Turf Toe Workup

  • Author: Blake Ohlson, MD; Chief Editor: Jason H Calhoun, MD, FACS   more...
 
Updated: Feb 17, 2012
 

Imaging Studies

Plain radiographs, including anteroposterior weight-bearing, lateral, and sesamoid axial views, are mandatory. Sesamoid impaction, avulsion, or diastasis may be observed on plain images. Contralateral views are highly recommended. These allow comparison of the sesamoid-to-joint distances on each side. The distal sesamoid-to-joint distance should be no greater than 3 mm (tibial) and 2.7 mm (fibular) when compared with those on the contralateral side. 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.

A forced dorsiflexion view also is recommended. Joint subluxation, sesamoid migration, separation of a bipartite sesamoid bone, or disruption of the medial or lateral capsuloligamentous complex, as shown in the image below, is better depicted on a forced dorsiflexion radiograph.

Typical method for obtaining a stress radiograph. Typical method for obtaining a stress radiograph.

The routine use of magnetic resonance imaging (MRI) is questionable. Currently, MRI is not recommended as part of the routine workup; however, some clinicians have begun using it to better define soft-tissue injury or osseous or articular damage. MRI may be particularly useful in the professional athlete who requires a high (ie, equal to preinjury) level of function.

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Other Tests

  • ROM testing is used to assess for instability, mechanical blockage, or hypermobility that may suggest tearing of the plantar plate.
  • Instability is assessed by performing a varus or valgus stress test and the dorsoplantar drawer test of the MTP joint. Positive findings with the former suggest collateral ligament damage, whereas positive results with the latter suggest a plantar capsuloligamentous tear.
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Contributor Information and Disclosures
Author

Blake Ohlson, MD  Staff Physician, Department of Orthopedic Surgery, Michigan State University, Kalamazoo Center for Medical Studies

Blake Ohlson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

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, and Texas Medical Association

Disclosure: AO North America Honoraria Speaking and teaching; Osteotech Consulting fee Consulting; Stryker Consulting fee Consulting; Biomet Consulting fee Consulting; AO North America Grant/research funds fellowship funding; MMI inc Honoraria Speaking and teaching

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

Disclosure: Medscape Salary Employment

Shepard R Hurwitz, MD  Executive Director, American Board of Orthopaedic Surgery

Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS  Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Patrick L. O'Connor, MD, to the development and writing of this article.

References

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  18. Athletic injuries to the soft tissues of the foot and ankle. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle. 7th ed. St Louis, Mo: Mosby-Year Book; 1999.

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  20. Watson TS, Anderson RB, Davis WH. Periarticular injuries to the hallux metatarsophalangeal joint in athletes. Foot Ankle Clin. Sep 2000;5(3):687-713. [Medline].

 
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Typical mechanism of turf toe injury. The foot is fixed on the ground in equinus position while an external force drives the metatarsophalangeal (MTP) joint into hyperextension.
Metatarsophalangeal (MTP) joint hyperextension with tearing of the plantar plate complex. Unrestricted motion of the proximal phalanx results in severe compression of the articular surface of the metatarsal head along with separation of the sesamoid components.
The capsuloligamentous-sesamoid complex of the hallux. Top, medial view. Bottom, plantar view.
Typical method for obtaining a stress radiograph.
Techniques for reconstructing a passively correctable claw-toe deformity.
Techniques for reconstructing a passively correctable claw-toe deformity.
Protection of the hallux metatarsophalangeal (MTP) joint is imperative after surgical intervention. The Darco Wedge shoe allows weight bearing on the hindfoot and simultaneous protection of the forefoot.
A 55-year-old man sustained this injury while attempting to prevent his large motorcycle from falling; he presented 8 months after the injury. Note the normal medial bipartite sesamoid bone on the opposite hallux.
Three months after surgery, the patient was pleased with the results despite less-than-perfect approximation.
Great toe dislocation. Video courtesy of Vinod K Panchbhavi, MD, FRCS, FACS.
Intraoperative steps. Video courtesy of Vinod K Panchbhavi, MD, FRCS, FACS.
Table. Classification Scheme for Tears of the Capsuloligamentous Complex
Grade Resultant Injury Associated Injury
1Stretch injury or minor tearing of the capsuloligamentous complex of the first MTP jointNone
2Partial tear of the capsuloligamentous complex of the first MTP joint without involvement of the articular surfaceNone
3Complete 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
HyperflexionHyperflexion injury to the hallux MTP joint with possible concomitant injury to lesser MTP jointsSprain or tearing of the dorsal capsule
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