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Orthopaedics
Sports Medicine
General Practice

Turf Toe

High EvidenceUpdated: 2025-12-26

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Red Flags

  • Sesamoid Retraction -> Surgical Indication (Grade 3)
  • Loose Fragments -> Intra-articular block
  • Hallux Valgus -> Chronic collateral insufficiency
  • Persistent Pain >3 months -> Missed diagnosis
Overview

Turf Toe

1. Clinical Overview

Summary

Turf Toe is a sprain of the Plantar Plate complex of the 1st Metatarsophalangeal (MTP) joint, typically caused by a forced hyperextension injury (e.g., foot planted on artificial turf). The Plantar Plate is a thick fibrocartilaginous structure that reinforces the joint capsule and anchors the sesamoids. Injuries range from simple stretch (Grade 1) to complete rupture with sesamoid retraction (Grade 3). While often dismissed as "just a toe sprain", significant injuries can end an athlete's career due to chronic pain and loss of push-off power. [1,2,3]

Key Facts

  • The Anatomy: The "Plantar Complex" consists of:
    1. Plantar Plate: The core stabilizer.
    2. Sesamoids (Medial/Lateral): Embedded in the FHB tendons.
    3. Collateral Ligaments.
    4. Flexor Hallucis Brevis (FHB).
  • The Mechanism: Axial load applied to the heel while the toe is fixed in dorsiflexion (e.g., a lineman pushing off). The plantar structures fail under tension.
  • Sequelae: The most common long-term complication is Hallux Rigidus (stiff big toe) due to cartilage damage and scarring.

Clinical Pearls

"The Vertical Lachman": Stabilize the metatarsal. Grasp the proximal phalanx. Attempt to translate the phalanx dorsally (up). If it subluxes relative to the metatarsal, the plantar plate is torn.

"Sesamoid Migration": Check the AP X-ray. If one or both sesamoids have migrated proximally (towards the heel), the plantar plate is completely ruptured. The sesamoid should normally be under the metatarsal head.

"Taping is Treatment": For Grade 1/2 injuries, the mainstay of treatment is taping the toe into slight plantarflexion to prevent the painful hyperextension that re-injures the healing tissue.

2. Epidemiology

Demographics

  • Incidence: Common in American Football, Rugby, Soccer.
  • Risk Factors:
    • Artificial Turf: Harder surface + flexible shoes = higher torque.
    • Flexible Footwear: Lack of a rigid shank allows excessive forefoot bending.
3. Pathophysiology

Anatomy

  • Plantar Plate: A thick, rectangular fibrocartilage structure.
    • Origin: Metatarsal neck (weak).
    • Insertion: Proximal Phalanx base (strong).
    • Function: Resists hyperextension. Compressive load bearing.
  • Sesamoids: Increase the mechanical advantage of the FHB by 50%.
  • Intersesamoid Ligament: Connects the two sesamoids.

Classification (Anderson)

  1. Grade 1 (Stretch):
    • Attenuated plantar structures.
    • Localized tenderness.
    • No instability.
  2. Grade 2 (Partial Tear):
    • Partial rupture of plantar plate.
    • Diffuse tenderness / Ecchymosis.
    • Mild painful instability.
  3. Grade 3 (Complete Tear):
    • Complete disruption (Plate/Capsule/FHB).
    • Severe swelling.
    • Sesamoid retraction visible on X-ray.
    • Frank instability (Vertical Lachman +ve).
4. Clinical Presentation

Symptoms

Signs

Pain at the base of the big toe.
Common presentation.
Swelling.
Common presentation.
"My toe bent backwards".
Common presentation.
Inability to push off (run).
Common presentation.
5. Investigations

Imaging

  • X-Ray (Weight Bearing):
    • AP: Check sesamoid position (Proximal migration?).
    • Lateral: Possible loose bodies or avulsion fragments from the base of the phalanx.
  • MRI (Gold Standard):
    • Essential for grading the injury.
    • Visualizes the plantar plate disruption (signal intensity).
    • Assesses cartilage damage (Bone bruise).
6. Management Algorithm
                     TURF TOE
                        ↓
             IS IT STABLE? (Lachman)
            ┌───────────┴───────────┐
           YES                     NO
      (Grade 1/2)             (Grade 3)
           ↓                      ↓
     CONSERVATIVE          SESAMOID RETRACTED?
    (Rest, Tape)           ┌──────┴──────┐
                          NO            YES
                          ↓              ↓
                     CONSERVATIVE     SURGERY
                  (Boot/Cast 4-6w)    (Repair)
7. Management: Conservative

Indications

  • Grade 1 and 2 injuries.
  • Grade 3 injuries without sesamoid retraction or gross instability.

