Turf Toe: Hyperextension of the Metatarsal Phalangeal Joint


Turf Toe is a dreaded injury, specifically among those who play contact sport. The injury is associated with a constant jamming or hyperextension of the 1st (big) toe joint leading to an injury of the ligament supporting the joint or the joint itself. It will commonly occur on much harder grounds such as those made from artificial surfaces or those which have experienced significant drought. The first toe joint is a primary lever system for the powerful propulsion of a player and can leave them out of action for a significant amount of time.

Turf toe has been one of the most undertreated and over simplified injuries of the foot, the identification and following management protocols require a complete and systematic assessment of the foot as a whole and then the narrowing and specification of the first toe complex.
The severity of a first toe joint hyperextension injury is directly correlated to the amount of energy which is generated at the time of injury and the extent at which the toe is pushed past the individual’s available range of motion. Frimenko et al showed that those who had less than 78 degrees available at the first metatarsal phalangeal joint were 50% more like to sustain a turf toe injury.
The biomechanical pathogenesis of a turf toe injury is the excessive extension moment under increased force of the plantar capsule leading to an injury of the capsuloligamentous structures surrounding the first metatarsal phalangeal joint. Up to eight times an athlete’s body weight can be transmitted through the toe during an extensive moment which has the potential to rupture the capsule.

Contributing factors which are seen to increase the likelihood of a first to injury include; highly flexible shoes, increased forefoot contact time, the changing properties of artificial turf over time from increased play upon the surface, both varus and valgus stress mechanisms and the use of synthetic turf. The injury has been commonly viewed in the United States where synthetic turf has been available for field play for quite some time with Gridiron (American football) being played on these type surfaces since the late 1970’s.
The standard imaging desired for the identification of a turf toe injury is plain radiograph, with specific attention being paid to observations of malalignment or small avulsions at the first metatarsal phalangeal joint or chondral injury – sesamoid position can also be viewed. MRI is suggested if there remains a suspicion of injury which is not noted by plain radiograph.

Grade Description Management
One Least severe injury which commonly will be the result of a minor stretch without the compromise of tissue properties. There can be local edema, with little change in range of motion and the patient can weight-bear. Medical imaging will show no abnormality. 3-5 days in a boot
Protective mobilization with taping
NSAIDs
Ice
Strengthening
Two A partial tear of the capsule or ligaments surrounding the first MTPJ with diffuse pain and increased tenderness as well as mild edema. Strictly 2 weeks min non-weight bearing
Protective mobilization
1st Ray rehabilitation
Taping for return to sport
Custom orthotic with mortons extension
Three Acute plantar capsuligamentous disruption or chronic injury with high level of pain and tenderness Surgery is required
No weight bearing for 4-6 weeks
1st ray rehabilitation
Taping for return to sport
Custom orthotic with mortons extension

As you can see, such is the case with most soft tissue injuries, the best approach to take when treating Turf Toe is through a multi-facet one. Off-loading devices, strength and conditioning exercises and full range of motion rehabilitation is required to yield the best results.
Until next time, thanks for reading.

Jackson McCosker
Director /Chief Editor

References

Boike, A., Schnirring-Judge, M., & McMillin, S. (2011). Sesamoid Disorders of the FIrst Metatarsophalangeal Joint. Clinical Podiatry Medicine and Surgery, 2 – 16.

Childs, S. (2006). The Pathogenisi and Biomechanics of Turf Toe. Orthopaedic Nursing, 276 – 280.

Frimenko, R., Lievers, W., O’Rielly, P., Park, J., Hogan, M., Crandall, J., & Kent, R. (2013). Development of an Injury Risk Function for First Metatarsophalangeal Joint Sprains. Medicine and Science in Sport & Exercise, 2144 – 2150.

Jennings, D., & Gissane, C. (1994). Turf-Toe: Super League Toe. British Journal of Sports Medicine, 31-164.

VanPelt, M., Saena, A., & Allen, M. (2013). Turf Toe Injuries. In Sports Medicine and Arthroscopic Surgery of the Foot and Ankle (pp. 13 – 28). San Antonio: Department of Sports Medicine.

