Does your toe hurt THAT much?

Author: Aaron Thomas, MD

Peer-reviewer: Brandon Godfrey, MD

Editor: Alex Tomesch, MD

A 22 year old football player limps to the sideline after catching a sideline pass requiring him to land forcefully on his toes to complete the catch in bounds.  Now he is complaining of pain at his right 1st MTP saying that he thinks his "toe popped out".  A point of care ultrasound of the MTP joint is shown:

Figure 1. Image courtesy of Ultrasoundpaedia

1. What is your diagnosis?

2. What imaging modalities can confirm diagnosis?

3. What is your prognosis, disposition, and management?

-- See below for answers --

1. What is your diagnosis?

Turf Toe, a term used to describe an injury to the first MTP, can involve a number of structures that commonly result from a force applied to the dorsiflexed first phalanx of the foot.  Multiple ligaments, sesamoid bones, and surrounding structures which comprise the plantar plate can be injured.  Artificial playing surfaces and softer, more flexible cleats have contributed to increased risk of this injury [1]. Fig 1 does not show any appreciable structural damage. 

2. What imaging modalities can confirm your diagnosis?

MRI imaging can be used, however it requires specialized protocols and equipment to obtain optimal coverage and imaging [2].  Radiographs may demonstrate avulsions, metatarsal-phalanx impaction, or joint diastasis.  Ultrasound may have value in uncovering more serious injuries on the turf toe spectrum.  Imaging may demonstrate hypoechoic soft tissue edema, a thickened and hypoechoic plantar plate, ligament thickening or discontinuity, a hypoechoic cleft between the plantar plate and proximal phalanx, or an avulsion fracture from the plantar plate insertion at the base of the proximal phalanx [3].  

3. What is your prognosis, disposition, and management?

The Anderson clinical classification is one method of grading injuries and can assist in determining severity of injury (shown below).  Initial conservative management includes NSAID's, RICE, immobilization or taping, and occasionally steroid injections or the use of orthotics.  Grade 1 and 2 injuries generally do well with conservative management and return to play as symptoms improve.  Grade 3 injuries may benefit from referral for surgical treatment.  There is little solid evidence for one treatment pathway over another and a recent systematic review did not find specific timelines for treatment [4].  Indications for surgical referral on a non-emergent basis include traumatic hallux valgus, joint diastasis, proximal migration of sesamoid, sesamoid fracture, osteochondral injury, or large capsule avulsion. 

Turf Toe Trivia:

The term "turf toe" was given its moniker by Bowers and Martin in 1976 at West Virginia University.

Bowers KD, Martin RB.  Turf toe: a shoe-surface related football injury. Med Sci Sports 1976; 8(2): 81-3   

References:

1. Ashimolowo T, Dunham G, Sharp JW, Porrino J. Turf toe: an update and comprehensive review. Radiologic clinics of north America. 2018; 56(6): 847-858. Doi:10.1016/j.rcl.2018.06.002

2. Crain JM, Phancao J-P. Imaging of turf toe. Radiologic clinics of north America. 2016; 54(5): 969-978. Doi: 10.1016/j.rcl.2016.04.010

3. Meyer NB, Jacobson JA, Kalia V, Kim SM. Musculoskeletal ultrasound: athletic injuries of the lower extremity. Ultrasonography (seoul, korea). 2018; 37(3): 175-189. Doi: 10.14366/usg.18013

4. Seow D, Tengku Yusof TNB, Yasui Y, Shimozono Y, Kennedy JG. Treatment options for turf toe: a systematic review.  The journal of foot and ankle surgery: official publication of the American college of foot and ankle surgeons. 2020; 59(1): 112-116. Doi: 10.1053/j.jfas.2018.12.041

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