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.

Treatment of hallux rigidus

Conservative care of hallux rigidus focuses on the use of pads to limit the range of motion of the great toe or devices to stiffen the shoe. Turf toe straps are a great short term aid for symptoms of hallux limitus and hallux rigidus. Turf toe plates and carbon spring plates are two examples of inserts that can be used to stiffen the shoe. Shoe modifications are also used to decrease bending of the forefoot. The most common modification is called an anterior rocker sole, seen at right.

Surgical care of hallux rigidus may include a Keller bunionectomy, great toe fusion or implant arthroplasty. A Keller bunionectomy is an old procedure that utilizes the capsule of the great toe joint to create a new joint. The capsule, or lining of the joint is interposed in the position where the joint is resected. The disadvantage of the Keller bunionectomy is that the great toe is usually much shorter and floppy post-op.

Fusion of the great toe joint is accomplished by resection of the joint and fixation of the joint with crossed screws or a plate. A bone graft is often used to supplement shortening created when the joint is resected. The bone graft can be from bone bank bone or from the iliac crest (crest of the pelvis). Fusion of the great toe joint requires a 6-8 week period of non-weight bearing for proper healing.

Implant arthroplasty (joint replacement) involves resection of the joint and replacement of the joint with a flexible hinge. The following images show the steps used to perform implant arthroplasty of the great toe joint. Image 1 shows the pre-op planning and location of the incision. Images 2 and 3 show dissection of the joint and removal of arthritic spurring surrounding the the joint. Image 4 shows the trial implant sizers. Images 5-8 show remodeling of the joint with preparation of the implant site. Image 9-12 shoe placement of the implant and final closure. This procedure is performed at a hospital or surgery center under general anesthesia or local anesthesia with sedation. The procedure takes about and hour to complete. Patients can bear full weight on the foot immediately following surgery.

For additional information regarding the onset and development of hallux rigidus, please refer to our pages on hallux limitus.

Hallux limitus is caused by four contributing factors. These factors include the following;

1. A long 1st metatarsal.
2. An elevated 1st metatarsal (metatarsus primus elevatus).
3. An impaction injury of the 1st mpj resulting in an osteochondral defect (OCD) of the joint.
4. Systemic diseases that cause injury to the joint such as rheumatoid arthritis, lupus or gout.

Hallux limitus is graded in four stages;

Treatment of Hallux Limitus

Evaluation of the range of motion of the 1st mpj can be performed in two positions; relaxed and functional. In a relaxed position, with no resistance exerted by the calf, the 1st mpj shows normal range of motion without pain. In a functional position, when resistance is applied by the calf, the range of motion of the 1st mpj changes and hallux limitus can be more appropriately assessed. The term functional hallux limitus is applied to cases that have normal range of motion in a relaxed position, but decreased range of motion in a functional position.

Assessment of hallux limitus requires evaluation of the 1st mpj in both a relaxed and functional position. Is there crepitus (grating or cracking) with range of motion? Does the joint catch or pop? Is there pain with range of motion? Each of these signs can indicate a certain stage of hallux limitus.

Conservative care of stage 1 hallux limitus may include the use of a dancer's pad or orthotic custom made with a sub 1 cut out pad. These two types of pads are used in an attempt to increase the plantarflexion of the 1st metatarsal to improve range of motion of the 1st mpj. As we progress into more advanced stages of hallux limitus (2-4), the dancer's pads will no longer be effective. At this stage, we change treatment to a stiff insert with a rigid extension called a Morton's extension. A Morton's extension is used to stiffen the shoe to decrease painful range of motion. Another short term solution for stage 2-4 is to use a turf toe strap to limit range of motion.

