What is the recommended treatment for turf toe?

Turf Toe Treatment

For turf toe injuries, initiate immediate conservative management with rest, ice, compression, elevation (RICE protocol), NSAIDs for pain control, and rigid shoe modifications or taping to restrict dorsiflexion; reserve surgical repair for Grade III injuries with complete plantar plate disruption or persistent instability after 6-8 weeks of conservative treatment. 1, 2, 3

Initial Assessment and Grading

Turf toe represents a hyperextension injury to the plantar plate and capsuloligamentous complex of the first metatarsophalangeal (MTP) joint, most commonly occurring during sports with forefoot axial loading or pivotal movements 4, 5. The injury mechanism can vary beyond pure hyperextension to include hyperflexion ("sand toe"), valgus stress, or varus stress patterns 5.

Grade the injury severity to guide treatment decisions: 2, 5

• Grade I: Plantar capsule stretch with localized tenderness, minimal swelling, no ecchymosis
• Grade II: Partial tear of plantar plate with moderate pain, swelling, ecchymosis, and restricted motion
• Grade III: Complete disruption of plantar plate with severe pain, marked swelling, ecchymosis, and joint instability

MRI is the preferred imaging modality for evaluating the capsuloligamentous complex, assessing for chondral/osteochondral lesions, and confirming the diagnosis when radiographs are normal 1. Ultrasound demonstrates 96% sensitivity for plantar plate tears but has poor specificity 1.

Conservative Treatment (Grades I and II)

All Grade I and II injuries should receive conservative management initially: 2, 3, 5

Immediate Management (First 2-3 Weeks)

• Apply RICE protocol: Rest with limited weight-bearing (use crutches if necessary), ice application, compression, and elevation 6, 3
• Administer NSAIDs for pain control and inflammation reduction 1, 6
• Immobilize the joint with rigid taping or a walking boot to restrict dorsiflexion and allow healing 3, 5
• Use appropriate footwear: Open-backed shoes or extra-depth shoes with rigid soles and adequate toe box (1-2 cm longer than foot) to reduce pressure and prevent hyperextension 1, 6

Rehabilitation Phase (Weeks 3-8)

• Implement progressive weight-bearing as pain and swelling subside 6, 3
• Prescribe shoe modifications: Morton's extension (steel shank or carbon fiber plate) to limit MTP joint motion during push-off 3, 5
• Consider custom orthoses or insoles to redistribute pressure and support the longitudinal arch 4, 3
• Initiate stretching exercises targeting the plantar fascia and Achilles tendon once acute symptoms resolve 6

Most Grade I and II injuries resolve with 3-6 weeks of conservative treatment, though return to full athletic activity may require 6-12 weeks. 3, 5

Surgical Treatment (Grade III)

Surgical repair is indicated for Grade III injuries with complete plantar plate disruption, joint instability, or failure of conservative treatment after 6-8 weeks. 2, 3, 5

Surgical Indications

• Complete tear of plantar plate with joint instability 3, 5
• Displaced sesamoid fractures 3
• Large chondral or osteochondral defects 4, 3
• Persistent pain and functional limitation despite 6-8 weeks of conservative management 2, 5
• Vertical instability or diastasis of bipartite sesamoid 3

Surgical Techniques

Plantar plate repair with tenodesis is the most commonly reported surgical approach, involving direct repair of torn capsular structures and reinforcement with flexor hallucis brevis tendon 2, 7. The surgical approach allows for inspection and repair of the plantar plate, sesamoid complex, and collateral ligaments 3, 7.

Postoperative Management

• Immobilization in a walking boot for 4-6 weeks with progressive weight-bearing 3
• Transition to rigid-soled shoes with Morton's extension for an additional 6-8 weeks 3
• Gradual return to athletic activity typically requires 4-6 months postoperatively 3, 5

Common Pitfalls and Complications

Restricted dorsiflexion is the most frequently reported complication following both conservative and surgical treatment 2. This can lead to altered gait mechanics and transfer metatarsalgia 3.

Key pitfalls to avoid:

• Premature return to athletic activity before adequate healing, which increases risk of chronic instability and hallux rigidus 4, 3
• Inadequate immobilization or shoe modification in Grade II injuries, leading to progression to chronic instability 5
• Failure to recognize Grade III injuries requiring surgical intervention, resulting in persistent functional impairment 2, 5

Long-term sequelae include: 4, 3, 5

• Chronic pain and stiffness (hallux rigidus)
• Progressive osteoarthritis of the first MTP joint
• Inability to return to previous athletic level (reported in 20-29% of cases)
• Cock-up deformity with clawing of the hallux

Special Considerations

For diabetic patients with turf toe injuries, more aggressive offloading and frequent monitoring are essential due to increased risk of ulceration and delayed healing 6. Consider removable offloading devices or total contact casting if plantar wounds develop 6.

Athletes should avoid barefoot walking and use protective footwear both indoors and outdoors during the recovery period 1, 6. Gradual increase in weight-bearing activity by 1000 steps/day increments is safe once acute symptoms resolve, provided appropriate footwear is worn 1.