long-term sequelae.[11]

Complications

Complications of turf toe can include the following[12]:

• Loss of push-off strength
• Hallux rigidus
• Cock-up deformity
• Traumatic bunion deformity,
• Loose bodies in the joint space
• Joint fibrosis

Acute complications can include infections, scar formation secondary to hypertrophy, and plantar nerve neuroma development.

Deterrence and Patient Education

Patients need to understand the factors that can increase the risk of a turf toe injury, including competing on artificial turf and shoes with excessively flexible soles. The athlete must understand that their athletic footwear must be supportive and appropriate to the surface on which they compete. They should receive instruction on flexibility and strengthening exercises for the ankle and foot to increase their ability to withstand the stresses that accompany their athletic activities.

Pearls and Other Issues

A relatively common injury pattern is suspected in athletes playing contact sports on more rigid surfaces with shoe wear that allows first MTP hyperextension. Early diagnosis and immobilization is key to quick healing and recovery. Avoid steroid injection into the plantar plate.

Enhancing Healthcare Team Outcomes

Diagnosis and management of tor turf are made by an interprofessional team that includes a sports physician, orthopedic surgeon, podiatrist, nurse practitioner, radiologist, and an emergency department physician. The initial treatment is conservative, but most severe injuries require some type of surgery. The symptoms often take months to subside. The majority of patients have a good outcome, but future protection of the toe is highly recommended to prevent a recurrence.[13][14]