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Turf Toe Injury

The turf toe injury was originally described by Bowers and Martin in 1976. Turf toe is a general term that is used to describe a variety of injuries to the hallux plantar capsule, plantar muscles and the sesamoid complex.  


Its current incidence and epidemiology remain unknown, as the majority of literature describes small case-series and addresses diagnosis and treatment rather than epidemiology. The injury was further described by Rodeo et al. in 1990, who found that in a survey of 80 active players, up to 45% had suffered turf toe injuries in their professional careers, of which 83% occurred on an artificial turf.


Turf toe injury can easily be overlooked, and therefore, requires a careful assessment on initial presentation.  Turf toe injury represents a significant injury that requires early recognition and treatment, because a neglected injury can lead to long-term detrimental effects including decreased athletic performance, restricted 1st MTPJ motion, degenerative arthritis, hallux valgus deformity and potentially a premature end to the sporting career.


The two hallux sesamoids lie within the flexor hallucis brevis (FHB) tendon and sit on the plantar surface of the forefoot, directly underlying the first metatarsal head.  A bony ridge on the undersurface of the first metatarsal head, known as the crista, separates the sesamoids, delineating the medial and lateral metatarsal–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.


The usual mechanism of turf toe injury is an axial load of the 1st MTPJ in a fixed equinus foot. The load drives the hallux MTP joint into hyperextension, leading to attenuation or disruption of the plantar joint complex.  This can potentially lead to a spectrum of injuries ranging from a sprain of plantar structures to frank dorsal dislocation of the toe.

Clinical Presentation

Patients with acute injury present with swelling, plantar bruising and pain with weightbearing especially during push-off phase.  Point tenderness can prove to be a critical part of the assessment, along with palpation of the collateral ligaments, dorsal capsule and plantar sesamoid complex.  Tenderness proximal to the sesamoids suggests a low grade injury and distal to the sesamoids suggests a more serious and often unstable injury. Turf toe injury can be subtle.  A high index of suspicion must be kept in a patient with an injury to the first MTPJ.


Weightbearing AP and lateral radiographs of the foot, along with axial sesamoid views are obtained. There may not be an obvious bony abnormality, but a small fleck of bone may be visible, suggesting capsular avulsion.  


Location of the sesamoids under the metatarsal head is important. The distal sesamoid-to-joint distance should be no greater than 3 mm (tibial) and 2.7 mm (fibular), compared with those on the contralateral side.  


Proximal migration of one, of both, sesamoids is suggestive of plantar plate rupture, and a separation of 10.4 mm or more on the tibial side, or 13.3 mm on the fibular side, is 99% predictive of rupture of the plantar plate. CT or MRI is commonly performed to assess the extent of the injury and soft tissue disruption.


Clanton described a classification system, which was further modified by Anderson, and is based on the extent of injury:


Grade I - a sprain of the capsule without a loss of continuity, normal range of motion, no visible ecchymosis, ability to bear weight, normal plain radiographs and intact soft tissues on MRI with surrounding oedema.


Grade II - a partial tear of the plantar plate and capsule, with obvious swelling and ecchymosis, painful range of motion and difficulty in weight-bearing.  Radiographs may still be normal, but MRI demonstrates soft tissue oedema and high signal intensity that does not extend through the full thickness of the plantar plate.

Grade III - is a complete tear with loss of continuity of the plantar plate and capsule.  Concomitant injuries may also be found, including sesamoid fracture and dorsal metatarsal articular impaction.


There are no prospective randomised controlled trials in the literature to compare the treatment options for turf toe injuries.  Only a few retrospective case series exist, with level IV evidence, that primarily suggest non-operative management for Grade I and II injuries, and majority of grade III injuries.  Only one case series is available that supports the operative treatment for some cases of grade III injuries.


Conservative Treatment


Regardless of the stage of injury, the initial treatment is similar and includes general measure of rest, elevation, ice packs and pain management.  A walking boot, short leg cast or a toe spica extension in slight flexion is recommended, to keep the plantar soft tissues in a rested position. It is critical to establish whether the injury is stable or unstable before planning management.


Grade I

Along with the initial supportive measures, the great toe usually gets benefit from taping in a slightly plantarflexed position, with the use of a stiff-soled shoe or individualised orthotics with a Morton’s extension.  In cases of medially based injury, a toe separator may be beneficial to prevent the development of traumatic hallux valgus.  As the acute phase starts to settle, gentle range of motion can be commenced with return to low impact activities in 3 to 5 days.  


