Rehabilitation following turf toe injury and plantar plate repair

Is It Necessary to Repair the Plantar Plate in the Management of Metatarsophalangeal Joint Instability?

Lesser metatarsophalangeal joint (MTPJ) instability is a common cause of metatarsalgia and is associated with plantar plate pathology. The instability is often due to chronic attenuation and attritional changes of the plantar plate and collateral ligaments, leading to eventual rupture. The plantar plate and collateral ligaments serve as the primary stabilizers of the MTPJ, and rupture or attenuation of these ligaments leads to instability. Surgical intervention is often necessary for plantar plate tears, with various approaches and techniques available.

Management and Return to Play of the Elite Athlete for Common Sports-Related Injuries About the Foot

Foot injuries are one of the most commonly injured areas of the body in many collegiate and professional sports. The wide range of pathology, pathophysiology, mechanisms of injury, differences in sport demands, evolution of treatment, and variable return-to-play time lines make it difficult, at times, for physicians to treat these injuries. Modern diagnostic tools, surgical treatment devices, and rehabilitation protocols have allowed for more accurate and rapid diagnosis, an improved ability to reestablish normal anatomy, and accelerated return to play for many sports-related foot injuries. This summary will provide the most up-to-date, evidence-based treatment options for common sports-related foot injuries along with the authors' preferred method of treatment and return-to-play algorithms for the elite athletes.

From injury to rehabilitation: How kinesiology taping helps patients with first metatarsophalangeal joint sprain (turf toe) in pain reduction, gait parameters and functional ability improvement. A randomized clinical trial

Objective

Turf toe is a common sports injury that may affect mobility and functional ability. For complete recovery, rehabilitation modalities are required to overcome these issues. This study investigated whether kinesio taping (KT) would reduce pain, improve gait performance, and enhance the functional capacity of turf toe patients undergoing physical therapy.

Methods

sixty patients with grade II turf toe (age; 25-30 years) assigned randomly into three treatment groups; KT applied alongside an exercise program conducted three times/week for 12 successive weeks. (KT group; n = 20), placebo taping plus exercise (Placebo group; n = 20), or exercise only (Control group; n = 20). Pain, gait parameters, and functional ability assessed using VAS, 3D gait analysis, and 6MWT respectively pre- and post-treatment.

Results

There was a significant post-treatment decrease in VAS score in the KT group lower than the control or placebo group and a significant increase in 6MWT distance in the KT group higher than the control or placebo group (p < 0.001). Additionally, there was a significant post-treatment increase in step length, stride length, cadence and velocity of KT group higher than control and placebo group (p < 0.05). There was no significant difference in gait parameters between control and placebo groups post treatment (p > 0.05).

Conclusions

The findings of the study demonstrated that KT is a useful complementary modality to exercise in patients with turf toe, as it may result in more favorable improvements to pain, gait characteristics, and functional abilities. Further studies should be conducted to assess the long-term effects, different KT application methods, and tailored treatment protocols on turf toe.

Turf Toe Injuries in the Athlete: an Updated Review of Treatment Options, Rehabilitation Protocols, and Return-to-Play Outcomes

PURPOSE OF REVIEW

First metatarsophalangeal joint sprains or turf toe (TT) injuries occur secondary to forceful hyperextension of the great toe. TT injuries are common among athletes, especially those participating in football, soccer, basketball, dancing, and wrestling. This review summarizes the current treatment modalities, rehabilitation protocols, and return-to-play criteria, as well as performance outcomes of patients who have sustained TT injuries.

