Turf Toe 

Updated: Jul 16, 2020
Author: Blake L Ohlson, MD; Chief Editor: Vinod K Panchbhavi, MD, FACS 

Overview

Practice Essentials

Although several variations exist, the classic definition of turf toe is a hyperdorsiflexion injury of the first metatarsophalangeal (MTP) joint.[1, 2]  Some have suggested that the concept could usefully be broadened to encompass a variety of traumatic lesions of the first MTP joint.[3] Since approximately the 1980s, turf toe has received increased attention in the media because of its effect on college-level and professional athletes.[4, 5, 6, 7, 8]

Turf toe injury is most commonly seen when an axial load is delivered to a foot that is fixed in equinus. The typical scenario, which often occurs in football linemen, involves the fixation of the forefoot on the ground in the dorsiflexed position with the heel raised. An outside force then pushes the foot into further dorsiflexion, resulting in traumatic hyperextension of the hallux MTP joint (see the image below). Although turf toe is most frequently seen in football players,[9] it can occur in athletes in any sport (eg, basketball, soccer, or rugby).

Typical mechanism of turf toe injury. Foot is fixe Typical mechanism of turf toe injury. Foot is fixed on ground in equinus position while external force drives metatarsophalangeal (MTP) joint into hyperextension.

Although turf toe was once thought to be a low-morbidity injury, significant disability can occur with damage to the periarticular structures of the MTP joint complex. Such damage often is accompanied by long- and short-term sequelae. As many as 50% of individuals with turf toe injuries have persistent symptoms after 5 years. In the short term, running and pushing off are compromised, and players frequently miss games and practices. Possible long-term sequelae include hallux rigidus, hallux valgus, hallux cock-up deformity, and failure to regain pushoff strength.

Turf toe injury is classically defined as damage resulting from hyperextension of the first MTP joint. However several variations can occur that account for damage to specific anatomic structures in the capsuloligamentous-sesamoid complex. These include hyperplantarflexion injuries ("sand toe"), as well as valgus- and varus-type injuries. Because each mechanism affects different structures, an accurate history is crucial to understanding nonoperative and operative treatment modalities.[10]

Brophy et al found that in professional football players with a history of turf toe, first MTP dorsiflexion was significantly lower in halluces with a turf-toe history (40.6 ± 15.1º vs 48.4 ± 12.8º), and peak hallucal pressures were higher.[11]

Before the advent of artificial playing surfaces in the late 1960s, sprains to the hallux MTP joint were relatively uncommon. As artificial turf became popular in sports such as football, the incidence of MTP joint injuries appeared to increase. During a roundtable discussion in 1975 regarding the benefits and drawbacks of artificial turf, Garrick first suggested the relationship between first MTP joint sprains and the use of synthetic playing surfaces.[12]  One year later, Bowers and Martin introduced the term turf toe to describe a plantar capsuloligamentous sprain of the first MTP joint related to two predisposing factors: hard artificial surfaces and soft-soled shoes.[13]

The earliest synthetic surfaces contained a synthetic nylon ribbon that wore away over time. Beneath that was a foam underpad that quickly became packed down, leaving a virtual asphalt-carpet interface. As a consequence, the effect of surface hardness was originally thought to be responsible for turf toe injury.

After the development of artificial turf, many players complained of poor traction with traditional shoes designed for use on grass surfaces. Despite lower rates of injuries, the demand for increased speed and traction in sports (eg, football) led to the development of a more flexible shoe. A softer, soccer-style shoe replaced the traditional multicleated shoe containing a steel plate in the forefoot that was designed for grass surfaces. This shoe allowed a greater degree of motion in the MTP joints and placed significantly more stress across the forefoot.

In 1978, a major study from the University of Arkansas by Coker et al cited turf toe as a major cause of missed games and practices.[14]  However, it was not until 1986 that Clanton et al developed a classification scheme for describing the degree of severity for turf toe injury.[15]  With some minor revisions since its original publication, this system continues to help in guiding treatment, as well as in predicting return to play.

Most MTP joint injuries can be managed nonsurgically; however, when the injury is refractory to conservative treatment, surgery should be considered as an option. It should be noted that the need for surgical management is relatively uncommon. 

See Football Injuries: Slideshow, a Critical Images slideshow, to help diagnose and treat injuries from a football game that can result in minor to severe complications.

For patient education resources, see the First Aid and Injuries Center, as well as Broken Toe and Sprains and Strains.

