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Turf Toe

The term turf toe has become a commonly accepted name referring to a sprain involving the hallux (great toe) metatarsophalangeal (MTP) joint of the foot. The name was first coined in 1976 after it was found that the frequency of injuries to the MTP joint was much greater during competition on artificial playing surfaces. The injury is fairly common; it is seen most often in football, but it also occurs in other sports such as wrestling, basketball, and dance, among others. Because this particular joint plays a key role in running, sprinting, and cutting, an injury can result in significant functional disability. It is thought to be underreported and not always appreciated as the significant injury that it may be or can become if it is not appropriately managed.

Anatomy

The anatomy of the forefoot is intricate and quite complicated. The MTP joint of the hallux involves a metatarsal (long bone) with a rounded, cartilage-covered surface at the end, which joins with the concave base of the phalanx (toe bone). Stability of the MTP joint comes from medial (inside) and lateral (outside) collateral and metatarsosesamoid ligaments in addition to a strong plantar plate. There are also several different muscle tendons that run along either side and underneath the joint, attaching onto the phalanx. These structures together make up the intricate capsuloligamentous complex of the first MTP joint.

Motion in the joint consists primarily of plantarflexion (downward) and dorsiflexion (upward). Passive range of motion varies widely from 3 to 43 of plantarflexion and from 40 to 100 of dorsiflexion.

Causes

The two primary causes of turf toe are the advent of artificial playing surfaces and the coinciding introduction of flexible-soled turf shoes. Artificial playing surfaces were introduced in the 1960s, and with that came a dramatic increase in the number of turf toe injuries. This is due to the increased friction caused by the artificial surface and shoe interface. When artificial turf was introduced, players were typically wearing a grass cleat with a metal plate in the sole, which attached to the cleats and added stability to the forefoot. After playing on the artificial surface, players complained of traction problems, which led to the introduction of a flexible turf shoe. Both caused the incidence of turf toe injuries to increase dramatically.

As artificial turf ages, it stiffens. This has also been thought to contribute to the increasing incidence of turf toe injuries, although studies have not validated this hypothesis. Since natural playing surfaces are once again becoming the standard, it is expected that turf toe injuries will also decrease.

Mechanism of Injury

The most common mechanism of injury is hyperextension of the great toe. This often occurs with tackling in American football, where the forefoot is fixed on the playing surface with the heel raised in a dorsiflexed position. A force from the tackler is thus directed down the lower leg into the foot, causing an exaggerated dorsiflexion and subsequent hyperextension of the great toe. This hyperextension can lead to varying degrees of injury to the plantar plate, capsule, and collateral ligaments or the cartilage surface of the bone.

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