RECENT FINDINGS

Less than 2% of TT injuries require surgery, but those that do are typically grade III injuries with damage to the MTP joint, evidence of bony injury, or severe instability. Rehabilitation protocols following non-operative management consist of 3 phases lasting up to 10 weeks, whereas protocols following operative management consist of 4 phases lasting up 20 weeks. Athletes with low-grade injuries typically achieve their prior level of performance. However, among athletes with higher grade injuries, treated both non-operatively and operatively, about 70% are expected to maintain their level of performance. The treatment protocol, return-to-play criteria, and overall performance outcomes for TT injuries depend on the severity and classification of the initial sprain. For grade I injuries, players may return to play once they experience minimal to no pain with normal weightbearing, traditionally after 3-5 days. For grade II injuries, or partial tears, players typically lose 2-4 weeks of play and may need additional support with taping when returning to play. For grade III injuries, or complete disruption of the plantar plate, athletes lose 4-6 weeks or more depending upon treatment strategy.

Outcome of Turf Toe Injuries in NFL Players

The increase in artificial turf in the 1970s was thought to have contributed to increased incidence of turf toe injury in National Football League (NFL) players. To our knowledge, there are no publications that have analyzed the impact of this injury on performance. This is a retrospective case series. Online resources were used to identify NFL players who sustained a turf toe injury between the 2011 and 2014 seasons. The performance of each offensive skill player was analyzed separately by calculating their power rating (PR) over 6 seasons. Injured offensive skill players were then compared to a control group consisting of all RBs and WRs without a turf toe injury who competed in the 2012 season. Seventy-one turf toe injuries were identified. Twenty-nine occurred on grass, 29 on turf and the playing surface of 13 injuries could not be identified. The average PR prior to injury was 105.7/season (7.3/game), 87.3 (6.9/game) for the season of injury and 115.5 (8.1/ game) for postinjury seasons. The PR was not significantly different after a turf toe injury compared to before injury or to uninjured control player. There was no significant difference in NFL players' performances after turf toe injury based on power ratings.

Hallux Sesamoid Injury Characteristics in Young Athletes Presented to the Sports Medicine Clinic

OBJECTIVE

To investigate clinical diagnoses, sports participation, and return to sport timeline associated with hallux sesamoid injuries with sex comparisons.

DESIGN

Descriptive epidemiology study.

SETTING

Sports medicine clinics at a tertiary-level pediatric medical center.

PATIENTS

Six hundred eighty-three young athletes (546 women and 137 men).

INDEPENDENT VARIABLES

Sex (women vs men).

MAIN OUTCOME MEASURES

Clinical diagnoses, participating sports, and injury timeline.

RESULTS

The most common diagnosis was sesamoiditis (62.6%). The top 3 primary sports were dance (34.6%), running (13.7%), and soccer (11.7%). When stratified by sex, dance (40.1%), running (13.6%), and soccer (10.7%) were the top primary sports for women while running (19.4%), soccer (18.5%), and basketball (11.3%) were the leading diagnoses for male athletes. The mean time between injury occurrence and first clinic visit was 135.5 ± 229.3 days. The mean time between the first clinic visit and return to sport was 104.3 ± 128.2 days. Comparison by sex showed that women had a longer mean time than men (women: 111.5 ± 132.5 days, men: 67.2 ± 96.3 days, P = 0.001). The mean time from injury occurrence to return to sport was 235.2 ± 281.0 days. Women showed a longer mean timeline for return to sport compared with men (women: 245.2 ± 288.2 days, men: 179.3 ± 231.9 days, P = 0.014).

CONCLUSION

Sesamoiditis was the most common diagnosis, and dance, running, and soccer were top 3 sports. The most salient finding was that women taking almost twice as long to return the sport or activity compared with men, which likely stems from delay of reporting symptom onset to clinics.

High-resolution 3T magnetic resonance imaging and histological analysis of capsuloligamentous complex of the first metatarsophalangeal joint

Background

There are discrepancies in the understanding of the structure of the capsuloligamentous complex of the first metatarsophalangeal joint (MTPJ); this study aims to investigate the differences with previous anatomical reports of high-resolution 3T magnetic resonance imaging (MRI) and histological analysis in illustrating the structure of the capsuloligamentous complex of the first MTPJ.

