Turf toe injury

Introduction

The turf toe injury was originally described by Bowers and Martin in 1976. It is is a general term that is used to describe a variety of injuries to the hallux plantar capsule, plantar muscles and the sesamoid complex.  The injury can easily be overlooked, and therefore, requires a careful assessment on initial presentation.  Neglected injuries can lead to long-term detrimental effects including decreased athletic performance, restricted 1st MTPJ motion, degenerative arthritis, hallux valgus deformity and potentially a premature end to a sporting career.

 

Incidence

The incidence of turf toe injuries remains unknown, as the majority of literature describes small case-series and addresses diagnosis and treatment rather than epidemiology. Rodeo et al. in 1990, did however note a high prevalence in a survey of 80 American Football players, where up to 45% had suffered turf toe injuries in their professional careers, of which 83% occurred on an artificial turf.

 

Anatomy

​The two hallux sesamoids lie within the flexor hallucis brevis (FHB) tendon and sit on the plantar surface of the forefoot, directly underlying the first metatarsal head.  A bony ridge on the undersurface of the first metatarsal head, known as the crista, separates the sesamoids, delineating the medial and lateral metatarsal–sesamoidal joints. The abductor and adductor hallucis tendons insert on the medial and lateral bases of the proximal phalanx, respectively, and also give off small attachments to the sesamoids. A turf toe injury represents injury to some or all of this complex.

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Mechanism

The usual mechanism of turf toe injury is an axial load of the 1st MTPJ in a fixed equinus foot. The load drives the hallux MTP joint into hyperextension, leading to attenuation or disruption of the plantar joint complex.  This can potentially lead to a spectrum of injuries ranging from a sprain of plantar structures to frank dorsal dislocation of the toe.

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Presentation

Acute injuries present with:

  • Swelling.
  • Plantar bruising.
  • Pain with weightbearing especially during push-off phase.

Point tenderness is a critical part of the assessment, along with palpation of the collateral ligaments, dorsal capsule and plantar sesamoid complex.  Tenderness proximal to the sesamoids suggests a low grade injury and distal to the sesamoids suggests a more serious and often unstable injury. Findings may be subtle so a high index of suspicion must be kept in a patient with an injury to the first MTPJ.

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Imaging

Weightbearing AP and lateral radiographs of the foot, along with axial sesamoid views are first line investigations. These may be normal but a visible small fleck of bone is suggestive of capsular avulsion. The location of the sesamoids under the metatarsal head is important is assess for. The distal sesamoid-to-joint distance should be no more than 3 mm (tibial) and 2.7 mm (fibular), compared with those on the contralateral side.  Proximal migration of one, of both, sesamoids is suggestive of plantar plate rupture, and a separation of 10.4 mm or more on the tibial side, or 13.3 mm on the fibular side, is 99% predictive of rupture of the plantar plate. MRI is commonly performed to assess the extent of the injury and soft tissue disruption.

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Classification

​Clanton described a classification system, which was further modified by Anderson, and is based on the extent of injury:

Grade I - a sprain of the capsule without a loss of continuity, normal range of motion, no visible ecchymosis, ability to bear weight, normal plain radiographs and intact soft tissues on MRI with surrounding oedema.

Grade II - a partial tear of the plantar plate and capsule, with obvious swelling and ecchymosis, painful range of motion and difficulty in weight-bearing.  Radiographs may still be normal, but MRI demonstrates soft tissue oedema and high signal intensity that does not extend through the full thickness of the plantar plate.

Grade III - is a complete tear with loss of continuity of the plantar plate and capsule.  Concomitant injuries may also be found, including sesamoid fracture and dorsal metatarsal articular impaction.

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Treatment

Treatment is currently dictated by a few retrospective case series that exist. The majority of these suggest that that non-operative management for Grade I and II injuries, and majority of grade III injuries is sufficent.  Only one case series is available that supports the operative treatment for some cases of grade III injuries.

Conservative Treatment

Initial measures include rest, elevation, ice packs and pain management.  A walking boot, short leg cast or a toe spica extension in slight flexion is recommended, to keep the plantar soft tissues in a rested position. It is critical to establish whether the injury is stable or unstable before planning management.

Grade I

The great toe should be taped in a slightly plantarflexed position, supplemented with the use of a stiff-soled shoe or individualised orthotics with a Morton’s extension. For a medially sited injury, a toe separator is advised to reduced the risk of developing traumatic hallux valgus. Gentle range of motion activity can be commenced with return to low impact activities in 3 to 5 days.

