The term turf toe is used to describe a sprain of the first MTP joint, it’s a hyperextention injury to plantar plate and sesamoid complex of the hallux MTP joint.
Turf toe injury is more common in football, baseball, and soccer players.
Mechanism of Injury
The mechanism turf toe injury can also involve hyperflexion and varus and valgus stresses of the first MTP joint.
With forced hyperflexion of the hallux, tearing of the plantar plate and collateral ligaments can occur.
In the more severe injury, the capsule can actually tear off from the metatarsal head.
A fracture of the sesamoids can also occur, and posterior (dorsal) dislocation of the first MTP joint is possible.
Turf Toe Classification
Clanton and Ford have classified the severity of turf toe injury into 3 grades:
- Grade I: a minor stretch injury to the soft tissue restraints with little pain, swelling, or disability.
- Grade II: a partial tear of the capsuloligamentous structures with moderate pain, swelling, ecchymosis, and disability.
- Grade III: a complete tear of the plantar plate with severe swelling, pain, ecchymosis, and inability to bear weight normally.
|Grade I||Capsular strain||Stiff insole, turf toe taping, |
Immediate return to play.
|Grade II||Partial capsular tear||No athletic activity for 2 weeks, stiff insole, |
Return to play if painless 60-degree dorsiflexion present.
|Grade III||Complete tear of the plantar plate||Superior results demonstrated with operative repair of the plantar plate over conservative care|
Clinically, patients with turf toe present with a swollen, stiff, and red, first MTP joint.
They may have a history of a single dorsiflexion injury or multiple injuries to the great toe.
The joint may be tender, both plantarly and posteriorly (dorsally).
Players may have a limp and be unable to run or jump because of pain.
Turf toe typically develops into a chronic injury and long term results include decreased first MTP joint motion, impaired push-off, and hallux rigidus. Fifty percent of athletes will have persistent symptoms 5 years later.
Radiographic views include:
- weightbearing AP,
- Lateral view,
- oblique view.
- sesamoid axial views.
Radiographic findings may include:
- Increased the sesamoid-to-joint distance.
- Medial sesamoid may be displaced proximally.
- A sesamoid fracture
Bone scan is indicated if persistent pain, swelling, weak toe push-off with negative x-ray findings. It may show increased signal at 1st MTP joint.
MRI will show disruption of volar plate.
Turf Toe Treatment
The treatment for turf toe in the acute phase is rest, ice, a compressive dressing, and elevation, and NSAIDs are often prescribed.
The Turf Toe tapping is done with multiple loops of tape placed over the posterior (dorsal) aspect of the hallucal proximal phalanx and criss-crossed under the ball of the foot plantarly to limit dorsiflexion.
Occasionally, a forefoot steel plate is used.
Passive ROM and progressive resistance exercises are begun as soon as patient tolerance allows.
Patient returns to normal activities is based on the initial severity:
- Patients with grade I sprains are usually allowed to return to sports as soon as symptoms allow, sometimes immediately.
- Patients with grade II sprains usually require 3–14 days, rest from athletic training.
- Grade III sprains usually require crutches for a few days and up to 6 weeks, rest from sports participation.
A return to sports training too early after injury could result in prolonged disability. Return to play is indicated when the toe can be dorsiflexed 90 degrees.
Turf Toe Complications
- Hallux rigidus: a late sequela, treatment with cheilectomy versus arthrodesis, depending on severity
- Proximal phalanx stress fracture: may be overlooked.
- Wedmore IS, Charette J: Emergency department evaluation and treatment of ankle and foot injuries. Emerg Med Clin North Am 18:86–114, 2000.
- Hockenbury RT. forefoot problems in athletes. Med Sci Sports Exerc. 1999 Jul;31(7 Suppl):S448-58. doi: 10.1097/00005768-199907001-00006. PMID: 10416546.
- Sammarco GJ: Turf toe. Instr Course Lect 42:207–212, 1993.
- Omey ML, Micheli LJ. Foot and ankle problems in the young athlete. Med Sci Sports Exerc. 1999 Jul;31(7 Suppl):S470-86. doi: 10.1097/00005768-199907001-00008. PMID: 10416548.
- Glasoe WM, Yack HJ, Saltzman CL: Anatomy and biomechanics of the first ray. Phys Ther 79:854–859, 1999.
- Garrick JG. Characterization of the Patient Population in a Sports Medicine Facility. Phys Sportsmed. 1985 Oct;13(10):73-6. doi: 10.1080/00913847.1985.11708901. PMID: 27409750.
- Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
- Millers Review of Orthopaedics -7th Edition Book.