Methods

Nine fresh frozen cadaveric feet specimens (from two women and three men; aged 32 to 58 years) were used in this study. All specimens underwent MR examination with T1-weighted imaging and T2-weighted spectral attenuated inversion recovery in three planes. Subsequently, all cadaveric feet specimens were sliced into 2-mm-thick sections. The MRI features of the capsuloligamentous complex of the first MTPJ were analyzed in these specimens. Hematoxylin–eosin and Masson’s trichrome staining methods were used to explore the histologic features of the capsuloligamentous complex of the first MTPJ.

Results

Different from most previous studies, our results showed that the plantar plate could be divided into four portions including the central portion of the plantar plate, the intersesamoid, the sesamoid phalangeal and the metatarsosesamoid ligaments. The normal central portion of the plantar plate could be clearly visualized in the sagittal and coronal plane MR images. The intersesamoid ligament is a continuation of the central portion of the plantar plate on the sagittal plane on the gross specimen, the MR imaging, and the histological examination. On the coronal plane of the gross specimen and MR imaging, the sesamoid phalangeal ligaments and the central portion of the plantar plate can be seen as separate ligaments, but they appeared interwoven with the same continuous collagenous fibers on the histological analysis.

Conclusion

High-resolution 3T MRI allows accurate demonstration of the different anatomical details of the capsuloligamentous complex of the first MTPJ from previous anatomical reports. The histological analysis provides further understanding of the structures of the capsuloligamentous complex of the first MTPJ from previous studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02795-7.

Lateral Collateral Ligament Reconstruction Using Suture-tape for Chronic Varus Metatarsophalangeal Instability of The Hallux

Chronic varus instability or recurrent subluxation following isolated metatarsophalangeal dislocation of the hallux is a rare injury. A young Judo athlete with a history of repetitive sport injuries complained of recurrent medial dislocation of the hallux for 3 years. For prior injuries, he underwent manual reduction under local anesthesia and recovered with splint immobilization. Physical examination and fluoroscopic radiograph demonstrated the reducible but unstable first metatarsophalangeal joint to slight varus stress, and magnetic resonance imaging revealed an insufficient remnant of the lateral collateral ligament. For patients with the failed conservative treatment, no consensus has been reached regarding the best joint-salvage procedure to achieve a restoration of metatarsophalangeal stability and a fast return to sport activity. We report a case who achieved satisfactory clinical outcome through the collateral ligament reconstruction using a suture-tape.

Acute foot and ankle injuries and time return to sport

Foot and ankle sports injuries encompass a wide spectrum of conditions from simple contusions or sprains that resolve within days to more severe injuries that change the trajectory of an athlete’s sporting career. If missed, severe injuries could lead to prolonged absence from the sport and therefore a catastrophic impact on future performance. In this article, we discuss the presentation of the commonest foot and ankle sports injuries and share recent evidence to support an accurate diagnosis and best management practice.

Assessment and Treatment of Sports Injuries to the First Metatarsophalangeal Joint

Turf toe injuries have been increasing in numbers in recent years. Injury to the plantar restraints of the first metatarsophalangeal joint can lead to significant disability in athletes, affecting their push-off and ability to perform on the athletic field. Most turf toe injuries can be treated conservatively with rest, ice, compression, immobilization if needed, and a dedicated rehabilitation program; however, in some injuries, the plantar restraints are torn and the joint becomes unstable. If necessary, turf toe injury and its many variants can be surgically repaired with the expectation that the athlete will be able to return to play.

Turf Toe, Traumatic Hallux Valgus, and Hallux Rigidus -What Can I Do After an Metatarsophalangeal Fusion?

Turf toe injuries should be recognized and treated early to prevent long-term disability. The accurate clinical assessment and radiological evaluation of appropriate cases is important. Both conservative and surgical treatments play a major role in getting athletes back to their preinjury level. There are more recent reported case series and systemic reviews that encourage operative treatment as early as possible for grade III turf toe injury. If the patient presents late from a traumatic hallux injury with subsequent degenerative changes or has hallux rigidus from other etiologies, a first metatarsophalangeal arthrodesis should be considered to minimize pain and improve function.

