Turf Toe

INTRODUCTION

Though several variations exist, the classic definition of turf toe is a hyperdorsiflexion injury of the first metatarsophalangeal (MTP) joint. In the past 20 years, turf toe has received increased attention in the media because of its effect on collegiate and professional athletes.

History of the Procedure: Prior to the advent of artificial playing surfaces in the late 1960s, sprains to the hallux MTP joint were relatively uncommon. As artificial turf became popular in sports such as football, the incidence of MTP joint injuries appeared to increase. During a round-table discussion in 1975 regarding the benefits and drawbacks of artificial turf, Garrick first suggested the relationship between first MTP joint sprains and the use of synthetic playing surfaces. One year later, Bowers and Martin introduced the term turf toe to describe a plantar-capsular-ligamentous sprain of the first MTP joint related to 2 predisposing factors: hard artificial surfaces and soft-soled shoes.

The earliest synthetic surfaces contained a synthetic nylon ribbon that wore away over time. Beneath that was a foam underpad that quickly became packed down, leaving a virtual asphalt-carpet interface. As a consequence, the effect of surface hardness was originally thought to be responsible for turf toe injury.

After the development of artificial turf, many players complained of poor traction with traditional shoes designed for use on grass surfaces. Despite lower rates of injuries, the demand for increased speed and traction in sports (eg, football) led to the development of a more flexible shoe. A softer soccer-style shoe replaced the traditional multicleated shoe containing a steel plate in the forefoot that was designed for grass surfaces. This show allowed a greater degree of motion in the MTP joints and placed significantly more stress across the forefoot.

In 1978, a major study from the University of Arkansas by Coker et al cited turf toe as a major cause of missed games and practices. However, it was not until 1986 that Clanton and coauthors developed a classification scheme for describing the degree of severity for turf toe injury. With some minor revisions since its original publication, this system continues to help in guiding treatment and predicting of return to play.

Problem: Turf toe injury is most commonly seen when an axial load is delivered to a foot fixed in equinus. The typical scenario, which often occurs in football linemen, involves the fixation of the forefoot on the ground in the dorsiflexed position with the heel raised. An outside force then pushes the foot into further dorsiflexion, resulting in traumatic hyperextension of the hallux MTP joint (see Image 1). Although turf toe is most frequently seen in football players, it can occur in athletes in any sport (eg, basketball, soccer, rugby).

Once thought to be a low-morbidity injury, significant disability can occur with damage to the periarticular structures of the MTP joint complex. This often is accompanied by both long- and short-term sequelae. As many as 50% of those with turf toe injuries have persistent symptoms after 5 years. In the short term, running and pushing-off are compromised, and players frequently miss games and practices. Possible long-term sequelae include hallux rigidus, hallux valgus, hallux cock-up deformity, and failure to regain push-off strength.