Anatomy

To understand how turf toe injury occurs, a thorough understanding of all anatomic structures in and around the MTP joint is critical. Unlike a simple hinged joint, the hallux MTP joint functions more like a hammock or an acetabulum. It contains multiple centers of motion, including sliding, rolling, and compression.

As in the glenoid cavity of the shoulder, the shallowness of the articular surface of the proximal phalanx provides little stability to the joint. The capsuloligamentous-sesamoid complex contributes most of the stability observed in the MTP joint. This complex is made up of collateral ligaments, along with the plantar plate, flexor hallucis brevis, adductor hallucis, and abductor hallucis (see the image below).

Capsuloligamentous-sesamoid complex of hallux. Top Capsuloligamentous-sesamoid complex of hallux. Top, medial view; bottom, plantar view.

The medial and lateral collateral ligaments are composed of an MTP and a metatarsosesamoid ligament. They originate on either side of the metatarsal head and fan out distally to attach to the proximal phalanx.

The plantar plate is a strong, fibrous structure that is firmly attached to the proximal phalanx and is loosely attached to the metatarsal neck through the joint capsule. It blends with the sesamoids and tendons of the flexor hallucis brevis to provide structural support.

The sesamoid bones play a crucial role in providing stability to the MTP joint complex and in enhancing the tendon moment arm of the flexor hallucis brevis.

The flexor hallucis brevis originates on the cuboid and lateral cuneiforms before splitting into medial and lateral heads that extend beneath the first metatarsal bone. Tendon fibers envelop the sesamoid bones just proximal to an insertion point at the base of the proximal phalanx. The flexor hallucis brevis plays an integral role in providing push-off strength for the hallux.

The abductor and adductor hallucis tendons contribute additional stability through their insertions on the medial and lateral plantar portions, respectively, of the capsuloligamentous complex.

Proper function of the MTP joint is essential to normal foot biomechanics. The great toe typically bears twice the load of the lesser toes, and during normal gait, it withstands 40-60% of the body weight. This load increases several fold with running or jumping, and it may approach nearly 8 times an individual's body weight with a running jump.

The normal MTP joint is in approximately 16º of dorsiflexion relative to the longitudinal axis of the first metatarsal, and it has a passive arc of motion in the range of 3-43º plantarflexion and 40-100º dorsiflexion. During normal gait, this angle is 60º on average, but it may decrease to 25-30º dorsiflexion in a stiff-soled shoe without affecting gait.

In high-performance activities, such as professional and college-level sports, the drive has been to produce lighter, softer-soled shoes that provide increased MTP joint motion. An increase in speed and flexibility occurs at the expense of stability, with greater stresses across the forefoot.

Pathophysiology

The normal MTP joint functions with a smooth gliding motion except during full dorsiflexion, when some compression occurs. Tears of the joint capsule occur at the metatarsal neck rather than at the proximal phalanx because the metatarsal neck is its weakest point of attachment.

Once the capsure is torn, unrestricted motion of the proximal phalanx results in severe compression of the dorsal articular surface of the metatarsal head. This produces the potential for fracture or possibly even for dislocation (see the video below). Usually, the plantar portion of the ligamentous complex tears, and the plantar plate becomes detached distal to the sesamoids. Rarely, fracture of the sesamoid bone may occur (see the image below).

Great toe dislocation. Video courtesy of Vinod K Panchbhavi, MD, FRCS, FACS.
Metatarsophalangeal (MTP) joint hyperextension wit 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.

Other mechanisms of turf toe injury include valgus and varus injuries, as well as hyperflexion-related damage. Valgus injury is a variant of the dorsiflexion-type injury in which the medial ligamentous structures and, in some cases, the medial sesamoid bone are damaged. This most often occurs in the setting of pushoff, when internal rotation occurs on a fixed forefoot. Untreated, this may lead to bunion formation and contractures on the lateral side of the joint.

More rarely still, a varus injury may result from external rotation on a fixed forefoot. Patients may present with varus instability resulting from a torn lateral capsule as well as from rupture of the adductor hallucis tendon from the base of the proximal phalanx.

Hyperflexion occurs when the MTP joint is forced into exaggerated plantarflexion. This injury has been referred to as sand toe, in that it often occurs in beach volleyball players. The injury has also been known to occur in football players and dancers. A plantar foot with the MTP joints driven into exaggerated hyperflexion can result in tearing of the dorsal capsule. The anatomic structures that are damaged and the injury treatment required are different from those of classic turf toe and should be recognized as such.