Protocol

  • Acute Phase (0-72h): RICE. Crutches.
  • Grade 1:
    • Taping (Limit dorsiflexion).
    • Stiff-soled shoe / Carbon fiber insert.
    • Return to sport as tolerated (1-3 weeks).
  • Grade 2:
    • Walking Boot for 2 weeks to allow scar formation.
    • Then stiff shoe + taping.
    • Return to sport 3-6 weeks.
  • Grade 3:
    • Cast or Boot (Immobilization) in slight plantarflexion for 4-6 weeks.
    • Rehab starts at 6 weeks.
    • Return to sport 8-12 weeks (often longer).
8. Management: Surgical

Indications

  • Large Capsular Avulsion with unstable joint.
  • Sesamoid Retraction (Proximal migration).
  • Traumatic Bunion (Hallux Valgus development).
  • Loose Bodies blocking motion.
  • Failed Conservative: Persistent pain >6 months.

Technique

  • Approach: Plantar or Medial.
  • Repair: Direct suture repair of the plantar plate back to the proximal phalanx (using suture anchors or drill holes).
  • FHB Repair: If the tendon is avulsed.
  • Sesamoidectomy: Rare (only if fractured/necrotic).

Post-Op

  • Cast (Toe plantarflexed) for 4 weeks.
  • No running for 3-4 months.
9. Complications

Hallmark: Hallux Rigidus

  • Stiffness is the most common complication.
  • Scarring of the plantar plate restricts dorsiflexion.
  • Prevention: Early passive range of motion once healing is secure.
  • Treatment: Cheilectomy (removing dorsal bone spurs) or Fusion if severe.

Others

  • Cock-Up Deformity: If the plantar plate remains incompetent, the toe curls up due to unopposed extension.
  • Chronic Pain: From sesamoiditis.
10. Evidence & Guidelines

Carbon Fiber Inserts

  • Study: Proven to reduce dorsiflexion at the MTP joint and protect the repair during return to play. Standard of care for NFL players.

Return to Play

  • Waldrop et al: In NFL players, Grade 3 injuries resulted in missed playing time averaging 16 weeks. 50% of players with Grade 3 injuries never returned to their previous level of performance.
11. Patient Explanation

The Injury

You have severely sprained the "hammock" of ligaments under your big toe. This hammock supports your weight every time you push off to run.

Why does it hurt?

Because you bent the toe back further than it was designed to go, tearing the thick tissue underneath.

The Recovery

This is notoriously slow. You cannot rush it. If you run on it before it scars down, you will stretch it out again, leading to a chronically loose and painful toe.

  • Grade 1: A few weeks.
  • Grade 3: A few months.

Future

Your toe will likely be stiffer than the other side. You may need to wear stiff insoles in your sports shoes permanently.

12. References
  1. Bowers KD Jr, Martin RB. Turf-toe: a shoe-surface related football injury. Med Sci Sports. 1976.
  2. Anderson RB, et al. Turf toe injuries of the hallux metatarsophalangeal joint. Foot Ankle Int. 2002.
  3. Waldrop NE 3rd, et al. Turf toe injuries. Clin Sports Med. 2020.
13. Examination Focus (Viva Vault)

Q1: What is the "Vertical Lachman" test for the MTP joint? A: A test for Plantar Plate integrity. The examiner stabilizes the metatarsal and translates the proximal phalanx dorsally. laxity or subluxation compared to the contralateral side indicates a rupture.

Q2: Describe the vascular supply to the Medial Sesamoid. A: It is supplied by the medial plantar artery. It is more prone to AVN than the lateral sesamoid.

Q3: How does a "Turf Toe" differ from "Sesamoiditis"? A:

  • Turf Toe: Acute traumatic hyperextension sprain of the plantar plate/capsule.
  • Sesamoiditis: Chronic overuse inflammation of the sesamoid bones (often chondromalacia), usually without acute trauma.

Q4: What is the Anderson Classification Grade 3? A: Complete tear of the plantar plate and capsule. Often associated with sesamoid retraction and frank instability.

(End of Topic)

Last updated: 2025-12-26

At a Glance

EvidenceHigh
Last Updated2025-12-26

Red Flags

  • Sesamoid Retraction -> Surgical Indication (Grade 3)
  • Loose Fragments -> Intra-articular block
  • Hallux Valgus -> Chronic collateral insufficiency
  • Persistent Pain >3 months -> Missed diagnosis

Clinical Pearls

  • **"The Vertical Lachman"**: Stabilize the metatarsal. Grasp the proximal phalanx. Attempt to translate the phalanx dorsally (up). If it subluxes relative to the metatarsal, the plantar plate is torn.
  • **"Taping is Treatment"**: For Grade 1/2 injuries, the mainstay of treatment is taping the toe into slight plantarflexion to prevent the painful hyperextension that re-injures the healing tissue.

Guidelines

  • NICE Guidelines
  • BTS Guidelines
  • RCUK Guidelines