What is turf toe, a condition affecting the big toe in athletes who participate in sports involving running, jumping, or quick changes of direction?

What is Turf Toe?

Turf toe is a sprain of the first metatarsophalangeal (MTP) joint complex caused by forceful hyperextension (hyperdorsiflexion) of the great toe, resulting in injury to the plantar plate, capsuloligamentous structures, and potentially the sesamoid bones. 1, 2, 3

Mechanism of Injury

The injury occurs when the great toe is forcibly bent upward (hyperextended) beyond its normal range of motion, typically when: 2, 3, 4

• Contact with the playing surface (35.4% of cases) - such as when the foot is planted and the heel is driven over the toe 1
• Contact with another player (32.7% of cases) 1
• The athlete is pushing off during acceleration or cutting maneuvers 4

Anatomic Structures Involved

The injury affects the plantar plate complex of the first MTP joint, which includes: 5, 3

• Plantar plate (fibrocartilaginous structure on the plantar aspect of the joint)
• Capsuloligamentous complex (joint capsule and supporting ligaments)
• Sesamoid bones (may sustain fractures in severe cases) 1
• Collateral ligaments and surrounding soft tissues 3

Grading System

Turf toe injuries are classified into three grades based on severity: 2

• Grade I: Stretching of the plantar complex with minimal tearing; athletes typically miss 3-5 days 2
• Grade II: Partial tear of the plantar plate; athletes typically miss 2-4 weeks 2
• Grade III: Complete disruption of the plantar plate with severe instability; athletes miss 4-6 weeks or more, may require surgery 2

Epidemiology and Risk Factors

The overall incidence in NCAA football is 0.062 per 1000 athlete-exposures, with athletes nearly 14 times more likely to sustain the injury during games compared to practice. 1

Key risk factors include: 1, 6

• Playing surface: Third-generation artificial turf has significantly higher injury rates (0.087 per 1000 athlete-exposures) compared to natural grass (0.047 per 1000 athlete-exposures) 1
• Footwear: Lightweight shoes with flexible soles provide inadequate support and increase risk 6
• Player position: Running backs and quarterbacks are most commonly affected 1
• Sport type: Most common in football, soccer, basketball, dancing, and wrestling 2

Clinical Presentation

Athletes present with: 6

• Pain localized to the plantar aspect of the first MTP joint
• Swelling and hyperemia around the joint 6
• Difficulty with push-off during gait or running 4
• Tenderness to palpation over the plantar plate 6

Diagnostic Imaging

MRI is the preferred imaging method for evaluating suspected turf toe by directly assessing the capsuloligamentous complex, plantar plate integrity, and detecting chondral or osteochondral lesions. 5

• Radiographs typically show only soft-tissue swelling unless concomitant fracture is present 6
• Ultrasound can visualize the plantar plate in the sagittal plane with 96% sensitivity for detecting tears 5
• MRI remains the gold standard for grading injury severity and surgical planning 5

Treatment and Prognosis

Less than 2% of turf toe injuries require surgery, with operative intervention reserved for grade III injuries with severe instability, significant bony injury, or complete plantar plate disruption. 1, 2

• Non-operative management: Consists of 3-phase rehabilitation lasting up to 10 weeks 2
• Operative management: Requires 4-phase rehabilitation lasting up to 20 weeks 2
• Performance outcomes: Athletes with low-grade injuries typically return to prior performance level; approximately 70% of athletes with higher-grade injuries maintain their performance level regardless of treatment approach 2
• Mean time lost: 10.1 days across all injury grades 1

Common Pitfall

The term "turf toe" is sometimes used loosely to describe any first MTP joint pain, but in imaging and clinical practice, it specifically refers to plantar plate complex injury from hyperextension mechanism - not sesamoiditis, hallux rigidus, or other first MTP pathology. 3