What is the management of a turf toe injury?

Management of Turf Toe Injury

The management of turf toe injury should follow a graded approach based on severity, with initial treatment focusing on RICE protocol (rest, ice, compression, elevation), followed by appropriate immobilization and rehabilitation to prevent long-term complications.

Diagnosis

MRI is the preferred imaging method for evaluating suspected turf toe injuries by directly assessing the capsuloligamentous complex and any associated chondral or osteochondral lesions 1.

Key diagnostic findings include:

• Pain and tenderness at the first metatarsophalangeal (MTP) joint
• Swelling around the joint
• Limited range of motion
• Pain with passive dorsiflexion of the great toe

Classification and Treatment Algorithm

Grade I (Mild Sprain)

• Stretching of the plantar plate without tear
• Treatment:
  • RICE protocol for 24-48 hours
  • Taping of the toe in slight plantar flexion
  • Stiff-soled shoes or steel plate inserts
  • Limited weight-bearing as tolerated
  • Return to activity in 1-2 weeks

Grade II (Moderate Sprain)

• Partial tear of the plantar plate
• Treatment:
  • RICE protocol
  • Immobilization with stiff-soled shoe or walking boot for 2-3 weeks
  • Taping in plantar flexion
  • Progressive weight-bearing
  • Consider kinesiology taping alongside exercise program 2
  • Return to activity in 2-4 weeks

Grade III (Severe Sprain)

• Complete rupture of the plantar plate with possible sesamoid displacement
• Treatment:
  • Immobilization with non-weight bearing cast for 2-4 weeks
  • Transition to walking boot for additional 2-4 weeks
  • Surgical intervention if:
    • Diastasis or retraction of sesamoids
    • Vertical instability
    • Traumatic hallux valgus deformity
    • Chondral injury or loose body
    • Failed conservative treatment 3
  • Return to activity in 8-16 weeks

Rehabilitation Protocol

1. Acute Phase (0-2 weeks):

   • RICE protocol
   • Non-weight bearing or protected weight bearing
   • Gentle range of motion exercises if tolerated

2. Subacute Phase (2-6 weeks):

   • Progressive weight bearing
   • Toe flexor strengthening exercises
   • Joint mobilization
   • Proprioceptive training

3. Return to Activity Phase (6+ weeks):

   • Sport-specific exercises
   • Gradual return to previous activity level
   • Protective taping or bracing during sports

Prevention Strategies

• Use of appropriate footwear with adequate stiffness in the forefoot
• Avoid excessively flexible shoes, especially on artificial turf
• Consider orthotic devices for athletes with previous injury
• Taping the toe before athletic activity for those with history of turf toe

Important Considerations

1. Footwear Modification: Shoes should be firm, comfortable, with appropriate length and width, rounded toe, and flexibility 1. Consider shoes with steel-plate insertions to prevent hyperextension of the first MTP joint 4.

2. Complications: Without proper management, turf toe can lead to:

   • Chronic instability
   • Hallux rigidus (restricted dorsiflexion)
   • Degenerative joint changes
   • Recurrent sprains 5

3. Return to Sport: Athletes should demonstrate full pain-free range of motion and adequate strength before returning to competition. A gradual return with protective taping is recommended.

4. Surgical Indications: Unstable injuries require surgical intervention and plantar-plate repair 4. This includes cases with sesamoid retraction or diastasis, significant joint instability, or failure of conservative management.

Common Pitfalls

1. Misdiagnosis: Turf toe is often misdiagnosed as a simple sprain. Thorough evaluation including MRI is crucial for severe cases.

2. Premature Return: Returning to activity too soon can lead to chronic problems and prolonged recovery.

3. Inadequate Immobilization: Failure to properly immobilize the joint in more severe cases can lead to persistent instability.

4. Overlooking Rehabilitation: Comprehensive rehabilitation is essential for restoring normal joint mechanics and preventing recurrence.