By Maggie Catlin
As the football season gets underway, many look forward to months of great plays and great injuries. Already in just the first week of play, Patriots starting quarterback, Tom Brady, tore both the medial collateral ligament (MCL) and anterior cruciate ligament (ACL) in his knee. Other injuries typically associated with football include concussions, spinal injuries, fractures, and muscle strains. One of the more prevalent injuries, however, is a sprain to one of the big toe ligaments. This injury was dubbed “turf toe” by two researchers, Bower and Martin, due to the dramatic rise in its incidence since the invention of artificial turf in the 1960s. It is estimated to occur in 45% of all National Football League players; among its victims have been Dion Sanders when he was cornerback for the Dallas Cowboys and Kyle Boller of the Baltimore Ravens. Among university athletes it is the 3rd most common injury (after knee and ankle traumas) that causes a loss of playing time; and although ankle injuries are 4 times more common than turf toe, turf toe may account for a significantly greater proportion of missed playing time.
Anatomy of the 1st MTP Joint
The big toe joint (1st metatarsal phalangeal or 1st MTP joint) is composed of 4 bones, 9 ligaments, and 3 muscular attachments. It is capable of an extended range of motion in order to allow the body to instantly transmit weight bearing loads from a position of maximum toe plantarflexion (when the heel of the foot first strikes the ground) to moderate toe dorsiflexion (when the foot and big toe are coming back off the ground). The big toe bone (1st phalanx) glides on the most distal foot bone (1st metatarsal) throughout the range of motion. The joint capsule and surrounding ligaments provide stability to the joint against inward and outward forces applied during running, cutting, and pivoting. There are also two small bones (sesamoids) that lie in one of the muscle tendons crossing the underside of the MTP joint. These bones provide a fulcrum to make the muscle more efficient.
During full MTP dorsiflexion (when the big toe is coming off the ground in walking/running or when squatting) the gliding movement between the 1st phalanx and 1st metatarsal stops, as the joint capsule is stretched to its greatest potential. Further movement into dorsiflexion creates joint compression. If a great enough force is applied to the 1st MTP joint in this position it results in a sprain or tear of the capsule around the neck of the 1st metatarsal bone. If enough force is supplied to disrupt the capsule there may also be injury to articular cartilage, one or both sesamoid bones, or subchondral bone.
What is Turf Toe?
In most turf toe injuries the mechanism involves an athlete’s foot being planted, his heel raised up off the ground, and his 1st MTP joint hyperdorsiflexed upwards. This is accompanied by a downward force applied through the 1st MTP that results in injury to the capsule. Turf toe can also result when the 1st MTP is forcibly dorsiflexed upwards during a tackle play or is jammed inside the toe box when an athlete stops short. Usually with a hyperdorsiflexion injury the plantar portion of the ligament complex tears while the plantar plate becomes detached distal to the sesamoid bones. Once the joint capsule is torn, unrestricted motion of the proximal phalanx results in severe compression of the articular surface of the metatarsal head. This produces the potential for fracture or dislocation.
Injury to the capsuloligamentous structures of the 1st MTP may also occur with valgus, varus, or hyperflexion forces to the joint – although these are not considered true “turf toe”. A valgus force is applied during a mechanism of push-off with internal rotation around a fixed forefoot; this results in the medial collateral ligament and sometimes the medial sesamoid bone being damaged. If this injury is left untreated it may lead to bunion formation and/or lateral joint contractures. A varus force is applied during a mechanism of exernal rotation around a fixed forefoot. This results in injury to the lateral capsule and rupture of the adductor hallucis tendon from the base of the 1st proximal phalanx. Finally, hyperflexion injury occurs when the big toe is forcibly rolled under the foot and the dorsal capsule is injured. This is most common in beach volleyball and is therefore termed “sand toe”.
Each mechanism of injury affects different structures of the joint and an accurate diagnosis is crucial in proper treatment of the injury.
