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Turf toe is a sprain of the big toe joint resulting from injury during sports activities. The injury usually results from excessive upward bending of the big toe joint.

The Anatomy

The big toe, or great toe, of the human foot is called the Hallux in Latin. It has a very complicated anatomy. This is because the big toe is the cornerstone for normal human walking or gait. Therefore, there are lots of moving parts involved in its functionality!

The great toe is composed of 3 bones:

  • the first metatarsal bone
  • the proximal phalanx, i.e. first toe bone
  • the distal phalanx, i.e. the last bone at the tip. 

There are also 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 includes 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) – also works to straighten the toe. 

Additionally, 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 (patella) is another example of a sesamoid bone within a tendon. During weight-bearing activities, weight is placed upon the sesamoids. 

The flexor hallucis brevis combined tendon (containing the sesamoids) and the collateral ligaments of the MTP joint ultimately attach together to form a sling called the sesamoid sling. This sling, along with the MTP capsule, restrains and supports the MTP joint.

The Potential for Injury

Any injury that sprains or damages the capsule, collateral ligaments, or sesamoid sling of the big toe may result in stiffness, swelling and pain at the great toe MTP joint. 

Such an injury is common in athletics and a variety of sports, and is known as Turf Toe. This term was coined at the University of West Virginia, where experts noticed an increase of great toe injuries on the new campus Astroturf.

A common mechanism of injury is hyperextension, where the toe is forced backward, towards the foot. When this occurs, the sesamoid complex may be torn as well as the capsule. 

Another common injury mechanism is forced plantar flexion, where the toe is bent backward 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. 

Additionally, fractures of the metatarsal head or proximal phalanx of the toe or sesamoid may accompany the soft tissue injuries of turf toe.

The Diagnosis

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 assess and evaluate:

  • looseness or instability of the joint
  • the amount of swelling
  • the range of motion of the first MTP joint
  • whether the flexor hallucis brevis muscles (containing the sesamoids are intact) and can flex the toe. 

X-rays are also taken to determine whether there is an associated fracture. A more sophisticated x-ray, called a CT scan, may be necessary to determine whether an injury to the sesamoids has occurred.

The Treatment

Immediate (Acute) Care

In cases of acute care, when the first metatarsophalangeal joint is stable and no fracture exists, we begin exercises that focus on protecting an active range of motion and traction. Edema or swelling control is also initiated. Weight-bearing activities are limited and must take place in a protective boot.

When the soft tissue is healed between 3 to 6 weeks post-injury, strengthening of the toe flexors and extensors is begun. Progressive weight-bearing in the boot is initiated. 

At 6 weeks postinjury, weight-bearing in the shoe is begun and progressive resistive exercises are initiated. We then work on balance and proprioception (i.e. awareness of the body and movement), and slowly build out patients back up to health (i.e. the ability to run). 

Lastly, sport-specific activities are included in therapy in order to prepare the athlete for their particular sport.

During this process, 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 and order patients to avoid weight-bearing activities altogether (until there is sufficient stability to begin range-of-motion exercises). 

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

Long-Term/Severe Care

In severe cases instability, where the supporting collateral ligaments of the MTP joint or sesamoid sling have 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 also be required.

Associated fractures of the sesamoids may be treated conservatively with rest and a protective boot; may require surgical fixation; or require removal of a small piece of the sesamoid and repair of the surrounding flexor hallucis brevis.

In chronic turf toe cases (i.e. greater than 3-months-old), a careful examination is performed to:

  • determine whether the discomfort is coming from the MTP joint or the sesamoid complex
  • measure a patient’s range of motion
  • determine the extent of the soft tissue injuries (often done via x-ray and MRI testing)

During treatment, weight-bearing is permitted as tolerated in a shoe with a protective carbon fiber plate or boot. Therapy is immediately begun to reduce swelling and to help the patient regain range of motion. 

In severe cases, a capsulotomy (release of the soft tissue structures around the first MTP joint) may be required to loosen the joint. The surgery is performed on an outpatient basis with general or spinal anesthesia. 

Afterwards, a protective dressing and boot are prescribed. Early aggressive range of motion therapy is begun and weight-bearing activities are 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 the most severe cases (i.e. involving sesamoid injuries), excision of the involved sesamoid and repair of the flexor hallucis brevis may be required. And in cases that have resulted in severe arthritis of the first MTP joint, a fusion of the first MTP joint may be required. This procedure is performed on an outpatient basis with general or spinal anesthesia. The arthritic joint surface is removed, and a small plate or screws are inserted to hold the joint together while bone formation occurs and the fusion between the two bones become solid. A protective boot is prescribed and no weight-bearing is allowed 6 weeks or until the fusion is solid. Afterward, therapy is begun. A shock absorbing shoe with a carbon fiber plate is used for athletic activity.