Turf toe

Introduction

Turf toe is an injury of the first metatarsophalangeal (MTP) joint caused by hyperextension of the big toe, commonly occurring in athletes. It is frequently seen in sports that involve pushing off the forefoot on hard surfaces. Early recognition and appropriate management are essential to prevent chronic pain and functional limitations.

Definition and Classification

Definition of Turf Toe

Turf toe is a traumatic sprain of the plantar complex of the first MTP joint, typically resulting from hyperextension of the hallux. The injury affects the ligaments, joint capsule, and sometimes the plantar plate, leading to pain, swelling, and limited motion.

Classification

• Grade I: Mild sprain with stretching of the plantar structures, minimal swelling, and pain.
• Grade II: Moderate sprain with partial tear of the plantar structures, increased swelling, bruising, and limited function.
• Grade III: Severe sprain with complete rupture of the plantar structures, significant swelling, ecchymosis, instability, and marked functional impairment.

Etiology and Risk Factors

Mechanism of Injury

• Hyperextension of the hallux during rapid push-off or sudden change in direction
• Direct trauma to the toe or forced dorsiflexion while the forefoot is planted

Sports and Activities

• American football, soccer, and basketball due to sudden acceleration and deceleration
• Track and field events, especially sprinting and jumping
• Other activities performed on artificial turf or hard surfaces

Predisposing Factors

• Wearing shoes with limited flexibility or improper fit
• Playing on hard or artificial surfaces
• Previous injuries to the first MTP joint increasing vulnerability

Anatomy Relevant to Turf Toe

• First Metatarsophalangeal Joint: Synovial joint connecting the first metatarsal to the proximal phalanx of the hallux, allowing flexion and extension.
• Plantar Plate and Joint Capsule: Fibrocartilaginous structures providing stability to the MTP joint.
• Ligaments, Tendons, and Musculature: Collateral ligaments, flexor hallucis brevis tendon, and surrounding muscles contribute to joint stability and propulsion during gait.

Clinical Presentation

Symptoms

• Pain at the first metatarsophalangeal joint, especially during push-off or running
• Swelling and bruising around the big toe
• Stiffness and reduced range of motion
• Difficulty bearing weight on the forefoot

Physical Examination Findings

• Localized tenderness over the plantar aspect of the MTP joint
• Edema and ecchymosis in moderate to severe cases
• Instability or crepitus in grade III injuries
• Pain elicited on passive dorsiflexion of the hallux

Diagnostic Evaluation

History Taking

• Details of injury mechanism, including hyperextension or direct trauma
• Previous injuries to the first MTP joint or forefoot
• Symptoms such as pain onset, swelling, and limitations in activity

Imaging Studies

• X-ray to rule out fractures or sesamoid injuries
• MRI to assess ligament, joint capsule, and plantar plate injuries
• Ultrasound for dynamic evaluation of soft tissue structures

Differential Diagnosis

• Sesamoiditis: Inflammation of the sesamoid bones beneath the first metatarsal head causing forefoot pain.
• Hallux Rigidus: Degenerative arthritis of the first MTP joint resulting in stiffness and pain.
• Fractures of the Proximal Phalanx or Sesamoid Bones: Trauma-induced fractures that may mimic turf toe symptoms.
• Collateral Ligament Sprains: Lateral or medial ligament injuries producing localized tenderness and swelling.

Management

Non-Pharmacological Management

• Rest and activity modification to avoid further stress on the MTP joint
• Ice application to reduce pain and swelling
• Compression bandaging or taping for joint stabilization
• Use of stiff-soled shoes or orthotics to limit hyperextension

Pharmacological Management

• Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation
• Topical analgesics as adjunct therapy for localized pain

Surgical Management

• Indicated in complete ligament or plantar plate rupture or chronic instability
• Surgical repair or reconstruction of plantar plate and joint stabilization procedures

Rehabilitation and Return to Sport

• Physical therapy to restore range of motion and strengthen the muscles supporting the first MTP joint
• Gradual progression to sport-specific drills and activities
• Monitoring for pain or swelling during training to prevent re-injury
• Criteria-based return to play, including pain-free movement, stability, and functional performance

Complications and Prognosis

• Chronic pain or stiffness if the injury is not properly managed
• Recurrent turf toe injuries, particularly in athletes returning to sport prematurely
• Development of hallux valgus or osteoarthritis in severe or untreated cases
• Potential for long-term functional limitations affecting athletic performance

Prevention

• Selection of proper footwear with stiff soles and adequate forefoot support
• Use of protective taping or bracing during high-risk sports activities
• Training on appropriate surfaces to reduce excessive hyperextension forces
• Education on proper technique and body mechanics to minimize injury risk

References

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