Treatment Options for Turf Toe: A Systematic Review

Turf toe is hyperextension injury of the plantar plate at the first metatarsophalangeal joint. Etiologies have often included sports/activities with excessive forefoot axial loading and/or violent pivotal movements. The purpose of the systematic review was to systematically review and present an overview for the current evidence-based treatment options of turf toe. Both authors systematically reviewed the PubMed and EMBASE databases from inception to April 2016 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The level of evidence and quality of evidence were assessed by using the Level of Evidence for Primary Research Question of the Journal of Bone and Joint Surgery, and the quality of evidence was assessed with use of the Newcastle-Ottawa scale. Data were collected and categorized into: case reports and case series. Eight studies (16 turf toes) met the aforementioned criteria and were included. Five case reports and 3 case series reported various treatment options for turf toe. Specifically, 3 studies reported solely conservative treatment (n = 5), 1 study reported solely surgical treatment (n = 1), and 4 studies involved patients in conservative and/or surgical treatments (n = 10). All studies were of level of clinical evidence 4 and quality of clinical evidence score 2 (poor quality). Conservative treatment included closed reduction and immobilization, and surgical treatment included plantar plate tenodesis. Restricted dorsiflexion was the most common complication reported. Turf toe is an underreported injury with no evidence-based treatment guideline to date. Future studies of higher level and quality of evidence with a specific classification system (Jahss or Anderson) consistently reported are warranted for the development of an optimal guideline to determine the most appropriate treatment for each specific severity in injury.

High-Resolution MRI of the First Metatarsophalangeal Joint: Gross Anatomy and Injury Characterization

The first metatarsophalangeal joint (MTPJ) is vital to the biomechanics of the foot and supports a weight up to eight times heavier than the body during athletic activities. The first MTPJ comprises osseous and cartilaginous surfaces along with a complex of supporting structures, including the dorsal extensor tendons, collateral ligaments, and a plantar plate complex. In contradistinction to the lesser MTPJ plantar plates, a single dominant fibrocartilaginous capsular thickening does not exist at the first MTPJ. Instead, the plantar plate complex comprises a fibrocartilaginous pad that invests the hallux sesamoids and is inseparable from the plantar capsule, the intersesamoid ligament, paired metatarsosesamoid and sesamoid phalangeal ligaments (SPLs), and the musculotendinous structures. Acute injury at the first MTPJ is typically secondary to forced hyperextension-turf toe-and can involve multiple structures. During hyperextension, the resulting forces primarily load the distal SPLs, making these structures more susceptible to injury. SPL injuries are best seen in the sagittal plane at MRI. Radiography can also aid in diagnosis of full-thickness SPL tears, demonstrating reduced sesamoid excursion at lateral dorsiflexed (stress) views. Hallux valgus is another common condition, resulting in progressive disabling deformity at the first MTPJ. Without appropriate treatment, first MTPJ injuries may progress to degenerative hallux rigidus. The authors detail the anatomy of the first MTPJ in cadaveric forefeet by using high-resolution 3-T and 11.7-T MRI and anatomic-pathologic correlation. Injuries to the plantar plate complex, collateral ligaments, and extensor mechanism are discussed using clinical case examples. Online supplemental material is available for this article. ^©RSNA, 2020.

Turf Toe Review

Turf toe is a term used to describe myriad injuries to the metatarsophalangeal complex of the great toe, which have been associated with the introduction of artificial turf surfaces in sport. If not diagnosed early and treated properly, these injuries can result in chronic pain and loss of mobility. Accurate injury grading through physical exam and advanced imaging is essential to guide treatment, thereby minimizing long-term complications and maximizing an athlete's recovery and return to play. Levels of Evidence: Level V.

