Turf Toe Treatment & Management

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 I injuries are treated by taping the great toe to the lesser toes to prevent movement of the hallux metatarsophalangeal (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 injuries are treated in the same way as grade 1 injuries are, but athletes may lose significantly more playing time. Lost playing time can range from 3-14 days. Use of a fracture walker and/or crutches is preferred.
• Grade 3 injuries usually require long-term immobilization in a boot or cast rather than surgical intervention. Frequently, these injuries result in 2-6 weeks of missed playing time. Return to play is generally acceptable when 50-60 º of passive dorsiflexion is possible without pain.

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.

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.

Open reduction and internal fixation should be used for diastasis of a bipartite sesamoid bone whenever possible. Severe fragmentation may necessitate complete sesamoidectomy. The surgical approach and repair is depicted in the images below. An ankle block is given in the usual fashion. The patient is placed prone, as this greatly facilitates the ease of operating. An ankle tourniquet is applied, and the foot is prepared and draped.

A plantar, gently curved, concave, medial incision is made. This incision is slightly C shaped, with the proximal and distal limbs being more medial than is the central portion, which is just lateral to the lateral sesamoid bone. The soft tissues are split bluntly and longitudinally to avoid injury to the digital nerves. In the case depicted below, the long flexor sheath was intact, and marked intrafracture fibrosis required resection. The retracted proximal aspect was tethered after 8 months; therefore, moderate, blunt dissection of the soft tissue was required to mobilize it.

In this case, the fragments were temporarily held with bone-holding clamps and then fixed with headless screws (Acutrak, 14 mm, Mini). A substantial amount of soft tissue remained, and this was closed with polydioxanone (PDS-20; Ethicon) or a similar long-acting, absorbable suture. This process may be likened to the repair of a displaced, transverse midpatellar fracture with suture of the torn medial and lateral retinaculum. The instruments, especially the cannulated drill bit, must be sharp; if not, the result will be compromised, as shown in the postoperative radiograph below, indicating less-than-perfect reduction. Perfect reapproximation of the skin edges with 4-0 nylon minimizes the potential for a painful incision.

If the volar 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.

Postoperatively, the sutures are removed in 2 weeks, and the patient is advised to avoid dorsiflexion moments of the hallux for about 8 weeks. The site is protected in plaster with a toe extension. Once the cast is removed, further protection with a stiff sole shoe, with or without a rocker bottom, is needed for an additional 4-6 weeks.

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

Joint synovitis or osteochondral defect often requires debridement or cheilectomy.

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

Immediate postoperative care consists of external mobilization at 5-10° of plantar flexion for a minimum of 4 (preferably 6) weeks. This is followed by protective passive ROM under direct supervision of an athletic trainer or physical therapist. Active and passive dorsiflexion are avoided. When the patient is not participating in physical therapy, protection of the hallux MTP joint is imperative.^[12]

Non – weight-bearing ambulation is continued for 4 weeks in a removable posterior splint or fracture walker. Another possible option is a Darco Wedge shoe. This allows weight bearing on the hindfoot and simultaneous protection of the forefoot, as shown in the image below. ROM is gradually increased. After that time, protected ambulation is allowed in a cast boot. Active ROM begins at 2 months. The patient may wear an athletic shoe with a stiffened forefoot that limits MTP joint dorsiflexion.

After approximately 3-4 months, many patients are able to return to athletic activity. Equipment modification is essential. Patients should use 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.

It may be 6-12 months before preinjury level of function is achieved.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Sprains and Strains Center. Also, see eMedicine's patient education articles Broken Toe and Sprains and Strains.

Joint stiffness or persistent pain, especially with running, is the most common complication. Loss of push-off strength, hallux rigidus, traumatic bunion deformity, cock-up deformity, arthrofibrosis, and loose joint bodies also may occur.

In many cases, if adequate compliance is achieved, conservatively and surgically treated patients can return to their preinjury level of function. However, some disability is possible with either form of treatment.

At present, the incidence of persistent symptoms and late-onset sequelae requires further understanding. In the literature, the incidence of persistent symptoms is as high as 50% after 5 years.

Further insight into the usefulness of imaging methods such as MRI is necessary. Some surgeons believe that MRI allows for grading of the injury, the appreciation of findings not evident on physical examination or plain radiographs, and the development of a treatment plan. Above all, turf toe clearly represents a significant injury that deserves adequate recognition and treatment, especially in light of the complications that may occur when the condition is mismanaged.