Figure 1. Anteroposterior radiograph of the right great toe.
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Figure 2. Lateral radiograph of the right great toe.
A 19-year-old college football player presents with a 2-day history of severe great toe pain on the right foot following an injury sustained during a game. He believes the toe was injured when another player fell on the back of his foot, forcing his big toe into the ground. Physical examination reveals a severely swollen great toe with almost no passive motion of the metatarsophalangeal (MTP) joint. The patient has severe pain with any motion of the MTP joint. Anteroposterior and lateral radiographs of the great toe are obtained (Figures 1 and 2).
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Turf toe is a common sports-related injury of the great toe. The typical mechanism of injury is hyperdorsiflexion of the first MTP joint when an axial load is placed on the heel. The injury typically occurs when the heel is raised and the forefoot is fixed to the ground. A force through the heel drives the forefoot into the ground causing hyperextension of the MTP joint. An example of this mechanism occurs when a football player falls on the back of another player’s plantarflexed foot. Risk factors for turf toe injury include playing on hard surfaces such as older-style turf fields and wearing more flexible shoes.
Injury severity may vary from a mild grade 1 injury to a severe grade 3 injury. Grade 1 injuries result in a mild stretch (sprain) of the plantar plate (capsular-ligamentous complex), but the toe usually retains full passive range of motion. Grade 2 injuries result in partial tearing of the plantar plate with moderate swelling and limited painful mobility. Grade 3 injuries cause complete tearing of the plantar plate with severe swelling, bruising, and very limited mobility of the great toe.
Almost all turf toe injuries are treated with rest, ice, nonsteroidal anti-inflammatory drugs, and 2 to 6 weeks of immobilization of the toe with a stiff-soled shoe or walking boot. Athletes must have at least 50° to 60° of painless passive dorsiflexion in order to resume running and jumping. Up to 6 months may be required for severe Grade 3 injuries to heal and for players to return to sports. Indications for surgery include severe fracture or injury to the sesamoid bones; an unstable, deformed MTP joint; and a large capsular injury.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
1. Poppe T, Reinhardt D, Tarakemeh A, Vopat B, Mulcahey M. Turf toe: presentation, diagnosis, and management. JBJS Rev. 2019;7(8):e7
2. Watts E. Turf toe. OrthoBullets website. https://www.orthobullets.com/foot-and-ankle/7011/turf-toe. Accessed November 4, 2019.