Turf toe

Definition/Description

Turf toe is an injury to the first metatarsophalangeal joint (MTP) due to damage to the plantar capsule ligament complex due to hyperextension of the big toe. It can cause these structures to tear or completely fail.

Clinically Relevant Anatomy

The slightly concave shape of the proximal phalanx of the first metatarsal joint results in little joint stability. The plantar capsule is thicker at the proximal phalanges and thinner at the metatarsal heads. It supports the lower surface of the metatarsal head and Resist hyperextension of the metatarsophalangeal joint. [1] In addition to the plantar capsule and collateral ligaments, the MTP joint is dynamically stabilized by the flexor hallucis brevis (FHB), the sesamoid bone embedded in the tendon of the FHB, the adductor pollicus, and the abductor muscles Thumb tendon[2]

Epidemiology /Etiology

Turf toe was first described by Bowers and Martin in 1976. They studied West Virginia University football players and determined that an average of 54 injuries occurred in a season. [2][3] Further studies have shown that injuries occur more frequently Football is played on artificial turf.

This is caused by overloading the hallux MTP joint in an excessively dorsiflexed position, which occurs when one player falls onto another player’s heel. Too much adhesion on the upper, and when the player tries to stop quickly, the shoe sticks as the weight shifts forward, which can cause acute Turf toes. The chronic disease is mainly caused by running and jumping often in extremely flexible shoes. [2][4][5][6] Injuries often result not only from hyperextension but also from some degree of valgus stress.

Characteristics/Clinical Presentation

It is characterized by pain as the first symptom localized swelling ecchymosis and joint stiffness. With proper assessment, we can divide the disease into three grades, each with its own symptoms and treatment options.

• Grade I injury symptoms include:
  • Local swelling
  • Attenuation or stretching of plantar structures
  • Minimal ecchymosis.
• Grade II injury symptoms include:
  • Moderate swelling
  • Partial tear of plantar structures
  • Restricted motion as a result of pain.
• Grade III injury symptoms include:
  • Indicative swelling and ecchymosis
  • Complete destruction of the plantar structure
  • Weakness of the hallux flexion
  • High instability of the MTP joint.[2][3]

Differential Diagnosis

• Reverse turf toe
• Soccer toe
• Hallux rigidus
• Hallux limitus
• Hallux valgus 

Examination

The physical examination begins with observation and palpation of the sensitivity of the MTP joint of the hallux, assessing stability and flexion strength. Palpation focuses on the dorsal capsule of the collateral ligaments and the plantar sesamoid complex. [2]

If the pain is localized to the proximal sesamoid, it indicates a strain on the flexor hallucis brevis tendon junction, whereas a turf toe injury is distal to the sesamoid.

The various ranges of motion of the joints can also be used to identify different injuries. Comparing active flexion strength to the contralateral side may reveal disruption of the FHB or plantar plate. [2]

Inversion and/or valgus stress should also be applied to the collateral ligaments:

• Dorsal plantar drawer test (Thompson and Hamilton)[7][8] – this tests the ability of the plantar plate
• Active flexion and extension at the MTP and interphalangeal joints – this tests the extensor and flexor tendons and the plantar plate.

Medical Management

Conservative treatment is always the first line of intervention and may include injectable therapy. [9] If conservative treatment is unsuccessful, surgical intervention may be considered. The main criteria for surgical intervention are [2]:

• Large joint capsular avulsion with MTP joint instability
• Diastasis of bipartite sesamoid
• Diastasis of sesamoid fracture
• Retraction of sesamoid
• Traumatic hallux valgus deformity
• Vertical instability (positive Rahman test result)
• Loose body in MTP joint
• Chondral injury in MTP joint
• Failed conservative treatment

Physical Therapy Management

Each of the three levels of injury has a different approach to physical therapy, although initial therapeutic intervention for all three levels includes the RICE protocol (Rest Ice Compression Elevation).

Interventions for a Grade I Injury

Once the acute phase is over, slight plantar flexion limits movement, protects the toes from excessive movement, and provides pressure. Rehabilitation can begin 3 to 5 days after injury, starting with gentle passive plantarflexion and gradually increasing strength practise. Traction and dorsal and proximal gliding of the proximal phalanx on the first metatarsal can help restore normal ROM and strength. [10]

Patients can participate in non-weight bearing physical activities such as bicycle pool therapy and elliptical training. [2] It is recommended that athletes wear hard-soled shoes to limit the movement of the big toe. [2][3]

Interventions for a Grade II Injury

Grade II turf toe injuries require at least 2 weeks to return to activity, but the exact time depends on the sport the athlete is playing. The primary goals of treatment will focus on increasing range of motion and reducing pain and whether the athlete can tolerate passive joints Express mobilization.

Only after symptoms such as pain and swelling have subsided, more in-depth rehabilitation can begin. However, care must be taken to protect the toes, whether using grass toe boards or Morton’s stretch orthotics.

Pulsed ultrasound or iontophoresis may be used to control inflammation and help soft tissue heal. Positive exercises can also be introduced to encourage toe extension and flexion, such as toe curls, rolled towels, toe moves in a bucket of sand, and short feet practise. [10] As progress is made, athletes can engage in higher intensity activities (jogging, running, cutting, and jumping). [2][4]

Interventions for a Grade III Injury

Nonoperative treatment of grade III injuries requires 8 weeks of rehabilitation and plantarflexion immobilization. The hallux MTP joint should return to painless passive dorsiflexion of 50° to 60° before resuming physical activity. Full recovery may take up to 6 months. [2]

The most important part of lawn toe treatment is physical therapy rehabilitation and prevention with toe protectors/orthotics, but surgical intervention may be required in some cases. [2]