Outcomes of Chronic Turf Toe Repair in Non-athlete Population: A Retrospective Study

BACKGROUND

Turf toe injuries, though most common in athletes, can also occur in non-athletes. No study exists in the current literature investigating operative outcomes in non-athlete patients with chronic turf toe injury. In this study, we present our outcomes on operatively treated turf toe injuries in non-athletes in the only cohort yet studied.

METHODS

Using ICD-10 codes, we assembled a cohort of 12 patients who underwent operative repair of chronic turf toe injury from January 2012 through January 2018 at the investigating institution. These 12 patients were evaluated to determine demographic information, method of injury, length of time from injury to surgery, clinical and radiologic characteristics of the injury, and operative outcomes including mean preoperative and postoperative VAS (Visual Analog Scale) scores, preoperative and postoperative FFI (Foot Function Index) scores, and postoperative complications.

RESULTS

On initial clinical presentation, all 12 patients had local tenderness with associated painful range of motion. Four patients had restricted range of motion, all patients had a positive Lachman test, two had local edema, and eight had hallux valgus deformity. Mean VAS improved from 4.6 (range 2-9) to 1 (range 0-4). Mean FFI improved from 102.5 (range 56-177) to 61.75 (range 23-144). All patients had a negative Lachman test at final follow-up. No patients developed major complications or required revision surgery.

CONCLUSIONS

Our study is the first to investigate operative outcomes following chronic turf toe injury in non-athlete patients. Based on our study, surgeons and patients can expect significant improvement in overall pain and function following surgery.

First MTP joint instability - Expanding the concept of "Turf-toe" injuries

BACKGROUND

Although the classic definition of the Turf-toe injury refers to a very specific clinical and pathological picture, we think that the concept can be broadened to encompass a wide variety of traumatic lesions of the first metatarsophalangeal joint (MTP1). These are lesions typically difficult to diagnose, with a large variation of outcomes and a potential to impair patients' functional performance on a definitive and perennial basis. The objective of this study is to present the result obtained by treating 24 cases of traumatic injuries to the MTP1 joint in a midterm follow-up time.

METHODS

In the period from 1999 to 2016, 24 patients were treated with MTP1 joint instability - "Expanded Turf-toe" - diagnosis. All patients were performing sports activities when they were injured: soccer (33%); martial arts (17%); running (13%); tennis (8%); olympic gymnastics (8%) and others (basketball, slalom, motorcycling, surfing, and ballet) (21%). Injuries were classified as Grade I (2 patients - 8%), Grade II (8 patients - 33%) and Grade III (14 patients - 59%) lesions. All patients with grades I and II were treated conservatively whereas those classified as grade III were treated surgically.

RESULTS

After an average follow-up of 4.5 years we observed an improvement in the AOFAS hallux score from 42 to 82 points after treatment (p<0.001). The most frequent cause was axial load with various direction of stress at the first MTP. The mechanism of lesion varied among extension with hallux varism (42%), pure hyperextension (25%), extension with hallux valgism (21%), pure hyperflexion (8%) and hyperflexion with hallux valgism (4%). A separate analysis of each group showed a significant improvement in AOFAS Hallux scores after treatment: 51-84 (p<0.001) and 36-81 (p<0.001) for conservative and surgical groups, respectively. Four patients with GIII injuries (29%) and two with GII injuries (20%) did not resume their previous activities. Although pre-treatment AOFAS hallux scores were significantly different between groups, post-treatment scores were similar (p=0.615).

CONCLUSIONS

Turf-toe is a serious injury that may prevent a high percentage of patients from resuming their previous physical activities. Mechanism of lesion might be varied generating a wide range of lesions that fit into the expanded concept of the Turf-toe injury. Both forms of treatment lead to satisfactory results if well conducted. The correct identification, classification, and grading of first metatarsophalangeal joint (MTP) instability helps in decision making and selection of the adequate treatment.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Return to Sport After Turf Toe Injuries: A Systematic Review and Meta-analysis

Background

The prevalence of turf toe injuries has increased in recent years. However, uncertainty remains as to how to optimally treat turf toe injuries and the implications that the severity of the injury has on outcomes, specifically return to sport (RTS).

