Turf toe is a term used in athletic circles to describe an injury to the great toe joint.  In non-athletic patients, turf toe is known by another name; hallux limitus.  Hallux limitus describes a number of different contributing factors that lead to pain and limited motion of the great toe joint.  Turf toe represents just one of the four reasons that patients develop hallux limitus.  Those four reasons include;

• Direct physical injury to the great toe joint (turf toe) - injury to the articular cartilage or subchondral bone. These injuries may be due impaction injuries or hyperextension/flexion of the first MPJ. 

• Functional hallux limitus - biomechanical function that results in metatarsus primus elevatus and subsequent repetitive jamming of the first MPJ.

• Structural hallux limitus - limited range of motion caused by a long first metatarsal.
• Other conditions - synovitis, crystal deposition diseases such as gout, systemic arthritis, external physical influences such as Dupytren's contracture, etc.

But before we go any further, we need to understand that the terms turf toe and hallux limitus are indeed related but aren’t really synonymous. The fundamental difference between the two terms is the patient population that they affect. Turf toe is a term used in athletic circles that refers to an injury of the great toe joint. On the other hand, when we discuss hallux limitus, we’re actually referring to a broader, ‘non-athletic’ patient population and need to include all four causes of hallux limitus.

Think of turf toe (hallux limitus) as an isolated case of osteoarthritis limited to the great toe joint. As the injury progresses, a series of micro fractures will develop in the subchondral bone. The typical soft spongy character of the metaphyseal bone (supporting bone beneath the joint surface) changes to become brittle and hard. The result is that the articular cartilage looses its’ underlying support and becomes susceptible to damage.  What you see on x-ray is the slow progressive destruction of the joint.

Turf toe (hallux limitus) caused by a direct injury to the joint may or may not initially be obvious. Athletes may not remember an incident of pain since they’re often distracted by the event or game in which they’re involved. The onset of direct injury to the joint may be abrupt, but also may be insidious becoming increasingly more painful as the season progresses. The joint pain will subside with rest only to recur with increased activity. It’s not unusual to see symptoms of turf toe resolve in the off season only to recur with renewed exercise.

Treatment of turf toe

Treatment of turf toe varies and may include rest, shoe modifications, orthotics, steroid injections and surgery. The success of non-surgical care will vary with the stage of injury, the rate at which the injury is healing and how much osteoarthritis has occurred (see our pages on hallux limitus for staging). In stage 1 turf toe, use of a dancer's pad can decrease pain by plantarflexing the first metatarsal, thereby increasing the range of motion of the great toe joint.  A turf toe strap can help in stage 2 to limit motion of the joint.  We see varying degrees of success with orthotics that promote plantarflexion of the first ray, effectively treating metatarsus primus elevatus and peroneus longus dysfunction. Simple arch supports can make a significant difference in the symptoms of turf toe. Most successful are orthotics with a rigid Morton's extension beneath the great toe joint.  A Morton's extension is used to decrease the range of motion of the joint.  Alternatively, a full length, rigid, carbon graphite spring plate may also be used to limit range of motin of the great toe joint.

Should a patient not respond to conservative care of turf toe in a reasonable time period, we are not reluctant to suggest surgical revision to address the problem whether it be revisions of the joint defect, shortening of a long first metatarsal or structural revision of metatarsus primus elevatus. As mentioned before, the clinical appearance of dorsal lipping or visible radiographic changes are suggestive of moderately advanced osteoarthritis, a condition that can only be repaired by joint revision or replacement.

Remember, turf toe is just one form of hallux limitus.  Be sure to visit our page on hallux limitus for a thorough discussion of this condition.

Hallux - refers to the great toe.

Limitus - decrease range of motion.

Metaphyseal - softer bone found adjacent to joints and acts as a shock absorber for load bearing.

Rigidus - loss of all motion.

The great toe joint, or first metatarsal phalangeal joint (1st mpj) is made up of the 1st metatarsal (proximal) and the proximal phalanx (distal).

The motion of the great toe joint is dependant upon the plantarflexion of the first metatarsal. If the first metatarsal is limited in its' ability to plantarflex, the joint will jam resulting in functional hallux limitus, which as we know is one of the causes of turf toe.  For more information on this condition, please refer to the biomechanics tab in hallux limitus.

Turf toe caused by a direct injury to the joint may or may not initially be obvious. Athletes may not remember an incident of pain since they’re often distracted by the event or game in which they’re involved. The onset of direct injury to the joint may be abrupt, but also may be insidious becoming increasingly more painful as the season progresses. The joint pain will subside with rest only to recur with increased activity. It’s not unusual to see symptoms of turf toe resolve in the off season only to recur with renewed exercise.

Symptoms include pain with the onset of activity.  Swelling and stiffness of the great toe joint increases with activity.  Bruising may occur following the initial injury but is not commonly seen as turf toe progresses.

The differential diagnosis of turf toe includes;

Arthitis

Fracture

Gout

Joint infection

Joint or bone tumor

Synovitis

• Bunion

• Metatarsalgia

• Hallux Rigidus

• Hallux Limitus

This article was written by Jeffrey A. Oster, DPM and last updated 7/05/07. Additional references include;

Lombardi, C.M., Silhanek, A.D., Connolly, F.G., Dennis, L.N., Keslonsky, A.J. First Metatarsophalangeal Arthrodesis for Treatment of Hallux Rigidus: A Retrospective Study. J. Foot Surg. 40:3, 137-143, 2001
Unger, K., Rahimi, F., Bareither, D., Muehleman, C. The Relationship Between Articular Cartilage Degeneration and Bone Changes of the First Metatarsophalangeal Joint. J. Foot Surg. 39:1 24-33, 2000
Ronconi, P., Monachino, P., Baleanu, P.M.,Favilli, G. Distal Oblique Osteotomy of the First Metatarsal for the Correction of Hallux Limitus and Rigidus Deformity. J. Foot Surg. 39:3, 154-160, 2000