Turf toe injury

 

Introduction

  • described by Bowers and Martin in 1976
  • “Turf toe” describes a spectrum of injuries to the capsuloligamentous structures of the hallux MTPJ (plantar capsule, plantar muscles and the sesamoid complex)
  • typically sustained on artificial turf or hard ground
  • requires a high index of suspicion from history and examination (can be easily missed)
  • can lead to poor outcomes

 

Incidence

  • up to 45% of American football players, most on artificial turf
  • low incidence in the UK: ~ 1 turf toe injury per Premiership rugby union team every fourth season

 

Anatomy

  • two hallux sesamoids lie within the flexor hallucis brevis (FHB) tendon directly under the 1st MT head
  • the crista, a bony ridge on the undersurface of the 1st MT head, separates the sesamoids, delineating the medial and lateral MT–sesamoidal joints
  • the abductor and adductor hallucis tendons insert on the medial and lateral bases of the proximal phalanx, respectively, and also give off small attachments to the sesamoids
  • medial and lateral collateral ligaments at the 1st MTPJ contribute to valgus and varus stability
  • in normal gait, the capsuloligamentous complex of the 1st MTPJ withstands 40-60% of bodyweight; this can increase to 8x body weight during running and jumping
  • A turf toe injury represents injury to some – or all – of this complex

 

Mechanism

  • axial load of the 1st MTPJ in a fixed equinus foot
  • hyperextension force to the 1st MTPJ, causing attenuation or disruption of the plantar joint complex
  • leads to a spectrum of injuries, from plantar sprain to frank dorsal dislocation
  • variations include a valgus-directed force, causing medial injury, relative contracture of the lateral structures, and subsequent traumatic hallux valgus deformity

 

Presentation

  • detailed history is crucial
  • symptoms and signs may be subtle, and a high index of suspicion must be maintained:
    • swelling
    • plantar bruising
    • pain with weightbearing, especially during push-off
    • point tenderness to plantar structures / capsule / ligaments
  • tenderness proximal to the sesamoids suggests a low-grade injury
  • tenderness distal to the sesamoids suggests a more serious and often unstable injury
  • test range of motion, varus/valgus stress and dorsoplantar drawer test

 

Imaging

Radiographs:

  •  weightbearing AP and lateral radiographs and axial sesamoid views:
    • may be normal
      • look for a visible small fleck of bone, suggestive of capsular avulsion
    • location of the sesamoids under the MT head is important
      • the distal sesamoid-to-joint distance should be ≤3mm (tibial) and 2.7mm (fibular)
      • compare with standing x-rays of opposite side  
    • proximal migration of one, or both, sesamoids is suggestive of plantar plate rupture
    • a separation of ≥10mm on the tibial side, or 13mm on the fibular side, is 99% predictive of rupture of the plantar plate

MRI:

  • commonly performed to assess the extent of the injury and soft tissue disruption
  • identifies bone marrow oedema, loose body, 1st MTPJ arthrosis
  • differentiates bipartite sesamoids from fractures

 

Classification

Clanton (modified by Anderson), based on extent of injury:

  • Grade I: capsular sprain
    • no loss of continuity, normal range of motion, no visible ecchymosis, ability to bear weight
    • normal plain radiographs
    • intact soft tissues on MRI with surrounding oedema
  • Grade II: a partial tear of the plantar plate and capsule
    • obvious swelling and ecchymosis
    • painful range of motion
    • difficulty weight-bearing
    • radiographs may still be normal
    • MRI demonstrates soft tissue oedema and high signal intensity that does not extend through the full thickness of the plantar plate
  • Grade III: a complete tear
    • loss of continuity of the plantar plate and capsule
    • concomitant injuries may occur, incl sesamoid fracture and dorsal articular impaction

 

Treatment

  • based only on a few retrospective case series
  • most suggest that non-operative management is sufficient for Grade I and II injuries, and majority of grade III injuries
  • two case series support the operative treatment for some grade III injuries
  • establish if the injury is stable or unstable before planning management

 

Non-operative

  • initial measures: rest, elevation, ice packs and pain management
  • walking boot, short leg cast or a toe spica extension in slight flexion

Grade I

  • tape the big toe in a slightly plantarflexed position
  • stiff-soled shoe or individualised orthotics with a Morton’s extension
  • for a medial injury, a toe separator may help to reduce the risk of developing traumatic hallux valgus
  • commence gentle range of motion at 3-5 days, with retuen to low impact activities

Grade II

  • supportive treatment as for grade I
  • athletes are likely to lose ~ 2 weeks of playing
  • after resolution of acute pain and swelling:
    • early gentle passive motion
    • low-impact activities with the use of toe protection
    • gradual return to higher impact activities of running, jumping, pivoting

Grade III

  • athletes may require up to 8 weeks of immobilisation
  • recommended that the 1st MTPJ should have 50° to 60° of painless dorsiflexion before returning to running or high impact activities
  • may take up to 6 months for complete symptom resolution
  • Surgery may be indicated (see below)

​Outcomes/evidence

  • Clanton et al:
    • 56 turf toe injuries – retrospective review over 14 years
    • 54 injuries (96%) occurred in football players on synthetic turf
    • non-operative treatment initially as above, then gradual mobilisation and return to sports
    • 53 (95%) were able to return to sports; however, 50% reported ongoing pain and stiffness
    • only one patient required surgery – avulsion fracture of the 1st MT –  returned to play after 8 weeks
  • George et al:
    • 147 turf toe injuries in collegiate American football players over 5 seasons
    • 14x more likely to sustain the injury during games than practice
    • mean loss of 10 days of sport
    • higher injury rate on artificial surfaces compared to natural grass
    • most occurred from contact with the playing surface (35%) or contact with another player (33%)
    • non-operative measures were the mainstay of treatment, leading to satisfactory recovery and return to sports
    • <2% required surgery

