History
Taking a detailed history is the first step in the treatment of all turf toe injuries. The clinician should determine the specific series of events leading to the injury.
Physical Examination
Physical examination then follows, with attention to the presence and location of pain, swelling, and ecchymosis. [21] The examination may be difficult in the acute stages because of pain; however, all structures, including the collateral ligaments, sesamoids, plantar plate, and dorsal capsule, should be palpated.
Range-of-motion (ROM) testing should be performed by carefully looking for instability, mechanical block, or hypermobility that may suggest tearing of the plantar plate. Instability is assessed by performing the varus or valgus stress test and the dorsoplantar drawer test of the metatarsophalangeal (MTP) joint.
A positive result with the former test suggests collateral ligament damage, whereas a positive finding with the latter suggests a plantar capsuloligamentous tear. Incidentally, the dorsoplantar test is performed with the MTP joint in 30º of dorsiflexion. Finally, examination of all structures is aided by comparison to the contralateral side.
Classification
Injuries are graded as follows:
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Grade 1 injury - Localized tenderness with minimal swelling and no ecchymosis
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Grade 2 injury - More widespread tenderness with mild-to-moderate swelling and ecchymosis
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Grade 3 injury - Severe and diffuse tenderness and swelling, moderate to severe ecchymosis, and painful ROM
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.
Table 1 below shows the classification scheme for tears of the capsuloligamentous complex, including for hyperflexion and dorsiflexion injuries.
Table 1. Classification Scheme for Tears of Capsuloligamentous Complex (Open Table in a new window)
Grade |
Resultant Injury |
Associated Injury |
1 |
Stretch injury or minor tearing of capsuloligamentous complex of first MTP joint |
None |
2 |
Partial tear of capsuloligamentous complex of first MTP joint without involvement of articular surface |
None |
3 |
Complete tear of capsuloligamentous complex; tearing of plantar plate from its origin on metatarsal head/neck with dorsal impaction of proximal phalanx into metatarsal head |
Articular cartilage/subchondral bone bruise, sesamoid fracture, diastasis of sesamoids, medial/lateral injury |
Hyperflexion |
Hyperflexion injury to hallux MTP joint with possible concomitant injury to lesser MTP joints |
Sprain or tearing of dorsal capsule |
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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.
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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.
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Capsuloligamentous-sesamoid complex of hallux. Top, medial view; bottom, plantar view.
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Typical method for obtaining stress radiograph.
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Techniques for reconstructing passively correctable claw-toe deformity.
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Techniques for reconstructing passively correctable claw-toe deformity.
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Protection of hallux metatarsophalangeal (MTP) joint is imperative after surgical intervention. Darco Wedge shoe allows weightbearing on hindfoot and simultaneous protection of forefoot.
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Great toe dislocation. Video courtesy of Vinod K Panchbhavi, MD, FRCS, FACS.
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Intraoperative steps. Video courtesy of Vinod K Panchbhavi, MD, FRCS, FACS.
Tables
Grade |
Resultant Injury |
Associated Injury |
1 |
Stretch injury or minor tearing of capsuloligamentous complex of first MTP joint |
None |
2 |
Partial tear of capsuloligamentous complex of first MTP joint without involvement of articular surface |
None |
3 |
Complete tear of capsuloligamentous complex; tearing of plantar plate from its origin on metatarsal head/neck with dorsal impaction of proximal phalanx into metatarsal head |
Articular cartilage/subchondral bone bruise, sesamoid fracture, diastasis of sesamoids, medial/lateral injury |
Hyperflexion |
Hyperflexion injury to hallux MTP joint with possible concomitant injury to lesser MTP joints |
Sprain or tearing of dorsal capsule |