Turf Toe Classification
Grade I: Micro- or minor tearing of the capsuloligamentous complex of the 1st MTP joint. No associated injuries.
Grade II: Partial tear of the capsuloligamentous complex of the 1st MTP joint without involvement of the articular surface. No associated injuries.
Grade III: Complete tear of the capsuloligamentous complex of the 1st MTP joint, tearing of the plantar plate from its origin on the metatarsal head/neck, and dorsal impaction of the proximal phalanx into the metatarsal head. Associated injuries include articular cartilage or subchondral bone bruise, sesamoid fracture, diastasis of the sesamoids, and medial or lateral ligament injury.
Signs and Symptoms of Turf Toe
Grade I: Localized tenderness with minimal swelling and no bruising
Grade II: Widespread tenderness with mild to moderate swelling and bruising. Range of motion is moderately restricted and there is pain with weight bearing.
Grade III: Severe and diffuse tenderness and swelling, moderate to severe bruising, and painful range of motion.
Significant disability can occur with damage to structures of the 1st MTP joint complex. Of all individuals with turf toe, 50% will have persistent symptoms after 5 years. Possible long term effects include failure to regain push-off strength, hallux rigidus, hallux valgus, hallux cock-up deformity, arthrofibrosis, and loose joint bodies.
Treatment of Turf Toe
Most cases of turf toe are treated conservatively. In the acute stages, treatment is centered on decreasing inflammation and promoting healing with rest, ice, compression, and elevation. Nonsteroidal anti-inflammatory drugs (NSAIDs) may aide in minimizing pain and inflammation. In higher grade sprains crutches and a short leg cast with a toe spica in slight plantarflexion or a walker boot may be prescribed for the first week or more.
After 3-5 days the big toe is taped to the lesser toe to prevent movement of the 1st MTP joint. Tape should be applied to limit dorsiflexion with multiple loops of tape placed over the dorsal aspect of the proximal phalanx and criss-crossed under the ball of the foot. Athletes may also use an insole containing a carbon fiber steel plate in the forefoot. The goal of both the use of taping and/or an insole is to restrict forefoot motion. Physical therapy for passive range of motion and progressive resistance exercise are started as soon as symptoms allow. Athletes with a grade I sprain are usually able to return to play immediately with only mild pain, while athletes with a grade II sprain are typically unable to return for 3-14 days.
The 1st MTP is immobilized for 1+ weeks in a boot or cast. Return to play is allowed when 50-60 degrees of passive dorsiflexion is possible without pain. This typically translates into 2-6 weeks before return to sport.
Surgery is indicated in cases of hallux malalignment, traumatic bunion deformity, diminished flexor strength, clawing of the great toe, generalized synovitis, or advanced degenerative joint disease. Surgery is also indicated when conservative treatment fails – evidenced by persistant pain with pushing-off, cutting, or pivoting. Athletes are usually able to return to sport 3-4 months after surgery, but it may be 6-12 months before pre-injury level of function is achieved.
Prevention of Turf Toe
The most effective way to prevent turf toe is to limit predisposing factors.
1. Artificial turf and playing surfaces
2. Athlete’s experience and years of sports participation
3. Athlete’s position in their sport
4. Athlete’s weight
5. Flattening of the 1st MTP
6. FB players – defensive & offensive running backs, wide receivers, linemen
7. Foot pronation
8. Hallux degenerative joint disease
9. Increased ankle dorsiflexion
10. Increased friction between the athletic shoe and the turf
11. Increased toe box flexibility and decreased number of cleats in the shoe
12. Pes planus
13. Prior 1st MTP joint injury
Shoe modifications incorporating a stiffer sole or an orthotic with a rigid forefoot section will aide in limiting hallux dorsiflexion and prevent hyperdorsiflextion reinjury. After primary injury, the toe should be taped for support in all future athletic activity as a means of prevention of reinjury.
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