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Turf Toe Workup

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

Imaging Studies

Plain radiographs, including weightbearing anteroposterior (AP), lateral, and sesamoid axial views, are mandatory. Sesamoid impaction, avulsion, or diastasis may be observed on plain images.[14] Favinger et al, in a review of 671 foot radiograph series, concluded that in the appropriate clinical setting, sesamoid diastasis should be considered when the sesamoid interval in the bi- or multipartitie sesamoid of the hallux exceeds 2 mm on a routine AP radiograph.[15]  

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 dorsiflexion stress view may provide additional clues in characterizing the injury. 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 dorsiflexion stress radiograph.

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

Magnetic resonance imaging (MRI) is most often indicated in grade 2 and 3 injuries. T2-weighted sequences in particular can be of use in identifying soft-tissue injuries (eg, plantar plate disruption), as well as disruption of the articular surface.

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Other Tests

Range-of-motion (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 metatarsophalangeal (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 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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