Injectable cortisone is often used to treat hallux limitus. There is some debate as to the merit of using cortisone for the treatment of hallux limitus. As noted above, the majority of cases of hallux limitus are due to aberrations in the biomechanical properties of the 1st mpj. Therefore, common sense would say that the most effective method of treatment for hallux limitus would be to change or alter the biomechanical property that is casing problems. For instance, if hallux limitus is due to a long first metatarsal, then the optimal treatment would be to shorten the first metatarsal. Cortisone cannot treat these biomechanical factors and therefore must have only a minimal role in the treatment of hallux limitus.

There are a number of common surgical procedures used to correct hallux limitus. One method of care is a procedure called a cheilectomy. Cheil means lip and a cheilectomy is a procedure that focuses exclusively on resection of the dorsal exostosis (the lip) of the 1st metatarsal head. A second type of surgery for hallux limitus is a metatarsal osteotomy and cheilectomy. The metatarsal osteotomy, often called a Youngswick's modification of an Austin bunionectomy, creates an break in the bone that can either shorten or plantarflex the head of the metatarsal. The osteotomy is important because it addresses the primary reason for hallux limitus (metarsus primus elevatus and a long first metatarsal). It should be noted that there is not universal agreement among doctors as to which of these procedure is the best solution for hallux limitus.

Many surgeons believe that hallux limitus can be corrected with a simple cheilectomy. The advantage to performing just a cheilectomy is that a person will regain some range of motion and be back on their feet relatively quickly. The disadvantage to performing just the cheilectomy without osteotomy is that the primary biomechanical reason for hallux limitus will not be addressed. In time, the dorsal lip will return and arthritis within the joint will increase. The disadvantage of an osteotomy is that it increases the difficulty of the surgery and increases healing time.

Cheilectomy and osteotomies are procedures applicable to stage 2 and 3 hallux limitus. In addition to these procedures, revision of the joint may be performed to repair or induce regeneration of the cartilage. Transchondral drilling is a technique used by many doctors to resurface the joint during surgery. Transchondral drilling means that a fine drill is used to drill through the hard layer of bone (subchondral bone) just beneath the surface of the cartilage. Drilling provides access to bone cells in the marrow of the bone that can become cartilage cells. These cells are known as pleuri-potential cells and are considered a form of stem cell.  Another technique used to resurface the joint involves the use of a osteochondral graft often referred to as an OAT procedure or osteo-articular transfer. OAT grafts can be harvested from other joints (often the knee) to transfer to the damaged cartilage of the 1st mpj. Synthetic bone graft material  and metallic implants can also be used for joint resurfacing.

Surgical repair of stage 4 hallux limitus again has disagreement among doctors as to the best choice of procedure. In stage 4, often referred to as hallux rigidus, the surface of the joint is so badly damaged that the joint is not salvageable. Implant arthroplasty is one choice. Implant arthroplasty involves resection of the joint and replacement of the joint with an implant. The advantage of implant arthroplasty is that the implant will maintain the normal length of the toe and preserve normal range of motion. Another technique used in stage 4 hallux limitus is fusion of the 1st mpj. Fusion of the joint requires a period of non-weight bearing for proper healing. The disadvantage of 1st mpj healing is that the toe may be shortened due to resection of the joint. A bone graft may be taken from the hip to supplement length. Another disadvantage of fusion is permanent stiffness of the 1st mpj. The last option for stage 4 hallux limitus is a Keller bunionectomy. A Keller bunionectomy is a procedure where the base of the great toe is resected and a new joint created using a flap of the joint capsule. This technique is called an interpositional arthroplasty; interposing the soft tissue to create a joint. The advantage of a Keller bunionectomy is that it is easy for patients to get back on their feet. The disadvantage is that the great toe becomes loose, short and floppy.

Surgical correction of hallux limitus is performed at a hospital or outpatient center. The procedure takes approximately 1 hours to complete. A local anesthetic with sedation or general anesthesia is used. Patients are able to bear weight on the foot immediately post-op for limited periods of time. A walking cast will be used for 6 weeks post-op. Variations in this procedure may include K wire fixation or absorbable pin fixation.