With the beginning of the NFL season and college football in full swing, I decided to talk about an injury called turf toe which is a common football injury. Turf toe is an injury to the first
metatarsophalangeal joint (MTP )
that is described as a sprain or tear to the capsule or ligamentous
structures. The American Orthopaedic
Foot and Ankle Society defines turf toe as a plantar capsular ligament sprain.
(Tewes, 1994) The anatomy, predisposing
factors and causes of turf toe are important in order to understand this
sports-related injury. The diagnosis,
treatment and forms of rehabilitation will be illustrated as well as specific
complications if left untreated.
The
anatomy of the first MTP joint is
fairly complex. It is a synovial joint
incorporating four articulating bones.
They are the first metatarsal, a proximal phalanx, and a medial and
lateral sesamoid bone. The sesamoid
bones are located inferiorly and “act as fulcrums to increase the power of the
muscles which cross them”. (AthleticAdvisor, 2005) The first MTP
joint is surrounded by a capsule which serves as attachment sights for the
abductor hallicus, adductor hallicus and the flexor hallicus brevis on the
plantar side. While the tendon of
extensor hallicus longus forms the roof of the capsule on the dorsal great toe.
(Dykyj, 1989) The last muscle in this complex
is the flexor hallicus longus which runs between the two sesamoid bones attaching
to the distal phalanx.
The
mechanism of injury involves a hyperextension to the first MTP joint which results in capsular damage and or
compression to the dorsal articular surface. (Rodeo, 1990) The shoe or cleat grips hard into the turf,
causing the foot to go into forced dorsiflexion during push-off. The increase in number of cleats on the
football shoes leads to increased traction and an increase in incidence of turf
toe. (Clanton et al. 1986) Also, with
the foot in this toe-off position, it is common in football for an external
force to drive the toe into further dorsiflexion. Other predisposing factors include increased
flexibility of the forefoot, which will allow hyperextension of the first MTP joint.
(Clanton et al. 1986) Clanton suggests
that a stiffened forefoot in the boot of football players sustained less turf
toe injuries. (Clanton et al. 1986)
Coker suggested that shoe fit could be a contributing factor, explaining
that wider feet require large sized shoes, subjecting the first MTP joint to greater flexion and extension stress.
(Coker et al. 1978) Probably the biggest
influence on turf toe injuries is the artificial turf, hence the name of the
injury. Grass has been replaced by turf
in the late 1960’s, and the reported incidence of first MTP
joint injuries has increased after introducing artificial turf. (Clanton,
1994) Football athletes are chronically
in three-point stances, and require tremendous amounts of power from this
position with the foot relatively flat.
This requires excessive dorsiflexion and extension of the first MTP joint. (Sammarco, 1995) During push-off, the great toe is the last
structure in contact with the ground. Up
to eight times a person’s body weight can be transferred through the great
toe. (AthleticAdvisor, 2005)
Diagnosis
includes questioning the patient with regard to the mechanism of injury. This will provide information about what
structures may be injured. The patient
will report sudden onset of pain after forced hyperextension. (Clanton et al.
1986) Physical exam will show evidence
of swelling, ecchymosis and painful passive ranges of motion. Active ranges of
motion of dorsiflexion and plantarflexion in the first MTP
may be decreased. (Bowers, 1976) When examining the patient, he or she may
have an antalgic gait, externally rotating their lower extremity to avoid
dorsiflexion during push-off. (Bowers, 1976)
Imaging may be required in severe cases to rule out avulsion fractures
on the first metatarsal head or proximal phalanx, or even sesamoid bone
fractures. (Churchill, 1998) It may also
be advantageous to assess any articular or joint damage with plain film
radiography. Grading turf toe injuries
involves interpreting signs and symptoms to assess tissue disruption. Grade 1 sprain involves tenderness, minimal
swelling, no ecchymosis and negative x-rays. (Churchill, 1998) In this case the plantar capsule is
stretched. Grade 2 turf toe is a
partially torn plantar capsule and the patient will have diffuse tenderness,
moderate swelling, ecchymosis, and restriction of motion. (Churchill,
1998) Grade 3 injuries have completely
torn plantar capsules and may have a compression injury to the dorsal articular
surface. There will be severe
tenderness, considerable swelling, ecchymosis and marked restriction in range
of motion. (Churchill, 1998)
Treatment for turf toe is very similar
to other types of ligament sprains. In
the acute stages rest, ice, compression and elevation (R.I.C.E.) is an
effective and conservative method to minimize inflammation in all grades of
turf toe. (Churchill, 1998) Grade 1
injuries can usually be taped to allow only for minimal extension of the great
toe and limit dorsiflexion of the foot. (Nicholas, 1995) Stiff-soled shoes or rigid orthotics with a
Morton’s extension reduces motion of the first MTP
joint to protect from re-injury. (Clanton, 1994) Grade 2 injuries should avoid physical
activities for 1 to 2 weeks, while grade 3 injuries should be sidelined for 3
to 6 weeks. Grade 3 injuries may require
surgery for capsule repair or removal of loose bodies. (Coker et al.,
1978) Non steroidal anti-inflammatory
drugs and ultrasound can also be used in acute stages to reduce pain and
inflammation. Following the acute
stages, it is essential to have a proper rehabilitation program to regain full
range of motion and strength in the foot and ankle. The strength and endurance of the foot can be
addressed by using Therabands. (AthleticAdvisor, 2005) The first MTP
joint can be addressed by doing gentle range of motion exercises, and
ultimately progress to more aggressive long-axis distraction manipulation to
reduce the compression. Such
rehabilitation is crucial to prevent hallux rigidus, a painful progressive loss
of motion in the first MTP joint.
(AthleticAdvisor, 2005) With hallux
rigidus, patients report history of trauma, compression and repetitive
hyperextension of the first MTP
joint. (Churchill, 1998) This may also
ultimately result in degenerative arthritis of the great toe. (AthleticAdvisor,
2005)
In
summary, turf toe is a fairly common injury seen in sports that are played on
artificial turf, especially football.
This hyperextension injury of the first MTP
joint has several predisposing factors, which includes increased flexibility,
large shoes with many cleats, and of course the adoption of the less resilient
turf. Treatment for this capsular injury
involves conventional R.I.C.E. methods and proper footwear, orthotics and
taping to prevent further injury.
Rehabilitation is important to regain full function, and prevent future
complications in the great toe.
For more information Dr. Brent Moyer can be contacted at Brant Arts Chiropractic 905-637-6100. www.drbrentmoyer.com Twitter: @brantartschiro Facebook: Brant Arts Chiropractic
References
AthleticAdvisor (2005). Turf-Toe.
http://www.athleticadvisor.com/injuries/LE/foot&ankle/turf_-_toe.htm
Bowers K.D, (1976). Turf-toe: a shoe
related football injury. Medicine Science and Sports Exercise. 8:81-83
Churchill, R.S., (1998). Managing Injuries of the Great Toe. The
Physician and Sportsmedicine. Vol 26-9, Sept 98.
Coker, T.P. et al., (1978).
Traumatic lesions of the metatarsophalangeal joint of the great toe in athletes.
The American Journal of Sports Medicine. 6: 326-334.
Clanton, T.O., (1994). Turf
Toe. Clinics in Sports Medicine.
13, (4): 731-741.
