Turf Toe

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Summary

A Turf toe is an injury to the great toe joint. It occurs when the great toe is forced upward such as may occur when an athlete cuts hard on artificial turf. With too much upward force on the great toe the soft-tissues (capsule) lining the base of the great toe joint is injured or in some instances completely torn. This leads to pain and swelling in the toe. Treatment for partial tears of the capsule includes rest, ice, avoiding aggravating activities, taping or shoes to limit movement of the great toe, and most of all time – often 2-8 weeks or more. Complete ruptures of the capsule require surgery and a prolonged recovery of 4-6 months.

Clinical Presentation

Turf toe injuries result in pain at the base of the great toe. They usually occur after an acute injury although repetitive force upward movement of the great toe may also lead to an injury of the capsule of the great toe. Commonly an athlete will be changing direction suddenly on the playing field and the great toe will be forced upwards as the foot rolls over the toe which is planted on the ground. With enough force the soft-tissues (capsule) on the undersurface of the great toe will be torn either partially or completely. Patients will complain of pain in the great toe, noticeable swelling, a limp, and an inability to run on the foot.

Physical Examination

Patients with turf toe injuries will have pain in the great toe region especially at the base of the toe in the sole of the foot (plantar surface). The great toe will often be swollen. Moving the great toe upwards will often create pain. If the capsule is significantly torn the great toe joint may be noted to be unstable. A noticeable limp may be observed as patients try not to load the injured area of their foot.

Imaging

Plain x-rays should be reviewed to rule out other injuries such as sesamoid fractures and other fractures involving the great toe. However, x-rays in turf toe injuries are usually negative.
A stress x-ray or fluoroscopy may demonstrate excessive movement (instability) of the great toe joint when the great toe joint is stressed.
An MRI will reveal evidence of the soft-tissue (capsular) injury.

Classification of Turf Toe injuries

A classification system has been presented by Clanton et al in 2007
Grade 1: Attenuation of the plantar soft-tissue (capsule) of the great toe
Grade 2: Partial tear of the plantar soft-tissue of the great toe
Grade 3: Complete tear with instability of the plantar soft-tissue

Treatment

Non-Operative Treatment

Non-operative treatment is usually effective for grade 1 and 2 turf toe injuries (partial tearing). The principles of treatment are to limit great toe movement while healing occurs and to control the symptoms of pain. Common non-operative treatment includes:

  • Ice and Elevation: Acute injuries will benefit from ice and elevation to help decrease the swelling and allow for healing
  • Rest Activity modification: Patients will initially often have to avoid all activities and in acute severe turf toe injures crutches are often needed.
  • Limiting great toe motion: A Cast Boot (CAM Walker), or a rigid soled shoe can be used to limit motion through the great toe and protect the injured tissue while it heals. The extent of the injury and the time in the recovery process will usually determine which of these options is chosen. As the individual starts to return to sporting activity they will often benefit from taping the big toe and using a Morton’s extension splint. Both of these treatments are designed to limit the motion of the great toe and thereby protect it.
  • Anti-inflammatory pain medications (NSAIDs): NSAIDs may be helpful to decrease the pain. Care must be taken to avoid taking too many NSAIDs not only can they be hard on your stomach, but there is some evidence that they may have an adverse effect on soft-tissue healing.

Operative Treatment

In Turf toe injuries where there is complete tearing of the plantar soft-tissues of the great toe surgical repair may be needed. As well some turf toe injures that do not adequately recover may benefit from turf toe surgery.
The surgery involves:

  1. Cleaning out any debris (cartilage fragments, etc.) that might be found in the great toe joint
  2. Repairing the torn soft-tissue (plantar plate or plantar capsule) at the base of the great toe.

Recovery can be prolonged and often involves:

  • 6-8 weeks of non-weight-bearing or limited weight-bearing to allow the soft-tissue repair to heal
  • 6-8 weeks of controlled rehabilitation while still protecting the repair in a boot or stiff soled shoe
  • 6-8+ weeks of increasing controlled sports-specific exercises

It is not uncommon for swelling to persist for many months. It is also not uncommon to have some residual symptoms even after a seemingly successful surgery.

Potential Complications

The following general complications can occur:

Potential complications that are specific to turf toe surgery include:

  • Failure of the joint capsular repair
  • Neuritis from an injury to a branch of the medial plantar nerve