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Turf Toe Treatment & Management

  • Author: Blake L Ohlson, MD; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
 
Updated: Jun 13, 2016
 

Approach Considerations

Most metatarsophalangeal (MTP) joint injuries can be managed nonsurgically. However, when the injury is refractory to conservative treatment, surgery should be considered as an option.

Complications of turf toe injury that may necessitate surgical intervention include the following:

  • Sesamoid fracture
  • Separation of a bipartite sesamoid bone [15]
  • Proximal migration of the sesamoids
  • Instability with accompanying persistent pain or synovitis
  • Osteochondral injury, cartilage flap or loose body within the hallux MTP joint

Contraindications for surgical intervention are nonspecific and include those that apply to any surgical procedure. Contraindications include active local infection or open dermatologic lesions, advanced dysvascularity, and minimal or absent pain and dysfunction.

Patients with turf toe injuries are typically young and healthy. Therefore, they are unlikely to have local or systemic conditions that preclude surgery.

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Medical Therapy

Conservative management in the acute stages, regardless of grade, consists of rest, ice, compression, and elevation (RICE). Taping is not recommended in the acute stages because of swelling and the risk of vascular compromise. Nonsteroidal anti-inflammatory drugs (NSAIDs) may help minimize pain and inflammation. In some cases, a short leg cast with a toe spica in slight plantarflexion or a walker boot may be used for the first week to help decrease pain. Gradual range of motion begins in 3-5 days following injury.

After the acute stages, conservative management is based on the grade of injury, as follows:

  • Grade 1 - These injuries are treated by taping the great toe to the lesser toes to prevent movement of the hallux MTP joint; players may also consider using an insole containing a carbon fiber steel plate in the forefoot; as always, the overall goal is to restrict forefoot motion; usually, persons with grade I injuries can return to play immediately, with only mild pain
  • Grade 2 - These injuries are treated in the same way as grade 1 injuries are, but athletes may lose significantly more playing time (3-14 days); use of a fracture walker and/or crutches is preferred
  • Grade 3 - These injuries usually require long-term immobilization in a boot or cast rather than surgical intervention; lost playing time may be in the range of 2-6 weeks; return to play is generally acceptable when 50-60º of passive dorsiflexion is possible without pain

As a reference, National Collegiate Athletic Association (NCAA) football participants have missed an average of 10.1 days of playing time before returning to competitive play.

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Surgical Therapy

When conservative treatment fails, as evidenced by persistent pain and difficulty with pushing off and with cutting or pivoting motions, surgical therapy may be indicated. It should be noted that the need for surgical management is relatively uncommon. Analysis of players in the NCAA indicated that fewer than 2% of injuries ultimately require surgical treatment. This value may be higher however in elite professional athletes.[12]

Although most cases are managed conservatively, the treating physician should be alert to the presence of hallux malalignment, traumatic bunion deformity, diminished flexor strength, clawing of the great toe, generalized synovitis, or advanced degenerative joint disease. Clinical findings such as these often indicate that surgical intervention is required.

Operative details

Injuries resulting in sesamoid fracture or diastasis of a bipartite sesamoid are managed according to the pattern of injury. Options include resection of the smaller fragment and complete sesamoidectomy. The former should be combined with advancement and repair of the capsule to the remaining fragment. If complete sesamoidectomy is required, transfer of the abductor hallucis to the defect has been suggested as a means of reinstating joint stability.

A medial or plantar approach can be used, depending on the type of injury. A medial- or plantar-based approach can be accomplished with the patient supine. Some have suggested that positioning the patient prone helps facilitate easier exposure when a plantar approach is necessary. Whenever a plantar approach is required, care should be taken to avoid an incision line that passes directly over either sesamoid. Use of a curvilinear incision can help avoid the risk of a painful scar occurring directly over a boney prominence.

Careful coaptation of the wound edges, as well as avoidance of weightbearing and suture removal until the incision is completely healed, can help minimize the risk of painful scar formation. Use of a thigh or ankle tourniquet is acceptable. However, the tourniquet should be let down before closure to ensure that meticulous hemostasis is maintained. This, in turn, minimizes unnecessary swelling and delayed wound healing. The overall goal is to avoid painful scar formation.

