A metatarsophalangeal joint sprain is an injury to the connective tissue between the foot and one of the toes. When the big toe is involved, it is known as “turf toe”.
Turf toe is not a term you want to use when talking to a head football coach about his star running back or the ballerina before her diva debut. “Turf toe” is the common term used to describe a sprain of the ligaments around the big toe joint. Although it’s commonly associated with football players who play on artificial turf, it affects athletes in other sports including soccer, basketball, wrestling, gymnastics, and dance. It’s a condition that’s caused by jamming the big toe or repeatedly pushing off the big toe forcefully as in running and jumping.
Bowers and Martin coined the term turf toe to acknowledge the predisposing factor of artificial synthetic surfaces on hallux metatarsophalangeal (MTP) joint sprains. They found that injuries occurred most frequently in athletes playing on artificial turf who wore flexible, soccer-style shoes. More recently data collected from The National Collegiate Athletic Association 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.
- Footwear – Throughout the past several decades, football shoes have evolved from the traditional 7-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 (ROM) – The risk of turf toe appears to be related to the range of ankle motion in 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.
Medical History and Physical Examination
During your appointment, your doctor will talk to you about your general health and your toe symptoms, and ask you to describe how you injured your toe.
During the physical examination of your foot, your doctor will check for swelling, bruising, and the range of motion of your MTP joint. Your doctor will bend your toe up, move it up and down, and side to side, looking for instability that might suggest a tear in the plantar complex. He or she may also perform the same range of motion tests on your healthy toe as a comparison.
Examining the range of motion in your toe may be painful. If needed, your doctor may inject the area with a numbing medicine prior to the range-of-motion tests.
Other tests that your doctor may order to help confirm your diagnosis include:
- X-rays. This imaging test creates clear pictures of dense structures, like bone. Although the plantar complex is made up of different soft tissues, your doctor may order x-rays to make sure there are no other problems in your toe. These may include small bony pull-off fractures where the plantar complex attaches to the bones, and fractures or movement of the two small sesamoid bones.
- Magnetic resonance imaging (MRI) scan. These studies can create better images of soft tissue and can show soft tissue and cartilage injuries. An MRI scan may be useful in Grade 2 and 3 injuries or when abnormalities are noted on the x-rays.
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 50-60º of passive dorsiflexion is possible without pain.
As a reference, NCAA football participants have shown and average of 10.1 days before returning to competitive play.
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. It should be noted that the need for surgical management is relatively uncommon. Recent analysis of players in the NCAA indicate less than 2% of injuries ultimately require surgical treatment. This value may be higher however in elite pro athletes.
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.
Injuries resulting in sesamoid fracture or diastasis of a bipartite sesamoid are managed based upon the pattern of injury. Options include resection of the smaller fragment versus 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 to reinstate stability to the joint.
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 avoiding weight bearing and suture removal until the incision is completely can help minimize the risk of painful scar formation. Us of a thigh or ankle tourniquet is acceptable. However, the tourniquet should be let down prior to 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 scarformation. Anesthesia may be accomplished with a general anesthetic or 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, 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.
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 5-10 degrees plantarflexion. Patients remain non weight bearing for 4-6 weeks, followed by transition to a cam walker boot. Physical therapy can be instituted at this time with gentle active dorsiflexion and protected passive ROM. 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 months to a year to fully approximate pre-injury level of function.
The turf toe injury often occurs as a result or combination of fatigue, muscle imbalance, or stress on a body part at an inopportune moment. Appropriate workloads for the stage of training also help prevent injuries. Injury can be prevented through proper preparation for sports participation.
A combination of flexibility, strength, fitness, and dynamic stability may help to prevent injury to the big toe. Appropriate muscle strengthening, cardiovascular conditioning, flexibility, balance, core strength, and posture are major factors in both prevention and prevention of reinjury. Flexibility or range of motion of the toe joints may be indicators of injury. Flexibility is determined by the amount the toe can be flexed actively and passively. Greater flexibility of the foot and ankle lessen the chance of injury. There is no particular exercise or stretch that will prevent the injury.
Strength also plays a role. The stronger the body the less susceptible to injury it becomes. One of the keys is that both the muscle that moves the body part through that range of motion and the opposing muscle must also be strong. A decreased range of motion may predispose the joint to injury. Meanwhile, hydration keeps the tissue supple and the muscle working correctly. Unfortunately, there is no magic cure for prevention of turf toe besides developing the components needed for safe participation in sport.
The basic guideline to prevent injuries is to determine if one is in good health by having a physical exam to evaluate cardiovascular function and the possibility of disease or any other general medical problems. Before beginning activities, diseases such as gout, diabetes, certain types of arthritis, and neuropathies should be treated. Shoes and socks appropriate to one’s activity will also be a deterrent to injury, as proper fitting footwear can help minimize the effect of bad biomechanics.
Turf toe is a metatarsalphalangeal joint sprain that affects the big toe. It is an injury to the joint and to the connective tissue between that toe and the foot. This occurs when the toe is bent backwards from the foot and commonly takes place on artificial turf or hard surfaces. It might also occur when something falls on the person’s calf when the toes and knee are touching the ground and the calf is parallel to the floor or playing surface. Other causes include jamming the big toe into the foot, or repeatedly pushing or jumping off from the toes. Football players, soccer players and dancers are especially prone to turf toe.
Turf toe injury should be treated with rest, ice, compression, and elevation. The most important treatment for turf toe, especially directly after the injury, is rest. Athletes who return to sports too soon after a metatarsalphalangeal joint sprain risk making that injury worse, which will lengthen recovery time and may lead to chronic pain or lameness. For first-time or minor sprains, running and jumping on hard surfaces should be limited for up to one month, and more severe injuries should be rested for up to three months.
Toe Pick-up Exercises
Toe pick-up exercises build strength, flexibility and dexterity. Put several marbles and a bowl on the floor by your bare feet. Use your toes to pick up each marble individually and drop it into the bowl. Continue until all the marbles are in the bowl, then repeat.
Towel scrunches help with flexibility, strength, and dexterity. Sit on a chair and place a towel on the floor by your feet. Grip the towel using your toes. Raise your feet off the floor and hold onto the towel. Hold your feet in the air for up to 10 seconds, then release the towel. Repeat five to seven times.
Short foot exercises help get you back into pre-injury shape. Sit on a chair with your feet flat in front of you on the floor. Keeping your toes flat, lift the arch of your foot up without rolling your foot to the outside. Hold this position for five seconds, then release and repeat until the foot is fatigued.
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.
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. 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.