Turf Toe

“Turf toe” is the common term used to describe an injury or sprain of the metatarsophalangeal joint (MTP joint) of the big toe and its surrounding ligaments and capsular structures known as the plantar plate. This injury commonly occurs in football players who play on artificial turf (hence the term “turf toe”), but can occur in other athletes where hyperextension of the MTP joint is possible. Artificial turf is known to have less “give” or resistance than regular grass surfaces. As a result, this injury is most commonly seen in athletes playing on artificial surfaces, where cleats are likely to stick and resist sliding, causing the toe to move into an abnormal position of hyperextension resulting in injury to the joint and plantar plate.

Anatomy

The metatarsophalangeal joint (MTP) of the first toe is comprised of the 1st metatarsal bone which articulates with the proximal phalanx to form the joint. The joint is stabilized by a number of important osseous and soft tissue structures, including the capsular ligaments (medial and lateral collateral ligaments and the intermetatarsal ligament), tendons of the muscles of the big toe (flexor hallucis brevis, adductor hallucis, and abductor hallucis), the medial and lateral sesamoid bones, and the plantar plate. The plantar plate is a thick fibrous band of tissue located on the undersurface of the MTP joint that is particularly important in stabilizing and protecting the joint. The plantar plates serves to protect the head of the metatarsal from pressure and prevent hyperextension of the big toe, which can lead to damage to the joint and the other supporting structures. Typically, the plantar plate and supporting ligaments of the hallux allow for up to 90 degrees dorsiflexion, but this will depend on the individual.

Mechanism of Injury

Turf toe is described as a hyperextension injury to the plantar plate and sesamoid complex of the hallux MTP joint. In layman’s terms, excessive extension of the big toe (hyperextension) results in an injury or tear of the plantar plate. A combination of force (hyperextension of the big toe with an axial load applied to the heel) is usually required for these injuries which causes tearing of the plantar plate capsule-ligamentous complex. As stated, this most commonly occurs on rigid surfaces such as artificial turf where the toe gets stuck in a fixed, extended position while a traumatic force is applied to the heel. Turf toe injuries are serious and often associated with other injuries, including fractures of the sesamoid bones, cartilaginous injury of the MTP joint, or stress fractures of the proximal phalanx. These injuries can be debilitating and often require extensive rehabilitation for athletes.

Turf toe injuries are graded I, II, and III:

Grade I: Sprain of the plantar plate

Grade II: Partial tear of the plantar plate

Grade III: Complete tear of the plantar plate

Treatment

Non-Operative Treatment

Non-operative treatment is typically indicated for all grades of injury. Modalities include rest, non-steroidal anti-inflammatories (NSAIDs), and immobilization in a stiff-soled shoe or CAM walking boot to limit motion across the joint, allowing for repair. Platelet-rich plasma (PRP) can also be used to accelerate healing of the soft tissue structures that are injured around the MTP joint. Physical therapy is started early, once the joint has become stable enough to allow for safe range of motion without the risk of further injury.

Surgery

Surgical repair of turf toe injuries is usually only indicated for Grade III injuries that have failed to improve with conservative management. Indications for surgical intervention may also include retraction of the sesamoid bones, fracture of a sesamoid with diastasis, a loose osteochondral fragment within the joint,  or a post-traumatic deformity of the hallux that has developed as the result of the injury.

All turf toe injuries should seek immediate assessment by a qualified sports medicine physician. Expected return to activity is within 3-4 months following the injury or surgical intervention, however this may depend on the degree of injury and associated injury to the MTP joint and surrounding structures.

Clinical Studies

Turf toe: soft tissue and osteocartilaginous injury to the first metatarsophalangeal joint.

Rehabilitation following turf toe injury and plantar plate repair.

Radiographic evaluation of plantar plate injury: an in vitro biomechanical study.

Incidence and risk factors for turf toe injuries in intercollegiate football: data from the national collegiate athletic association injury surveillance system.

The great toe: failed turf toe, chronic turf toe, and complicated sesamoid injuries.

Etiology and biomechanics of first metatarsophalangeal joint sprains (turf toe) in athletes.