Anesthesia may be accomplished with a general anesthetic or intravenous (IV) sedation combined with a metatarsal or ankle block.

If the plantar plate is avulsed from the distal poles and the sesamoids are intact, the plate can be reattached through drill holes or by using a tapered, threaded anchor with a suture attached. This is analogous to a repair for a ruptured quadriceps tendon.

Claw toe may be repaired through flexor-to-extensor tendon transfer if the MTP joint is passively correctable (see the images below). If an interphalangeal contracture is present, arthrodesis of that joint is added.

Techniques for reconstructing passively correctabl Techniques for reconstructing passively correctable claw-toe deformity.
Techniques for reconstructing passively correctabl Techniques for reconstructing passively correctable claw-toe deformity.

Joint synovitis or an osteochondral defect often necessitates debridement or cheilectomy.

Traumatic progressive hallux valgus is treated with release of lateral soft-tissue contractures and reconstruction of plantar and medial structures.

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Postoperative Care

Postoperatively, the sutures are removed in 2-4 weeks, and the patient is advised to avoid dorsiflexion moments of the hallux for about 8 weeks. The site is protected with a plaster toe spica splint in 5-10º of plantarflexion. Patients refrain from weightbearing for 4-6 weeks, after which time they transition to a cam walker boot. Physical therapy can be instituted at this time with gentle active dorsiflexion and protected passive ROM.[16]

The primary goal initially is to strike a balance between stability a restoration of motion to the joint. After 8 weeks, it is permissible to transition to a stiff-soled shoe, depending on the degree of swelling. Sports conditioning may begin 10-12 weeks postoperatively. Return to competitive play should be allowed no earlier than 4-4.5 months. Many individuals may require 6-12 months before regaining their full preinjury level of function.

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Complications

Joint stiffness or persistent pain, especially with running, is the most common complication. Loss of pushoff strength, hallux rigidus, traumatic bunion deformity, cock-up deformity, arthrofibrosis, and loose joint bodies also may occur. Acute complications can include infection, hypertrophic scar formation, and development of a painful plantar nerve neuroma. Ultimately these issues are largely preventable through meticulous surgical technique.

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Long-Term Monitoring

After approximately 4-6 months, many patients are able to return to athletic activity. Equipment modification is well worth consideration. Protection can be accomplished through an orthosis or insole that contains a stainless steel or graphite plate in the forefoot. Some insoles may be custom-molded and contain a Morton extension to decrease MTP joint motion. Depending on the type of sport or positioned played, adding stiffness to an existing shoe can affect a players balance and speed. This point should be carefully weighed against the goal of providing ongoing protection of the repair.

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Contributor Information and Disclosures
Author

Blake L Ohlson, MD Attending Orthopedic Surgeon, Lower Extremity and Foot and Ankle Reconstruction, Orthopaedic Specialists of Charleston, Roper Saint Francis Healthcare; Assistant Professor Orthopedic Surgery, Medical University of South Carolina

Blake L Ohlson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, South Carolina Orthopaedic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Vinod K Panchbhavi, MD, FACS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedics, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Additional Contributors

John S Early, MD Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship, Baylor University Medical Center

John S Early, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Medical Association

Disclosure: Received honoraria from AO North America for speaking and teaching; Received consulting fee from Stryker for consulting; Received consulting fee from Biomet for consulting; Received grant/research funds from AO North America for fellowship funding; Received honoraria from MMI inc for speaking and teaching; Received consulting fee from Osteomed for consulting; Received ownership interest from MedHab Inc for management position.

Acknowledgements

Patrick L O'Connor, MD Former Associate Professor, Department of Orthopedic Surgery, Kalamazoo Center for Medical Studies, Michigan State University College of Human Medicine

Disclosure: Nothing to disclose.

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

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

  3. Sanders TG, Rathur SK. Imaging of painful conditions of the hallucal sesamoid complex and plantar capsular structures of the first metatarsophalangeal joint. Radiol Clin North Am. 2008 Nov. 46(6):1079-92, vii. [Medline].