Sesamoid Disorders


The sesamoids are found on the plantar aspect of the first MTP head, imbedded within the plantar plate. Of the three sesamoids of the first toe, these are the most likely to develop an injury. Sesamoid injury are responsible for approximately 9% of foot and ankle injuries and 1-2% of running injuries. Sesamoid pain is commonly localized but can be associated with joint aches, sharp stabs or irritating niggles. With respects to medical imaging, plain radiograph is best taken in weight-bearing stance, however a anterio-posterior is capable of illustrating a bipartite sesamoid. CT Scan is capable of helping practitioners diagnose a stress fracture, nonunion or post traumatic changes.
The sesamoid complex is responsible for the transition of as little as 50% body weight and more than 300% body weight during propulsion leaving them susceptible to a number of injuries and pathologies including;

Hallux Limitus
Hallux limitus is a functional range of motion pathology secondary to obstruction or destruction of the 1st metatarsal phalangeal joint which significantly affects an individual’s gait and potentially leads to tertiary pathological issues such as bursitis and synovitis. So how does this involve the sesamoids?
It is important to understand that the sesamoids are imbedded within the Flexor Hallucis Brevis tendon which can lead to increased pressures directly upon the first metatarsal if the muscle belly or the tendon itself is taught and restricting extension.

Sesamoiditis
Sesamoiditis is a layman’s term for painful sesamoid associated with overuse/repetitive stress but fail to show changes with medical imaging. Clinically, direct palpation will illicit pain and a patient will present with a plantarflexed first ray or HAV. In the acute stages the use of ice and NSAIDs are advised however, long term results require the use of orthotic devices for anatomical modification or gait changes.

Osteoarthritis
Osteoarthritis of the sesamoid complex is in most cases related to trauma, chronic overuse poor range of motion or secondary to other pathologies related to the first MTPJ. HAV is one of the most common primary range of motion restrictors due to the malformation and misalignments of the joint leading to increased pressures upon the first MTPJ. See here: https://footnotesblogging.com/2015/07/20/osteoarthritis-joint-degeneration/

Nerve Impingement
Both the branches of the medial or lateral plantar nerve can become inflamed for a number of reasons. The medial plantar digital nerve may develop irritation due to restricted range of motion – as discussed earlier or excessive pronation at the mid to forefoot. The lateral plantar nerve is more likely to develop neuritis from the impinging of the fibular sesamoid when enlarged or inflamed leading to displacement.

Sesamoid Fracture
Sesamoid fractures are considered to be high risk whether acute or developed over time from repetitive stress. See: https://footnotesblogging.com/2015/05/07/breaking-bone-an-overview-of-stress-fractures-and-subsequent-management/ for the best information regarding this injury.

Infection
Infection within the sesamoids is rarely seen within healthy patients and more commonly will develop from osteomylitis associated with diabetic wounds. Treatment is aggressive and requires surgical intervention as soon as possible to reduce the risk of further bone infection.

As it can be seen from this brief summary, the sesamoids are important in the propulsion and stabilizing of the human body. These two 4 small bones are responsible for distributing weight evenly and acting as a pully system to increase tension of the Flexor Hallucis Tendon during propulsion of the gait cycle. Due to their high risk status, any injury should be treated seriously as the avascular nature can quickly lead to the development of fracture, necrosis and infection – of course in most health individual the risks is significantly reduced however, best treatment protocols should always be followed.

Hope you enjoyed reading.

Until Next Time.

Jackson McCosker
Director /Chief Editor

References

Boike, A., Schnirring-Judge, M., & McMillin, S. (2011). Sesamoid Disorders of the FIrst Metatarsophalangeal Joint. Clinical Podiatry Medicine and Surgery, 2 – 16.

Childs, S. (2006). The Pathogenisi and Biomechanics of Turf Toe. Orthopaedic Nursing, 276 – 280.

Frimenko, R., Lievers, W., O’Rielly, P., Park, J., Hogan, M., Crandall, J., & Kent, R. (2013). Development of an Injury Risk Function for First Metatarsophalangeal Joint Sprains. Medicine and Science in Sport & Exercise, 2144 – 2150.

Jennings, D., & Gissane, C. (1994). Turf-Toe: Super League Toe. British Journal of Sports Medicine, 31-164.

VanPelt, M., Saena, A., & Allen, M. (2013). Turf Toe Injuries. In Sports Medicine and Arthroscopic Surgery of the Foot and Ankle (pp. 13 – 28). San Antonio: Department of Sports Medicine.