Grade II

The supportive treatment is the same as for grade I injuries; however the athlete is likely to lose about 2 weeks of playing time.  After the resolution of acute pain and swelling, early gentle passive motion is started along with low-impact activities with the use of toe protection, with a gradual return to higher impact activities of running, push-off, jumping and pivoting.


Grade III

The athlete may require 8 weeks of immobilisation for appropriate recovery.  The first MTP joint should have 50° to 60° of painless passive dorsiflexion before considering returning to running or high impact activities.  It may take up to 6 months for complete resolution of symptoms in cases of a severe injury.

Coker et al. reported a retrospective case series of 8 turf toe injuries in collegiate football players.  Initial treatment included a period of rest with a plaster cast, crutches, and heel weight-bearing.  Players were allowed to progress on to walking, running and high impact activities when pain resolved, with the use of taping and modification of shoewear.  A few patients underwent surgery, as pain remained a persistent problem beyond 3 weeks of injury; however the demographics of these patients were not fully described in their study.  The long-term problems reported in this series were pain and stiffness.

Clanton et al. reported 56 turf toe injuries, in their retrospective review over a 14 year period.  54 injuries (96%) occurred in football players on synthetic turf.  Players were initially treated with usually measures as above, followed by gradual mobilisation and return to sports when pain resoled.  53 of the 56 players (95%) were able to return to sports; however half of these patients reported some level of ongoing pain and stiffness over a period of 5-year follow up. Only one patient required surgery, who had avulsion fracture of the first metatarsal and required 56 days to return to play.


Surgical Treatment


Surgery for turf toe injuries is rarely indicated.  Anderson described indications for surgery in Grade III injuries to include large capsular avulsions with an unstable MTP joint, diastasis of bipartite sesamoid, sesamoid fracture, retraction of sesamoid, traumatic hallux valgus, vertical instability, loose body in MTP joint, chondral injury and failed conservative treatment with persistent pain.

The aim of surgery is to restore the normal anatomy and stability of the MTP joint.  In case of isolated capsular disruption, the plantar soft tissue structures can be primarily repaired with end to end sutures.  In case of a traumatic hallux valgus suggesting medial soft tissue injury, an adductor tenotomy is performed percutaneously to balance the MTP joint.  The medial eminence may also require resection to allow a capsulodesis.  In case of sesamoid fracture, care should be taken to preserve as much bone as possible.

Occasionally complete sesamoidectomy becomes necessary [21], although it is best avoided if at all possible. Depending on the fragment size, some authors have suggested an open reduction and internal fixation, which although difficult, may be achievable using small screws (1.3 mm).

The only available study reporting the outcome of surgical intervention, is a retrospective case-series review by Anderson.  In this series, 9 patients underwent surgery for Grade III injuries with radiographic evidence of sesamoid migration and disruption of the plantar soft tissue complex on MRI scans.  The duration from injury to surgery ranged from 1 week to 7 months, with follow up from 1 to 10 years, via questionnaires.  Repair of the plantar plate complex was performed in all patients.  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.  Seven patients (78%) were able to return to full level of activity with minimal pain.  The remaining two 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.

George et al. reviewed the data of 147 turf toe injuries among collegiate football players over 5 seasons.  They reported that the athletes were nearly 14 times more likely to sustain the injury during games compared to practice/training sessions, with a mean loss of 10 days of athletic participation due to injury.  There was a significantly higher injury rate on artificial surfaces, compared to natural grass.  The majority of injuries occurred as a result of contact with the playing surface (35.4%) or contact with another player (32.7%).  Non-operative measures were the mainstay of treatment, leading to satisfactory recovery and return to sports.  Fewer than 2% of these players required surgery.


Following surgery, the foot is immobilised with a toe spica splint in plantarflexion and patient is kept non-weightbearing for 4 weeks.  Gentle passive range of motion is commenced at 1 week, avoiding excessive dorsiflexion.  At 4 weeks, protected weightbearing is commenced in a boot or heel loading shoe, along with active range of movement exercises out of splint.  At 8 weeks, a stiff-soled shoe and a turf toe plate is advised to prevent hyperextension and weightbearing is advanced as tolerated with protective taping and shoe wear.  Impact activities are introduced at around 12 weeks.


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