How Do You Manage a Significant Turf Toe Injury?
Injuries to the hallux metatarsophalangeal (MTP) joint are not uncommon, particularly in the running athlete.1-7 One of the more common mechanisms of hallux injury is a hyperextension force on a foot fixed to the ground in equinus. The subsequent ligamentous injury has been termed turf toe.2 The incidence of this injury has been on the rise and is thought to be the result of shoe/cleat-surface interaction, especially among football players on artificial turf.6 The severity of this injury can range from a mild sprain to frank dorsal dislocation of the hallux. Assessing the location and extent of soft tissue damage as well as any associated bony abnormalities is the first step in determining treatment and expected outcome.
Clinical exam exhibits swelling and tenderness about the hallux MTP joint. Ecchymosis of the plantar surface is often present. The resting position of the hallux should be noted and compared to the contralateral, uninjured foot to determine any malalignment. Loss of active motion is a common finding in the acute phase, but it is important to test the function of both the flexor hallucis brevis (FHB) and the flexor hallucis longus (FHL) during physical exam. Stability of the hallux MTP joint is the most important finding on physical exam. The vertical Lachman test is performed by holding the first metatarsal fixed and translating the hallux dorsally to determine vertical stability. It is also important to check varus and valgus stability, as variants of this injury exist that disrupt the collateral ligaments, particularly the medial structures, which may predispose to the athlete to progressive hallux valgus.1,7
Radiographic exam provides the most important information in determining whether operative intervention is warranted. Weight-bearing anteroposterior and lateral views of the forefoot should be obtained; however, they often provide little information by themselves. Fractures of the sesamoid, capsular avulsions, or varus/valgus angulation of the hallux may be evident. Contralateral views are recommended to gauge proximal migration of the sesamoid complex, a sign of complete rupture of the plantar plate (Figure 33-1). Live fluoroscopic evaluation is indispensable in evaluating these injuries. Passive and active motion of the hallux can demonstrate plantar soft tissue disruption by a lack of sesamoid excursion. This is not only invaluable diagnostic information, but also provides the patient with education and an understanding of the injury pattern. Magnetic resonance imaging has also become a standard part of the evaluation of these injuries.8 It provides excellent anatomic detail of the soft tissue, osseous, and articular structures and helps to guide the treatment plan, as well as prognosis and return to play (Figure 33-2).
Figure 33-1. Weight-bearing AP foot x-rays demonstrate retraction of the sesamoid complex on the left, when compared to the normal right foot.
Figure 33-2. An MRI demonstrating disruption of the plantar plate with edema and proximal migration of the sesamoid. Note the remaining distal tissue used for surgical repair.
Initial treatment is similar to most other soft tissue injuries and consists of RICE (rest, ice, compression, elevation). Nonsteroidal anti-inflammatory medications are useful in this phase of healing. The foot may be immobilized in a walking boot or cast with a toe spica extension. Taping or bracing can be used to pull the hallux into slight plantarflexion and varus to bring the injured tissues into opposition. Gentle range of motion can often be started several days after injury. Most athletes with low-grade injuries can return to play with taping or a rigid turf toe orthotic, as symptoms allow. Significant turf toe injuries often take several months to fully recover from. It is important to take into account an athlete’s sport, position, and specific requirements when deciding on a treatment plan.
Operative treatment of turf toe injuries is seldom required. Indications for surgery include the failure of nonoperative treatment with persistent pain and the inability to push-off or progressive deformity. Surgical intervention in the acute setting may also be considered for the following situations:
1. A large capsular avulsion with unstable joint (especially medial)
2. Diastasis of bipartite sesamoid or sesamoid fracture
3. Retraction of sesamoids (single or both)
4. Traumatic bunion/progressive hallux valgus
5. Positive (+) vertical Lachman test
6. Loose body or chondral injury
Surgical approaches include a longitudinal plantar medial incision that may be extended along the plantar surface in the flexor crease at the MTP joint or separate medial and plantar incisions. It is our practice to use separate incisions because it allows better wound healing and improved visualization of the lateral FHB complex. It is important to identify and protect the plantar digital nerves during the approach. Always evaluate the FHL tendon for split tears. The goal of surgery is primary anatomic repair of the injured tissues. This proceeds from lateral to medial and often can be performed with nonabsorbable suture, as a cuff of tissue is typically present at the base of the proximal phalanx. If the distal soft tissues are inadequate, suture anchors or drill holes may be required to secure the repair to the phalanx.
If a medial injury exists and a traumatic bunion had developed, a “modified McBride” bunionectomy can be performed in conjunction with the soft tissue repair. This removes the valgus deforming force of the adductor hallucis tendon. If there is diastasis or fracture of a sesamoid, we prefer to excise the smaller pole and repair the remaining soft tissue defect. Internal fixation of a sesamoid fracture proves to be a humbling experience. If the entire sesamoid must be excised, transfer of the abductor hallucis tendon may be considered. This not only provides tissue to fill the defect, but also functions as a dynamic flexor of the joint. Late reconstruction of these injuries is more difficult and may require lengthening of tissues proximal to the sesamoids or an FHL recession transfer for cock-up deformity of the hallux.
Postoperative rehabilitation strikes a delicate balance between soft tissue healing and early mobilization. Initially the hallux should be wrapped into slight plantarflexion and varus and the leg immobilized in a splint. Gentle passive range of motion and active plantarflexion under supervision can begin 7 to 10 days after surgery. The patient should remain nonweight bearing in a removable splint or boot for 4 weeks. Removable bunion splints can be used to protect the repair, especially at night. At 4 weeks, weight bearing in a boot is allowed. Transition to normal shoe wear with an appropriate turf toe plate or orthotic is allowed at 8 weeks. High-level athletes can expect return to sport at 3 to 4 months but may not see full recovery for 6 to 12 months.
1. Anderson RB. Turf toe injuries of the hallux metatarsophalangeal joint. Tech Foot Ankle Surg. 2002;1(2):102-111.
2. Bowers KD Jr, Martin RB. Turf-toe: a shoe-surface related football injury. Med Sci Sports. 1976;8(2):81-83.
3. Clanton TO, Ford JJ. Turf toe injury. Clin Sports Med. 1994;13(4):731-741.
4. Clanton TO, Butler JE, Eggert A. Injuries to the metatarsophalangeal joints in athletes. Foot Ankle. 1986;7(3):162-176.
5. Coker TP, Arnold JA, Weber DL. Traumatic lesions of the metatarsophalangeal joint of the great toe in athletes. Am J Sports Med. 1978;6(6):326-334.
6. Rodeo SA, O’Brien S, Warren RF, et al. Turf-toe: an analysis of metatarsophalangeal joint sprains in professional football players. Am J Sports Med. 1990;18(3):280-285.
7. Watson TS, Anderson RB, Davis WH. Periarticular injuries to the hallux metatarsophalangeal joint in athletes. Foot Ankle Clin. 2000;5(3):687-713.
8. Tewes DP, Fischer DA, Fritts HM, et al. MRI findings of acute turf toe. A case report and review of anatomy. Clin Orthop Relat Res. 1994;304:200-203.