Turf Toe: Diagnosis and Treatment
Turf toe is a sprain of the first metatarsophalangeal (MTP) joint complex, involving injury to the capsuloligamentous structures around the great toe, particularly the plantar plate. 1
Anatomy and Mechanism of Injury
Turf toe involves damage to the soft tissue structures of the capsuloligamentous complex of the first MTP joint, which may include:
- Plantar plate (primary structure affected)
- Sesamoid apparatus
- Joint capsule
- Collateral ligaments
The injury typically occurs through:
- Hyperextension of the great toe (most common mechanism)
- Contact with the playing surface (35.4% of cases)
- Contact with another player (32.7% of cases) 2
Risk factors include:
- Playing on artificial turf (significantly higher incidence compared to natural grass)
- Wearing lightweight, flexible shoes with inadequate support
- Playing positions requiring quick cutting movements (running backs and quarterbacks are most commonly affected) 2
Clinical Presentation
Patients with turf toe typically present with:
- Pain at the first MTP joint
- Swelling and hyperemia around the joint
- Limited and painful range of motion
- Difficulty pushing off during walking or running
- Tenderness on palpation of the plantar aspect of the first MTP joint
Diagnostic Imaging
MRI is the preferred imaging method for evaluating suspected turf toe as it directly evaluates:
- Soft-tissue structures of the capsuloligamentous complex
- Chondral and osteochondral lesions 3
Standard radiographs typically show only generalized soft-tissue swelling unless there is a concomitant fracture or sesamoid injury 1.
Classification and Treatment Approach
Treatment depends on the severity of the injury:
Grade 1 (Mild)
- Stretching of the plantar complex without tear
- Treatment: Rest, ice, compression, elevation (RICE), taping, and stiff-soled shoes
- Return to play: 1-2 weeks
Grade 2 (Moderate)
- Partial tear of the plantar complex
- Treatment: Immobilization in a walking boot, limited weight-bearing
- Return to play: 2-4 weeks
Grade 3 (Severe)
- Complete rupture of the plantar plate and sesamoid apparatus
- Treatment: May require surgical intervention for unstable injuries
- Return to play: 8+ weeks
For stable injuries where the plantar plate is not completely disrupted, nonoperative treatment with casting or a stiff-soled shoe, gradual weight bearing, and rehabilitation is recommended. Unstable injuries with complete plantar plate disruption require surgical intervention and repair 4.
Prevention Strategies
To prevent turf toe injuries:
- Use stiffer-soled shoes or shoes with steel-plate insertions
- Consider appropriate footwear for the playing surface
- Implement proper technique for cutting and pivoting movements
- Address any biomechanical issues that may predispose to injury
Long-term Considerations
Without proper treatment, turf toe can lead to:
- Chronic pain
- Joint stiffness
- Hallux rigidus (arthritis of the first MTP joint)
- Decreased athletic performance
Clinical Pearls
- Fewer than 2% of turf toe injuries require operative intervention 2
- The mean time lost due to injury is approximately 10 days 2
- Stress and instability testing are key components in determining whether surgical intervention is warranted 4
- Early diagnosis and appropriate management are essential to prevent long-term dysfunction
By understanding the anatomy, mechanism of injury, and appropriate treatment approaches for turf toe, clinicians can effectively manage this injury and help athletes return to play safely.