Grade II

The supportive treatment is the same as for grade I injuries; however athletes are likely to lose about 2 weeks of playing or ativity time.  After the resolution of acute pain and swelling, early gentle passive motion is started along with low-impact activities with the use of toe protection, with a gradual return to higher impact activities of running, push-off, jumping and pivoting.

Grade III

Athletes may require 8 weeks of immobilisation for appropriate recovery. It is recommended that the first MTP joint should have 50° to 60° of painless passive dorsiflexion before considering returning to running or high impact activities.  It may take up to 6 months for complete resolution of symptoms in cases of a severe injury.

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Coker et al. reported a retrospective case series of 8 turf toe injuries in collegiate football players.  Initial treatment included a period of rest with a plaster cast, crutches, and heel weight-bearing.  Players were allowed to progress on to walking, running and high impact activities when pain resolved, with the use of taping and modification of shoewear.  A few patients underwent surgery, as pain remained a persistent problem beyond 3 weeks of injury; however the demographics of these patients were not fully described in their study.  The long-term problems reported in this series were pain and stiffness.

Clanton et al. reported 56 turf toe injuries, in their retrospective review over a 14 year period.  54 injuries (96%) occurred in football players on synthetic turf.  Players were initially treated with usually measures as above, followed by gradual mobilization and return to sports when pain resoled.  53 of the 56 players (95%) were able to return to sports; however half of these patients reported some level of ongoing pain and stiffness over a period of 5-year follow up. Only one patient required surgery, who had avulsion fracture of the first metatarsal and required 56 days to return to play.

 

Surgical Treatment

Surgery is rarely indicated for turf toe injuries. Robert Anderson has described the indications for surgery are Grade III injuries that include large capsular avulsions with an unstable MTP joint, diastasis of bipartite sesamoid, sesamoid fracture, retraction of sesamoid, traumatic hallux valgus, vertical instability, loose body in MTP joint, and chondral injury.

​The aim of surgery is to restore the normal anatomy and stability of the MTP joint.  In isolated capsular disruption, the plantar soft tissue structures can be primarily repaired with end to end sutures. Traumatic hallux valgus suggesting medial soft tissue injury can additionally require adductor tenotomy percutaneously to balance the MTP joint, and medial eminence resection to allow a capsulodesis. In cases of sesamoid fracture, care should be taken to preserve as much bone as possible.

Complete sesamoidectomy may rarely be necessary , although is best avoided if possible. Depending on the fragment size, some authors have suggested an open reduction and internal fixation, which although difficult, may be achievable using small screws.

​Following surgery, the foot is immobilised with a toe spica splint in plantarflexion and patient is kept non-weightbearing for 4 weeks.  Gentle passive range of motion is commenced at 1 week, avoiding excessive dorsiflexion.  At 4 weeks, protected weightbearing is commenced in a boot or heel loading shoe, along with active range of movement exercises out of splint.  At 8 weeks, a stiff-soled shoe and a turf toe plate is advised to prevent hyperextension and weightbearing is advanced as tolerated with protective taping and shoe wear.  Impact activities are introduced at around 12 weeks.

 

The only available study reporting the outcome of surgical intervention, is a retrospective case-series review by Robert Anderson.  In his series, 9 patients underwent surgery for Grade III injuries with radiographic evidence of sesamoid migration and disruption of the plantar soft tissue complex on MRI scans.  The duration from injury to surgery ranged from 1 week to 7 months, with follow up from 1 to 10 years, via questionnaires.  Repair of the plantar plate complex was performed in all patients.  In 4 patients (44%), sesamoidectomies were performed due to fragmentation or degeneration, with abductor hallucis tendon transferred to fill in the defect in 3 of these patients.  Seven patients (78%) were able to return to full level of activity with minimal pain.  The remaining two patients were unable to return to full athletic activity; one due to persistent pain despite a stable toe, and the other developed severe hallux rigidus.

George et al. reviewed the data of 147 turf toe injuries among collegiate American football players over 5 seasons.  They reported that the players were nearly 14 times more likely to sustain the injury during games compared to practice/training sessions, with a mean loss of 10 days of athletic participation due to injury.  There was a significantly higher injury rate on artificial surfaces, compared to natural grass.  The majority of injuries occurred as a result of contact with the playing surface (35.4%) or contact with another player (32.7%).  Non-operative measures were the mainstay of treatment, leading to satisfactory recovery and return to sports.  Fewer than 2% of these players required surgery.

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References

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