What is the recommended management for turf toe?

Management of Turf Toe Injury

MRI is the preferred imaging method for evaluating turf toe injuries, as it directly evaluates the soft-tissue structures of the capsuloligamentous complex and assesses chondral and osteochondral lesions. 1

Definition and Mechanism of Injury

Turf toe is a hyperextension injury to the plantar plate at the first metatarsophalangeal (MTP) joint. The injury occurs when the great toe is forcefully dorsiflexed, causing damage to the plantar structures of the MTP joint. This injury has become more common with the use of artificial turf surfaces and lighter, more flexible footwear in sports.

Assessment and Diagnosis

Clinical Evaluation

• Pain, swelling, and limited motion of the first MTP joint
• Tenderness on palpation of the plantar aspect of the first MTP joint
• Assess stability of the joint by carefully testing range of motion
• Evaluate for ecchymosis around the joint

Imaging

• MRI is the gold standard for evaluating turf toe injuries 1
• Plain radiographs should be obtained to rule out fractures or dislocations
• Weight-bearing views can help assess joint alignment and stability
• Consider ultrasound as an alternative method for direct assessment of the plantar plate 1

Grading System

Turf toe injuries are typically classified into three grades:

1. Grade I: Stretching of the plantar complex with minimal swelling and localized tenderness
2. Grade II: Partial tear of the plantar plate with moderate swelling, ecchymosis, and restricted motion
3. Grade III: Complete rupture of the plantar plate with severe swelling, ecchymosis, and significant instability

Treatment Protocol

Conservative Management (Grade I and II injuries)

1. Acute Phase (0-7 days):

   • RICE protocol (Rest, Ice, Compression, Elevation)
   • Immobilization with a walking boot or cast
   • Non-weight bearing or limited weight bearing with crutches
   • NSAIDs for pain management

2. Subacute Phase (1-3 weeks):

   • Continued protection with a stiff-soled shoe or walking boot
   • Gradual increase in weight bearing as tolerated
   • Gentle range of motion exercises
   • Taping techniques to limit extension of the first MTP joint

3. Rehabilitation Phase (3-6 weeks):

   • Progressive strengthening exercises for intrinsic foot muscles
   • Proprioception and balance training
   • Gradual return to sport-specific activities
   • Use of a turf toe plate or carbon fiber insole to limit MTP extension

Surgical Management (Grade III injuries or failed conservative treatment)

Surgery is indicated in less than 2% of turf toe injuries 2 but should be considered for:

• Complete rupture of the plantar plate
• Unstable first MTP joint
• Presence of loose bodies or osteochondral lesions
• Failed conservative management after 6 weeks

Surgical options include:

• Direct repair of the plantar plate
• Tenodesis procedures
• Sesamoid fixation if displaced

Return to Play Considerations

• Athletes should demonstrate full, pain-free range of motion
• Adequate strength of the intrinsic foot muscles
• Ability to perform sport-specific movements without pain
• Consider protective equipment (stiff-soled shoes, carbon fiber insoles)
• Average time lost due to injury is approximately 10 days 2

Prevention Strategies

1. Footwear Modifications:

   • Use shoes with adequate stiffness in the forefoot
   • Ensure proper fit with 1-2 cm of space beyond the toes 1
   • Consider shoes with a wider toe box

2. Orthotic Devices:

   • Carbon fiber or steel inserts to limit first MTP extension
   • Custom orthotics to redistribute pressure

3. Playing Surface Considerations:

   • Be aware of increased risk on artificial turf surfaces 2
   • Third-generation artificial surfaces have a significantly higher injury rate compared to natural grass (0.087 vs 0.047 per 1000 athlete-exposures) 2

Long-term Complications

Without proper management, turf toe injuries can lead to:

• Chronic pain and stiffness
• Hallux rigidus (degenerative arthritis)
• Decreased push-off strength
• Recurrent instability
• Restricted dorsiflexion 3

Special Considerations

• Running backs and quarterbacks are at highest risk for this injury 2
• Most injuries occur from contact with the playing surface (35.4%) or another player (32.7%) 2
• The incidence in NCAA football is 0.062 per 1000 athlete-exposures 2
• If not diagnosed early and treated properly, these injuries can result in chronic pain and loss of mobility 4

By following this comprehensive management approach, most turf toe injuries can be successfully treated with conservative measures, allowing athletes to return to play without significant long-term sequelae.