Purpose

To determine RTS based on treatment modality and to provide clinicians with additional information when comparing operative versus nonoperative treatment of turf toe injuries in athletes.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review and meta-analysis was performed using the PubMed/Ovid MEDLINE/PubMed Central databases (May 1964 to August 2018) per PRISMA-IPD (Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Individual Participant Data) guidelines. RTS, treatment, severity of injury, athletic position, and sport were recorded and analyzed.

Results

Of 858 identified studies, 12 met the criteria for the final meta-analysis. The studies included 112 athletes sustaining a total of 121 turf toe injuries; 63 (52.1%) of these injuries were treated surgically, while 58 (47.9%) were treated nonoperatively, and 53.7% were classified by the grade of injury (grade I, n = 1; grade II, n = 9; grade III, n = 55). Overall, 56 (46.3%) injuries could not be classified based on the data provided and were excluded from the final analysis. The median time to RTS for patients treated nonoperatively was 5.85 weeks (range, 3.00-8.70 weeks) compared with 14.70 weeks (range, 6.00-156.43 weeks) for patients treated surgically (P < .001); however, there was variability in the grade of injury between the 2 groups. Similarly, patients who sustained grade II injuries returned to sport more quickly (8.70 weeks) than patients who had a grade I (13.04 weeks) or grade III injury (16.50 weeks) (P = .016). The amount of time required to RTS was significantly influenced by the athlete's level of play (16.50 weeks for both high school and college levels; 14.70 weeks for professional level) (P = .018).

Conclusion

The time to RTS for an athlete who suffers from a turf toe injury is significantly influenced by the severity of injury and the athlete's level of competition. Professional athletes who suffer from turf toe injuries RTS sooner than both high school and college athletes. However, there are a limited number of high-level studies evaluating turf toe injuries in the athletic population. Further research is necessary to clearly define the appropriate treatment and RTS protocols based on sport, position, and level of play.

Properties and Function of the Flexor Hallucis Capsularis Interphalangeus Tendon

INTRODUCTION

The fibrocartilagenous plantar plates of the forefoot are biomechanically important, forming the primary distal attachment for the plantar aponeurosis. They are integral to the function of the windlass mechanism in supporting the arches of the foot in gait. Dissection of the cadaveric hallux revealed an organised sagittal thickening of the dorsal side of the flexor hallucis longus (FHL) sheath, which attached the interphalangeal plantar plate to the metatarsophalangeal (MTP) plantar plate. A description of a similar structure was made in 1984 when it was termed the flexor hallucis capsularis interphalangeus (FHCI) - however, it has not been researched since, and we aim to study it further and identify its characteristics.

METHOD

Eight specimens were dissected from four cadavers. Two were stained and examined under magnification in both polarized and non polarized light. The remaining 6 were subjected to micrometer testing of their tensile properties.

RESULTS

Both the histological features and mechanical properties were consistent with tendon; with cross sectional area, ultimate tensile strength and stiffness varying between specimens.

CONCLUSIONS

Based on its location and properties, the FHCI tendon may be involved in limiting dorsiflexion of the first MTP joint and could have clinical relevance in pathological processes around both the first and second MTP joints. Clin. Anat., 33:689-695, 2020. © 2019 Wiley Periodicals, Inc.

Turf Toe Injury - Current Concepts and an Updated Review of Literature

Turf toe injuries can be a disabling if not recognized and treated early. A high index of suspicion, based on the mechanism of injury and appropriate imaging, helps in the timely diagnosis. These injuries are frequently known to occur on artificial playing surfaces, because of the increased traction at the shoe-surface interface. Stress and instability testing are key components to assess the need for surgical intervention. Accurate timely diagnosis and treatment can allow full return to physical activities for most athletes, back to their pre-injury level.

