Turf toe is an injury to the first metatarsal-phalangeal joint (MTP joint) in the foot. There are 5 metatarsal bones in the foot. Each articulates distally with the proximal phalanx of the toe. The big toe has a proximal and distal phalanx, whereas, the rest of the toes possess a proximal, middle, and distal phalanx.

In turf toe, the big toe is hyperextended upwards (dorsiflexion) that injures the proximal phalanx-first metatarsal (MTP) joint complex.

ANATOMY

The first MTP joint allows for dorsiflexion (towards the knee) and plantar flexion (away from the knee) movements of the big toe. Some sliding, rolling, and compression may occur.

The first MTP joint is stabilized by medial and lateral collateral ligaments that connect the metatarsal to the proximal phalanx of the big toe. There is a plantar plate that is a strong, fibrous structure attached to the proximal phalanx to the neck of the first metatarsal underneath the joint. Sesamoid bones are extra bones not directly connected to a central bone. The first MTP joint has two sesamoid bones, one on each side of the joint. These extra bones confer stability to the joint. ¹

The flexor hallucisbrevis tendon originates further up in the foot. It splits into medial and lateral heads beneath the first metatarsal. The Tendon fibers envelop the sesamoid bones and insert (end) at the base of the proximal phalanx. The flexor hallucisbrevis is important in creating push-off strength for the big toe. ²

The abductor and adductor hallucis tendons insert on the medial and lateral parts of the bottom of the MTP joint. These tendons contribute to the stability of the MTP joint.³

THE INJURY

Turf toe is most commonly seen when stress is delivered to a foot fixed to the turf. The typical scenario is a football lineman whose forefoot is on the ground in a dorsiflexed position with the heel raised. An outside force then pushes the foot into further dorsiflexion causing hyperextension of the first MTP joint.⁴

Turf toe is most often encountered in football players but can be seen in soccer, rugby, and basketball players.

The reason it is called turf toe is because a first MTP joint injury became much more frequent when artificial turf was introduced. Artificial turf is a harder surface than standard sod grass. There is less give-way on an artificial surface.

In addition, athletes playing on artificial turf wanted more flexible or soft-soled shoes. This type of shoe decreases the amount of stability present at the first MTP joint.

DIAGNOSIS

The physical exam comes first with attention paid to the location of pain, swelling, and bruising. Range of motion testing should be performed accessing for instability or hypermobility that suggests tearing of the plantar plate. A varus and valgus stress test are done checking for collateral ligament damage.Performing adorsoplantar drawer maneuver is necessary looking for plantar, joint capsule disruption.⁵

X-rays of the area will be taken searching for small bony avulsion fractures. Furthermore, seen on the x-rays is any sesamoid bony fractures or misalignment of the sesamoids relative to the MTP joint capsule.

An MRI may be done, especially for more severe injuries. The MRI will reveal soft-tissue damage or injury. ⁶

STAGING

Grade 1: The plantar-MTP joint complex has been stretched. There is pin-point tenderness with minimal swelling and no bruising.

Grade 2: Partial tearing of the plantar-MTP joint complex has occurred. There is widespread tenderness, moderate swelling and bruising present. Movement of the big toe is limited and painful.

Grade 3: The plantar-MTP joint complex is completely torn. Sesamoid bone fracture may be present. There is diffuse and severe tenderness with much swelling and bruising. Range of motion is diminished due to significant pain upon movement of the big toe.⁷

TREATMENT

Grade 1: injury is treated by taping the big toe to the lessor toes to prevent first MTP joint movement. A carbon fiber, stiff insole may be inserted into the shoe to support the MTP joint.

Grade 2: injuries require a walker boot and crutches for 7 to 14 days.

Grade 3: damage necessitates a boot or cast for 2 to 6 weeks. Return to play is recommended when there are 50 to 60 degrees of dorsiflexion possible without pain. ⁸

SURGERY

Rarely, surgery is needed to repair turf toe.

Surgery is indicated for:

• Sesamoid bone fracture
• Proximal migration of the sesamoid bones
• Persistent instability with refractory pain
• If the big toe becomes rigid or fixed in place
• A cartilage flap or loose body inside the MTP joint is seen on MRI

Postoperatively, the foot is placed in a cast. Patients remain
non-weight bearing for 4 to 6 weeks. The cast is then removed, and a walker boot is prescribed. The institution of physical therapy happens at this time with gentle, active dorsiflexion of the joint and range of motion exercises. After this, a stiff soled shoe is worn by the patient. Return to competition occurs after 4 to 6 months. ⁹

SUMMARY

First MTP joint sprain or turf toe is a nagging and fairly common injury, especially in football players. Depending on the severity, turf toe can be a debilitating injury. For professional football players, the average down time is 10 days.¹⁰Surgery is indicated for more advanced injuries and usually means 4 to 6 months off the field.

REFERENCES

1. McCormick J, Anderson R. “Turf Toe: Anatomy, Diagnosis, and Treatment.” Sports Health, 2(6): 487-494, 2010.
2. Ibid.
3. McCormick J, Anderson R. “The Great Toe: Failed Turf Toe, Chronic Turf Toe, and Complicated Sesamoid Injuries.” Foot Ankle Clin, 14(2): 135-150, 2009.
4. Kubitz E. “Athletic Injuries of the First Metatarsophalangeal Joint.” J Am Podiatr Med Assoc, 93(4): 325-332, 2003.
5. Coughlin M, Kemp T, Hirose C. “Turf Toe: Soft Tissue and Osteocartilaginous Injury to the First Metatarsophalangeal Joint.” PhysSportsmed, 38(1): 91-100, 2010.
6. Tewes D, Fischer D, Fritts H, et al. “MRI Findings of Acute Turf Toe. A Case Report and Review of Anatomy.” ClinOrthopRelat Res, 304: 200-203, 1994.
7. McCormick J, Anderson R. “Turf Toe: Anatomy, Diagnosis, and Treatment.” Sports Health, 2(6): 487-494, 2010.
8. Ibid.
9. McCormick J, Anderson R. “Rehabilitation Following Turf Toe Injury and Plantar Plate Repair.” Clin Sports Med, 29(2): 313-323, 2010.
10. Ibid.