  4. Kubitz ER. Athletic injuries of the first metatarsophalangeal joint. J Am Podiatr Med Assoc. 2003 Jul-Aug. 93(4):325-32. [Medline].

  5. McCormick JJ, Anderson RB. Turf toe: anatomy, diagnosis, and treatment. Sports Health. 2010 Nov. 2(6):487-94. [Medline].

  6. Coughlin MJ, Kemp TJ, Hirose CB. Turf toe: soft tissue and osteocartilaginous injury to the first metatarsophalangeal joint. Phys Sportsmed. 2010 Apr. 38(1):91-100. [Medline].

  7. Brophy RH, Gamradt SC, Ellis SJ, Barnes RP, Rodeo SA, Warren RF, et al. Effect of turf toe on foot contact pressures in professional American football players. Foot Ankle Int. 2009 May. 30(5):405-9. [Medline].

  8. Ryan AJ, Behling F, Garrick JG. Round table: artificial turf--pros and cons. Phys Sports Med. 1975. 3:41-50.

  9. Bowers KD Jr, Martin RB. Turf-toe: a shoe-surface related football injury. Med Sci Sports. 1976. 8(2):81-3. [Medline].

  10. Coker TP, Arnold JA, Weber DL. Traumatic lesions of the metatarsophalangeal joint of the great toe in athletes. Am J Sports Med. 1978 Nov-Dec. 6(6):326-34. [Medline].

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

  12. 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 Feb. 35(2):108-15. [Medline].

  13. Clanton TO, Ford JJ. Turf toe injury. Clin Sports Med. 1994 Oct. 13(4):731-41. [Medline].

  14. Schein AJ, Skalski MR, Patel DB, White EA, Lundquist R, Gottsegen CJ, et al. Turf toe and sesamoiditis: what the radiologist needs to know. Clin Imaging. 2015 May-Jun. 39 (3):380-9. [Medline].

  15. Favinger JL, Porrino JA, Richardson ML, Mulcahy H, Chew FS, Brage ME. Epidemiology and imaging appearance of the normal Bi-/multipartite hallux sesamoid bone. Foot Ankle Int. 2015 Feb. 36 (2):197-202. [Medline].

  16. McCormick JJ, Anderson RB. Rehabilitation following turf toe injury and plantar plate repair. Clin Sports Med. 2010 Apr. 29(2):313-23, ix. [Medline].

 
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Typical mechanism of turf toe injury. Foot is fixed on ground in equinus position while external force drives metatarsophalangeal (MTP) joint into hyperextension.
Metatarsophalangeal (MTP) joint hyperextension with tearing of plantar plate complex. Unrestricted motion of proximal phalanx results in severe compression of articular surface of metatarsal head along with separation of sesamoid components.
Capsuloligamentous-sesamoid complex of hallux. Top, medial view; bottom, plantar view.
Typical method for obtaining stress radiograph.
Techniques for reconstructing passively correctable claw-toe deformity.
Techniques for reconstructing passively correctable claw-toe deformity.
Protection of hallux metatarsophalangeal (MTP) joint is imperative after surgical intervention. Darco Wedge shoe allows weightbearing on hindfoot and simultaneous protection of forefoot.
Great toe dislocation. Video courtesy of Vinod K Panchbhavi, MD, FRCS, FACS.
Intraoperative steps. Video courtesy of Vinod K Panchbhavi, MD, FRCS, FACS.
Table 1. Classification Scheme for Tears of Capsuloligamentous Complex
Grade Resultant Injury Associated Injury
1 Stretch injury or minor tearing of the capsuloligamentous complex of the first MTP joint None
2 Partial tear of the capsuloligamentous complex of the first MTP joint without involvement of the articular surface None
3 Complete tear of the capsuloligamentous complex; tearing of the plantar plate from its origin on the metatarsal head/neck with dorsal impaction of the proximal phalanx into the metatarsal head Articular cartilage/subchondral bone bruise, sesamoid fracture, diastasis of the sesamoids, medial/lateral injury
Hyperflexion Hyperflexion injury to the hallux MTP joint with possible concomitant injury to lesser MTP joints Sprain or tearing of the dorsal capsule
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