 

Surgical Treatment

  • Anderson described the indications for surgery as Grade III with:
    • large capsular avulsions with MTPJ instability
    • diastasis of bipartite sesamoid
    • sesamoid fracture
    • retraction of sesamoid
    • traumatic hallux valgus
    • vertical instability
    • loose body in MTP joint
    • chondral injury
  • Aim of surgery:
    • to restore normal anatomy and stability of the MTP joint
  • In isolated capsular disruption, the plantar soft tissue structures can be primarily repaired with end-to-end sutures
  • Traumatic hallux valgus suggesting medial soft tissue injury can additionally require adductor tenotomy percutaneously to balance the MTP joint, and medial eminence resection to allow a capsulodesis
  • In cases of sesamoid fracture, some authors have suggested open reduction and internal fixation (technically difficult)
  • Complete sesamoidectomy may rarely be necessary, although best avoided if possible
  • Rehab:
    • the foot is immobilised post-op with a toe spica splint in plantarflexion
    • 4 weeks non-weightbearing
    • at 1 week: commence gentle passive range of motion
    • at 4 weeks: commence protected weightbearing in a boot or heel loading shoe, commence active range of movement
    • at 8 weeks: full weight-bearing in stiff-soled shoe, turf toe plate or taping is advised to prevent hyperextension
    • at 12 weeks: gentle return to impact activities

​Outcomes/evidence

  • Anderson – retrospective case series:
    • 9 patients underwent plantar plate repair for Grade III injuries with radiographic evidence of sesamoid migration and disruption of the plantar soft tissue complex on MRI scans  
    • duration from injury to surgery ranged from 1 week to 7 months, with follow up from 1 to 10 years
    • in 4 patients (44%), sesamoidectomies were performed due to fragmentation or degeneration, with abductor hallucis tendon transferred to fill in the defect in 3 of these patients
    • 7 patients (78%) were able to return to full level of activity with minimal pain.
    • 2 patients were unable to return to full athletic activity; one due to persistent pain despite a stable toe, and the other developed severe hallux rigidus
  • Limaye et al. reported results of 20 patients:
    • 10 resulted from football, 6 from running, 2 from gymnastics, 1 from motorcycle injury and 1 from ballet dancing
    • all patients had a minimum 6-month period of non-operative treatment prior to surgery
    • surgery was performed through full thickness dorsoplantar flaps, devitalised tissue was excised and repair performed using a suture anchor in the base of the proximal phalanx to reattach the sesamoid complex
    • it is not clear from the paper how many had surgery, but it was performed for all grade 3 injuries; MOXFQ score improved from median of 73 to 28 post-op, as well as improved pain scores

 

MCQs

  1. Turf toe most commonly results from which mechanism?
    1. Crush injury
    2. Hyperflexion
    3. Hyperextension
    4. Forced valgus
    5. Forced varus

 

  1. What is the most appropriate early management for a patient with an acute grade 2 turf toe injury?
    1. Scarf and akin osteotomies
    2. 1st MTPJ fusion
    3. Rest, ice, elevation, splinting in plantarflexion
    4. Plantar plate repair
    5. Rest, ice, elevation, taping in extension

 

  1. Which of the following is not considered part of the capsuloligamentous complex of the 1st MTPJ which can be injured in turf toe?
    1. Medial sesamoid
    2. Lateral sesamoid
    3. Adductor hallucis
    4. Extensor hallucis longus
    5. Medial collateral ligament

 

Answers: 1(c), 2(c), 3(d)

 

References

George E, Harris AH, Dragoo JL, Hunt KJ. Incidence and risk factors for turf toe injuries in intercollegiate football: data from the National Collegiate Athletic Association injury surveillance system. Foot Ankle Int, 2014. 35(2): p. 108-15

Pearce CJ, Brooks J, Kemp SP, Calder JD. The epidemiology of foot injuries in professional rugby union players. Foot Ankle Surg, 2011. 17: 113-118

Clanton TO and Ford JJ. Turf toe injury. Clin Sports Med 1994 13(4):  p.731-741

McCormick JJ, Anderson RB. Turf toe: anatomy, diagnosis, and treatment. Sports Health, 2010. 2(6): p. 487-94

McCormick JJ, Anderson RB. The great toe: failed turf toe, chronic turf toe, and complicated sesamoid injuries. Foot Ankle Clin, 2009. 14(2): p. 135-50

Kadakia AR, Molloy A. Current concepts review: traumatic disorders of the first metatarsophalangeal joint and sesamoid complex. Foot Ankle Int, 2011. 32(8): p. 834-9

Crain JM, Phancao JP, Stidham K. MR imaging of turf toe. Magn Reson Imaging Clin N Am, 2008. 16(1): p. 93-103, vi

Clanton TO, Butler JE, Eggert A. Injuries to the metatarsophalangeal joints in athletes. Foot Ankle, 1986. 7(3): p. 162-76

Limaye N, Sethi M, Ayyaswamy B. Outcomes of Surgical Management of Turf Toe: 12-Year Results. Cureus. 2024 Apr 8;16(4):e57808. doi: 10.7759/cureus.57808. PMID: 38721159; PMCID: PMC11077470

Clough TM, Majeed H. Turf Toe Injury - Current Concepts and an Updated Review of Literature. Foot Ankle Clin. 2018 Dec;23(4):693-701. doi: 10.1016/j.fcl.2018.07.009. Epub 2018 Sep 24. PMID: 30414661