pathology: turf toe

yogabook / pathologie / turf toe

Turf toe

Definition of

Abrupt changes of direction and, above all, contact with opponents can lead to twisting of the big toe as the ventrally prominent toe. Today’s artificial turfs allow players to play with lighter footwear, which provides less protection against impact trauma due to the less rigid sole, leading to dorsiflexion trauma, which is why this disorder is also known as turf (artificial turf) toe. The rarer sibling disorder with plantar flexion trauma is known as sand toe, as it occurs more frequently in beach volleyball, beach soccer and other barefoot sports with the possibility of contact with opponents. The injuries to the metatarsophalangeal joint caused by turf toe affect the joint capsule, the collateral ligaments, especially the medial collateral ligament and the plantar plate. In addition, the cartilage covering of the articulating bones or even the bones themselves can be affected. Turf toe is divided into three grades:

  1. plantar painful metatarsophalangeal joint, no bleeding, capsular overstretching without damage to the bone
  2. Pronounced swelling and pain, possibly bleeding, partial tear of the capsule, possibly small bony avulsion
  3. Pronounced pain, massive swelling, significant bleeding, significant capsular tear, joint instability

90% of diagnosed turf toes are grade 1. The incidence of turf toe is significantly lower than that of supination trauma, but the number of training sessions and competitions missed by athletes as a result is higher. In the case of surgically treated (i.e. at least grade 2) turf toe, the time to unrestricted, unsupported full weight-bearing is around 6-12 months, which is due to the fact that when the foot rolls, part of the load is placed on the metatarsophalangeal joint and the flexor tendons of the hallux, for which the capsule, cartilage, tendons and sesamoid bones must be in a physiological position. Since the trigger and the event are often trivialized, the severity of the injury and the consequences of the untreated case differ considerably. As early as 1990, figures showed that 45% of all players had suffered a turf toe injury in the course of their career. In 1994, a study showed that turf toe was the third most common cause of absence from competition after knee and ankle injuries. A very high proportion of turf toe injuries are traumatic, but it is also occasionally caused by overuse, especially in sports such as soccer, American football, athletics and basketball.

Cause

  1. Traumatic excessive flexion, dorsiflexion of the hallux in the metatarsophalangeal joint with or without or rotation in the metatarsophalangeal joint of the big toe

Predisposing

  1. Contact sports and sports with the possibility of opponent contact
  2. Too soft a sole when practicing the above sports

Diagnosis

  1. Predominantly clinical, additionally ultrasound, MRI (if necessary, with contrast)
  2. a proximal displacement of the sesamoid bones is a strong indication

Symptoms

  1. Pain on exertion when stepping and rolling the foot
  2. Tumor of the joint
  3. possibly instability
  4. Changed gait pattern due to pain avoidance
  5. Already from grade 1: plantar pressure pain, pain on movement during dorsiflexion, pain on exertion
  6. Grade 2 and above: markedly painful dosral flexion, pronounced hematoma and swelling
  7. Grade 3: pronounced pain avoidance behavior, instability of the joint

Complications

  1. untreated: hallux valgus, hallux limitus, hallus rigidus, rarely (depending on the injury) hallus varus

Therapy

The therapy varies according to the degree of injury:

  1. PECH, taping, Ridigus spring, sole stiffener or forearm crutches to relieve the toe; NSAIDs if necessary. After the pain has subsided (1-2 weeks), full resumption of training. Tapes and shoe reinforcement for a further 4-6 weeks
  2. In addition to grade 1: immobilization of the foot, e.g. with a short walker; training break for 6-8 weeks, followed by rehabilitation. Surgery if indicated
  3. additional surgery: conservative treatment results in 50% persistent instability, pain, stiffness, osteoarthritis
  4. Surgical indications (grade 2 and 3, promptly!):
  5. require surgical treatment: Flexor tendon tears(flexor hallucis longus), tears of the plantar plate, cartilage damage, free joint bodies, sesamoid fractures, capsular tears of the sesamoid bones
  6. all grades: no intra-articular injections for acute turf toe, for chronic turf toe: PRP, ACP
  7. Post-op: after one week of passive movement training, 4 weeks of short walker with full weight bearing, gradual return to full weight bearing within a further 4 weeks, followed by 3 months of sole stiffening. After 6-12 months unsupported return to full weight bearing