Turf Toe

Turf toe is the term used in athletic circles to describe a jamming or impaction injury of the great toe joint. 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. Turf toe 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.

Turf toe is also called hallux limitus or a dorsal bunion.  Turf toe represents just one of the four reasons that patients may 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.

It's important to understand that the terms turf toe and hallux limitus are indeed similar but aren’t 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.

Turf toe is graded in severity ranging from grade 1 through grade 4.  The following chart describes the clinical appearance, x-ray findings and corresponding treatment for each of the four stages of turf toe. 

Characteristic Findings By Stage Of Turf Toe.   Symptoms External appearance of the joint X-ray findings Treatment Stage 1 Vague joint pain. No change evident. No changes noted. Dancer's pad or sub 1 cut out in an orthotic. Stage 2 Increased frequency and duration of pain. Mild dorsal exostosis. Dorsal exostosis on lateral x-ray.   Carbon plate with Morton's extension. Possible joint revision. Stage 3 Pain with all activities. Large dorsal exostosis. Increased dorsal exostosis. Asymmetrical joint space narrowing. Youngswick osteotomy with joint revision. Stage 4 Significant pain with any range of motion of the joint. Enlargement of the entire joint. Flattening of the joint with prolific spurring surrounding the entire joint. Joint replacement, fusion or Keller bunionectomy.

Treatment of turf toe

Treatment of turf toe may include rest, shoe modifications, orthotics, steroid injections or surgery. The success of non-surgical care will vary with the severity of the initial injury, the current stage of injury, the rate at which the injury is healing and the general health of the patient.

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 motion of the great toe joint.

If a patient does not respond to conservative care of turf toe in a reasonable time period, there are several choices of surgical procedures that may be used to treat turf toe.  The most common surgical procedure addresses cases of turf toe in stages 2 &3.  This procedure is called a Youngswick modification of an Austin bunionectomy.  The Youngswick modification is used to shorten and plantarflex the 1st metatarsal as seen in the image to the left. This procedure is performed on an outpatient basis in either a hospital or surgery center.  The procedure is performed using either a general or local anesthetic with sedation.  Patients are able to bear partial weight the day of surgery.  Return to moderate athletic activities is realized in approximately 6 weeks. The following images show a Youngswick modification of an Austin bunionectomy for the treatment of stage 2 turf toe.  The post-operative x-ray to the right shows the shortening of the 1st metatarsal following the procedure.

Stage 4 turf toe represents complete destruction of the joint surfaces.  Stage 4 turf toe can be treated by either implant arthroplasty or joint fusion.  The choice between implant arthroplasty or fusion for the correction of stage 4 turf toe is open to debate.  The choice of procedure depends, in part upon your doctor's training and philosophical approach to the treatment of stage 4 turf toe. Patients considering these procedures should discuss treatment options for stage 4 turf toe with their doctor pe-operatively. 

The follow images show the steps necessary to complete implant arthroplasty of the great toe joint for cases of stage 4 turf toe.  This procedure is completed in either a hospital or surgery center using a general anesthetic or IV sedation with local anesthetic.  The procedure takes approximately 45 minutes to complete.  Patients are able to bear full weight the day of surgery.  Most patients return to an enclosed shoe at 3-4 weeks post-op.

Hallux - refers to the great toe.

1st metatarsal phalangeal joint (1st mpj) - the big toe joint. Made up by the 1st metatarsal bone on the proximal side of the joint and the proximal phalanx of the hallux on the distal side of the joint.

Bunion - an enlargement of bone at the medial aspect of the 1st metatarsal phalangeal joint.

Distal phalanx - the most distal phalange (bone) of a toe or finger. Most toes and fingers consist of three phalanges.

Hallux - Refers to the great toe.

Hallux limitus - limitation of the motion of the 1st metatarsal phalangeal joint (big toe joint)

Hallux rigidus - complete limitation of motion of the 1st metatarsal phalangeal joint. Also known as stage 4 hallux limitus.

Metatarsus primus elevatus - a fixed elevated position of the 1st metatarsal bone.

Middle phalanx - the middle phalange of a toe or finger. Most toes and fingers consist of three phalanges.

Phalange - plural for phalanx

Proximal phalanx - the most proximal phalange (singular) of a toe or finger. Most toes and fingers consist of three phalanges.

The 1st metatarsal bone, one of the five metatarsal bones, is located on the medial (inside) of the arch and is about the size of your index finger. The 1st metatarsal forms the proximal aspect of the 1st metatarsal phalangeal joint. The distal portion of the joint is compromised of the base of the proximal phalanx of the hallux.

Normal function of the great toe joint (1st metatarsal phalangeal joint) requires that the 1st metatarsal bone plantarflex (move down) to allow the proximal phalanx to ride up (dorsiflex). This hinge action needs to take place with each step. If the normal range of motion is limited in any way, jamming of the joint will occur and hallux limitus will ensue. There are two known biomechanical factors that contribute to the formation of hallux limitus. Those factors include;

A long 1st metatarsal - the relative length of the 1st and second metatarsals is very important in understanding the onset of hallux limitus. To explain the relevance of a long 1st metatarsal, consider this example; you have two bamboo poles that you hold under your left and right arms and extend directly out in front of you. The pole on the left is 5 feet long and the pole on the right is 10 feet long. You slowly lower the poles to the ground and the long (right) pole will hit the ground first, followed by the shorter pole. Now imagine the two poles as the 1st and second metatarsals of the left foot or right foot. For effective function of the great toe joint, the 1st metatarsal has to be that shorter pole. If it is longer, the normal hinge action will not occur and jamming will ensue.

An elevated 1st metatarsal (metatarsus primus elevatus)- as previously described, plantarflexion of the 1st metatarsal is required for the hallux to ride up onto the 1st metatarsal head. With an elevated 1st metatarsal, the hinge motion is limited and jamming ensues.

Direct injury to the joint - Impaction injury or hyperextension injury to the great toe joint is often called turf toe.  These injuries effect the normal biomechanics of the joint in a number of ways.  Turf toe injuries can result in bone contusions, damage to the articular surface of interposition of soft tissue or loose bodies within the joint.

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;

Arthritis

Fracture

Gout

Joint infection

Joint or bone tumor

Synovitis

• Bunion

• Hallux Rigidus

• Hallux Limitus

• Forefoot Pain

• Arthritis Of The Foot and Ankle

This article was written by Jeffrey A. Oster, DPM and last updated 2/8/13. 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