Turf toe refers to an injury that affects the big toe ligaments around the metatarsal phalangeal joint. It is especially prevalent among athletes particularly among football and soccer players. It occurs when the big toe Metatarsal-phalangeal joint is overstretched or torn with joint hyperextension.
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Turf Toe
Turf Toe
Anatomy
Anatomy: Medial Aspect of Left 1st Ray
Turf Toe
Sport activities at risk:
- Soccer players
- Dancers
- Gymnasts
Presentation:
- “Popping” feeling at time of injury
- Pain that increases with toe extension or weight bearing upon it
- Swelling and bruising
- Deformity
Clinical:
- Joint tenderness
- Lachman test for anteroposterior instability
- Assess varus & valgus instability
- Deformity
- Palpable fracture
Investigation:
- Joint tenderness
- X-rays: Exclude fracture. Assess proximal and distal joints. Assess sesamoid bone retraction. Unstable injury if on dorsiflexion stress views there is > 2mm proximal retraction of sesamoids of the affected MTPJ compared to the normal contralateral side.
- CT: Useful for evaluation of sesamoid fracture
- MRI: Useful for evaluation of soft tissue & articular integrity
Mechanism: Foot plantarflexed and fixed to the ground with the ankle in equines with an axial load applied, the big toe MTP joint is hyperextended (±varus/valgus component) and the plantar joint capsuloligamentous structures are under tension with failure of these structures.
Injury grading:
- Grade 1: stretched plantar complex
- Grade 2: Partial tear of plantar complex
- Grade 3: complete tear of plantar complex
Management
Low grade injury (Grade1-2) managed nonoperatively
- Grade 1: rest, ice compression and elevation. Return to sport after 2 weeks.
- Grade 2: Walking boot 4-6 weeks. Return to sport may take up to 3 months. Protect joint area with Carbon fiber plate or Morton’s extension to be instituted into footwear.
- Hight grade injury (Grade 3) with instability: complete immobilization in walking boot or surgery repair is a consideration.
Surgery options:
- Repair plantar plate ± augmentation. Augmentation include using abductor hallucis tendon ± modified McBride tenotomy of the adductor to counteract excessive abduction forces across the repaired joint.
Surgery Technique
Surgery: Suture Fixation
Surgery options include suture fixation with direct ligament approximation or fixation through tunnels ± graft augmentation ± tenotomy.
Suture fixation through tunnels
Post Surgery Rehabilitation
- Post surgery splint for 2 weeks followed boot or hard sole shoe with heel weight bearing.
- Passive plantarflexion at 2 weeks
- At 6 weeks well-cushioned athletic shoe with graphite/carbon plate insert support
- Return to sport conditioning after 3 months provided adequate healing with full return after rehabilitation around 6 months
Return to sport & match readiness:
- After appropriate rehabilitation
- Assess return to sport after completing battery of testing
Maintain fitness while recovering with non-weight bearing cycle ergometry
Foot strengthening exercise after healed plantar ligament complex
Resistance strength exercise after union
Download ASSIC performance fingerprint app or ASSIC strength/conditioning app for rehab guidelines under professional supervision
References
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- Plantar-Plate Disruptions: “the Severe Turf-Toe Injury.” Three cases in contact athletes. M C Drakos, R Fiore, C Murphy, C W DiGiovanni. J Athl Train. 2015 May;50(5): 553-560.
- Turf Toe Injury-Current concepts and an updated review of literature. TM Clough, H Majeed. Foot Ankle Clin. 2018 Dec;23(4): 693-701.
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