Turf toe

Turf toe refers to a sprain, partial tear, or complete tear of the first metatarsophalangeal (MTP) plantar plate ⁵.

Terminology

Plantar plate tears can be broadly divided into involving the 1st toe/ hallux/great toe and termed turf toe or sand toe, or the lesser metatarsals/toes 2 - 5, and termed plantar plate tears ⁵. 

Epidemiology

Originally described in American football players, it is common in professional athletes, especially on artificial surfaces, and is not particular to a specific sport. It is commonly seen in football, soccer, and baseball players.

Pathology

The mechanism in typical turf toe injuries is one of extreme traumatic dorsiflexion (hyperextension), often with superimposed varus or valgus angulation, which causes disruption of the plantar plate capsuloligamentous complex and allows unrestricted range of motion of the first MTP joint. Occasionally, fracture of the sesamoids or separation of bipartite sesamoids can be seen.

Variants

Many variants of turf toe injury have been described and include 

• valgus mechanism with injury of the medial capsuloligamentous structures

• varus mechanism with injury of the lateral capsuloligamentous structures and adductor hallucis tendon

• hyperflexion injury (forced plantar flexion) also known as “sand toe” as this is common in sand volleyball players and skimboarders causing injury to the dorsal capsular structures

Grading

Turf toe injuries are graded from 1-3 in severity:

• grade 1: stretch or minor tearing of the 1^st MTP capsuloligamentous structures

• grade 2: partial tearing of the capsuloligamentous structures with intact articular surface

• grade 3: complete disruption of the capsuloligamentous structures with impaction deformity of the MTP, articular cartilage damage, trabecular edema, sesamoidal fracture, or diastasis of sesamoidal fragments

Radiographic features

Ultrasound

• dynamic maneuvers with ultrasound can demonstrate discontinuity of the normal plantar plate

MRI

Partial-thickness tear

• following acute trauma, focal edema in an aspect of a plantar plate suggests low-grade sprain or tear, without discontinuity ⁵

Full-thickness tear

• discontinuity

• proximal retraction

• persistent hyper-extension of the proximal phalanx, or valgus/varus deviation of the toe

Indirect features of a plantar plate injury

• metatarsophalangeal joint synovitis

• flexor tendon sheath tenosynovitis

Treatment

Most turf toe injuries can be managed with rest, ice and elevation. Stiff-sole shoe or walking boot can be used as part of non-operative treatment modality. Surgical repair is reserved for severe cases that do that respond to conservative treatment options.

See also

• plantar plate tears

• Morton neuroma