Turf Toe

Michael W Bowman M.D. FACS

The great toe of the human foot is called the Hallux in Latin.  It is the cornerstone for normal human walking or gait.  The great toe is composed of the 3 bones, the first metatarsal bone, the proximal phalanx or first toe bone, and the distal phalanx or the last bone at the tip.  There are two joints in the great toe.  The interphalangeal joint(IP joint) and the metatarsal phalangeal joint(MTP joint).  Each joint has a lining called the capsule which holds the joint fluid in place.  Each joint has two ligaments, the medial collateral ligament and lateral collateral ligament, on the medial and lateral side of the joint, respectively to stabilize the joint.  An extensor tendon, the extensor Hallucis longus(EHL) straightens the toe.  Two flexor tendons, the flexor Hallucis longus(FHL) and the two heads of the flexor hallucis brevis(FHB) are located on the bottom of the plantar aspect of the great toe.  The FHL flexes the last or IP joint.  The FHB. is very powerful and flexes the MTP joint, allowing us to push off during activities such as running or diving.  Contained inside of the FHB, underneath the MTP joint, are two small bones called the sesamoids.  The kneecap or patella is another example of a sesamoid bone within a tendon. During weight-bearing, weight is upon the sesamoids. the flexor hallucis brevis combined tendon containing the sesamoids and the collateral ligaments of the MTP joint attach together to form a sling called the sesamoid sling.  This sling along with the MTP capsule restrains and supports the MTP joint.

Any injury that sprains or damages the capsule, collateral ligaments were sesamoid sling may result in stiffness, swelling and pain at the great toe MTP joint.  Such an injury is common in athletics and is known as Turf Toe.This term was coined at the University of West Virginia in by Bowers and Martin who noticed an increase of great toe injuries on the new Astroturf. Turf toe may occur in many sports as well as other injuries. A common  mechanism of injury is hyperextension, where the toe is forced backwards, towards the foot. the sesamoid complex may be torn as well as the capsule.  Another common injury mechanism is forced plantar flexion, a where the toe was bent backwards underneath the foot.  In this case the dorsal capsule and collateral ligaments are torn.  Severe injuries may result in actual dislocation of the toe at the MTP joint.  Fractures of the metatarsal head or proximal phalanx of the toe or sesamoid  may accompany the soft tissue injuries of turf toe.

Treatment of an acute turf toe injury begins with a careful assessment of the original injury and a thorough physical examination of the foot.  We assessed looseness or instability of the joint, the amount of swelling and range of motion of the first MTP joint.  We evaluate whether the flexor hallucis brevis muscles  containing the sesamoids are intact and can flex the toe.  X-rays are taken to determine whether there is an associated fracture.  A more sophisticated x-ray, called a  CT scan, baby necessary to determine whether an injury to the sesamoids has occurred.

When the first metatarsophalangeal joint is stable and no fracture exists,we begin early protected active range of motion and traction and passive range of motion. edema or swelling control is initiated.  Weight-bearing is limited in a protective boot. when the soft tissue is healed between 3 to 6 weeks postinjury, strengthening of the toe flexors and extensors is begun.  Progressive weight-bearing in the boot is initiated.  At 6 weeks postinjury weight-bearing in her shoe is begun and progressive resistive exercises is initiated.  We then work on balance, proprioception N. progress to running.  Lastly sport specific activities are included in order to prepare the athlete for their particular  sport. a protective steel or carbon fiber plate may be inserted into the shoe to protect the first MTP joint with athletic activities.

If the first MTP joint is unstable, we protect the foot in a boot with nonweightbearing until there is sufficient stability to begin range-of-motion exercises.  In severe cases instability, where at the supporting collateral ligaments of the MTP joint or sesamoid sling has been completely torn, surgical repair of the ligaments or sesamoid sling may be required.  In cases where a fracture involving the joint exists, repair of the fracture or removal of small fracture pieces may be required. associated Fractures of the sesamoids may be treated conservatively with rest and a protective boot, may require surgical fixation, or removal of a small piece of the sesamoid and repair of the surrounding flexor hallucis brevis.

In all acute turf toe cases, protection of the toe, early protected motion and strengthening her critical to avoid first MTP joint stiffness, pain and arthritis, which are the most common complications from turf toe injury.

In chronic turf toe cases (greater than 3-month-old), a careful examination is performed to determine whether the discomfort is coming from the MTP joint or the sesamoid complex. the range of motion is measured.  X-rays and MRI may be performed to determine the extent of the soft tissue injuries. weight-bearing is permitted as tolerated in a shoe with a protective carbon fiber plate or boot.  Therapy is begun to reduce swelling and to help regain range of motion.  In severe cases, a capsulotomy or release of the soft tissue structures around the first MTP joint, baby required to loosen the joint.  The surgery as an outpatient procedure performed with general or spinal anesthesia.  Afterwards a protective dressing and boot are used.  Early aggressive range of motion therapy is begun and weight-bearing as limited for two to 6 weeks.  Once range of motion is reestablished, strengthening of the great toe is initiated.  After 6 weeks, the treatment protocol for acute injuries is followed.

 In severe cases, involving sesamoid injuries, excision of the involved sesamoid and repair of the flexor hallucis brevis may be required.  In cases that have resulted in severe arthritis of the first MTP joint, fusion of the first MTP joint may be required. this procedure is performed as an outpatient with general or spinal anesthesia.  The arthritic joint surface is removed, and a small plate or screws were inserted to hold the joint together while bone formation occurs and the fusion between the two bones become solid.  A protective boot with  no weight-bearing is utilized for 6 weeks or until the fusion is solid.  Afterwards therapy is begun.  A shock absorbing shoe  with a carbon fiber plate is used for athletic activity.