Etiology

Bowers and Martin coined the term turf toe to acknowledge the predisposing factor of artificial synthetic surfaces on hallux MTP joint sprains.[13] They found that injuries occurred most frequently in athletes playing on artificial turf who wore flexible, soccer-style shoes.

Data collected from The National Collegiate Athletic Association (NCAA) Injury Surveillance System has been useful in identifying key susceptibility factors. Injuries seem more likely to occur in games as opposed to practices and with artificial as opposed to natural grass. Furthermore, a greater percentage of injuries appear to occur in running backs and quarterbacks. More detail regarding causative factors is located below.[16]

Footwear

Throughout the past several decades, football shoes have evolved from the traditional seven-cleat shoe containing a metal plate in the sole designed for grass surfaces to a more flexible, soccer-style shoe designed for grass surfaces and, finally, to a shoe designed for artificial turf. These changes in shoe type have allowed increased speed at the expense of stability. The absence of a stiff sole places the forefoot, and specifically the MTP joints, at much greater risk of sustaining stress-type injuries. Athletes wearing flexible turf shoes are much more prone to injury than are those wearing shoes containing a stiff forefoot.

Synthetic surfaces

Artificial grass contains a higher coefficient of friction and tends to lose some of its resiliency and shock absorbency over time. The combination of increased surface friction and a hard undersurface is believed to play a major role in the natural history of the injury. A higher coefficient of friction places the forefoot at greater risk of becoming fixed to the playing surface. Thus, the forefoot becomes more prone to an external force that places the hallux MTP joint in a position of extreme dorsiflexion.

Ankle range of motion

The risk of turf toe appears to be related to the range of motion (ROM) in the ankle of the injured person. A greater degree of ankle dorsiflexion has been correlated with the risk of hyperextension to the first MTP joint.

Miscellaneous

Other factors have been postulated to play a role in turf toe. These include a player's position, weight, and years of participation, as well as hallux interphalangeal degenerative joint disease, pes planus, and prior injury. For the most part, study results regarding these factors are largely inconclusive. Another point worth mentioning, however, is that a number of groups have, after researching the question, found no correlation between MTP joint ROM and the associated risk of turf toe.

Epidemiology

The actual incidence of turf toe has never clearly been defined. In certain sports, such as football and rugby, a predisposition to turf toe injury is higher than it is in other sports. A retrospective 5-year analysis of NCAA football players showed an overall incidence of 0.062 per 1000. This value may actually be higher in elite professional players. Division I athletes encountered nearly twice the number of turf toe injuries as compared with lower-division athletes.[16]

Turf toe ranks as the third most common injury (after knee and ankle traumas) causing loss of playing time among university athletes.[17] Although ankle injuries are up to four times as common as turf toe, the latter may account for a significantly greater proportion of missed playing time.

Prognosis

In many cases, if adequate compliance is achieved, conservatively and surgically treated patients can return to their preinjury level of function.[9, 18] Studies have shown good results with operative repair in professional athletes.[19, 20] However, some disability is possible with either form of treatment.

Pinter et al assessed outcomes in 12 nonathlete patients who underwent operative repair of chronic turf toe injury.[18]  On initial clinical presentation, all 12 had local tenderness with associated painful ROM; four had restricted ROM; all 12 had a positive Lachman test; two had local edema; and eight had hallux valgus deformity. With treatment, mean Visual Analogue Scale (VAS) scores improved from 4.6 (range, 2-9) to 1 (range, 0-4), and mean Foot Function Index (FFI) scores improved from 102.5 (range, 56-177) to 61.75 (range, 23-144). At final follow-up, all patients had a negative Lachman test. None of the patients developed major complications or required revision surgery.

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.

Although acutely based injuries to the plantar plate and surrounding structures are better defined today, less information is available regarding the management of chronic or late diagnosed injuries.

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.

 

Presentation

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:

  • Grade 1 injury - Localized tenderness with minimal swelling and no ecchymosis
  • Grade 2 injury - More widespread tenderness with mild-to-moderate swelling and ecchymosis
  • 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

 

Workup

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.[22, 23] 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 multipartite sesamoid of the hallux exceeds 2 mm on a routine AP radiograph.[24]  

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)[25, 26, 27] 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.

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.

 

Treatment

Approach Considerations

To date, no evidence-based treatment guideline has been developed for turf toe.[28] 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 [24]
  • 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.

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 (ROM) 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.

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.[28] 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.[16, 19]

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.

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.[29]

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.

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.

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.