Turf toe: A clinical update

Turf toe is a condition that describes injury to the plantar metatarsophalangeal-sesamoid complex of the great toe.

It is a relatively rare and debilitating condition, particularly seen in American footballers after the introduction of harder, artificial ‘turf’ surfaces.

Turf toe represents a significant injury to the hallux and requires a high index of suspicion.

If unrecognized, it can lead to chronic problems including reduced push-off strength, persistent pain, progressive deformity and eventual joint degeneration.

Patients with chronic injuries may have worse outcomes, and therefore early, accurate diagnosis and initiation of treatment play a vital role.

A multidisciplinary team approach is key for successful return to sport.

Cite this article: EFORT Open Rev 2018;3:501-506. DOI: 10.1302/2058-5241.3.180012

Operative Outcomes of Grade 3 Turf Toe Injuries in Competitive Football Players

BACKGROUND

Turf toe is a term used to describe a hyperextension injury to the first metatarsophalangeal joint. Although the vast majority of turf toe injuries can be treated successfully without operative intervention, there are instances where surgery is required to allow the athlete to return to play. Although there is a plethora of literature on turf toe injuries and nonoperative management, there are currently few reports on operative outcomes in athletes.

METHODS

We obtained all cases of turf toe repair according to the ICD-10 procedural code. The inclusion criteria included: age greater than 16, turf toe injury requiring operative management and at least a varsity level high school football player. The charts were reviewed for age, BMI, level of competition, injury mechanism, football position, setting of injury and playing surface. In addition, we recorded the specifics of the operative procedure, a listing of all injured structures, the implants used and the great toe range of motion at final follow-up visit. The AOFAS Hallux score and VAS was used postoperatively as our outcome measures. Our patient population included 15 patients. The average follow-up time was 27.5 months.

RESULTS

The average patient was 19.3 years old with a body mass index of 32.3. The average playing time missed was 16.5 weeks. The average dorsiflexion range of motion at the final follow-up was 42.3 degrees. At final follow-up, the average AOFAS Hallux score was 91.3. The average VAS pain score was 0.7 at rest and 0.8 with physical activity.

CONCLUSION

Complete turf toe injuries are often debilitating and may require operative management to restore a pain-free, stable, and functional forefoot. This study represents the largest cohort of operatively treated grade 3 turf toe injuries in the literature and demonstrates that good clinical outcomes were achieved with operative repair.

LEVEL OF EVIDENCE

Level IV, case series.

Turf Toe and Disorders of the Sesamoid Complex

A turf toe injury encompasses a wide spectrum of traumatic problems that occur to the first metatarsophalangeal joint. Most of these injuries are mild and respond well to nonoperative management. However, more severe injuries may require surgical management, including presence of diastasis or retraction of sesamoids, vertical instability, traumatic hallux valgus deformity, chondral injury, loose body, and failed conservative treatment.

Plantar-plate disruptions: "the severe turf-toe injury." three cases in contact athletes

OBJECTIVE

To present 3 cases of plantar-plate rupture and turf-toe injury in contact athletes at 1 university and to discuss appropriate diagnosis and treatment algorithms for each case.

BACKGROUND

Turf toe is a common injury in athletes participating in outdoor cutting sports. However, it has been used as an umbrella term to describe many different injuries of the great toe. In some cases, the injury can be so severe that the plantar plate and sesamoid apparatus may be ruptured. These patients may be better managed with surgery than with traditional nonoperative interventions.

DIFFERENTIAL DIAGNOSIS

Turf toe, plantar-plate disruption, sesamoid fracture.

TREATMENT

For stable injuries in which the plantar plate is not completely disrupted, nonoperative treatment with casting or a stiff-soled shoe, gradual weight bearing, and rehabilitation is the best practice. Unstable injuries require surgical intervention and plantar-plate repair.

UNIQUENESS

Turf toe and injury to the first metatarsophalangeal joint are relatively common injuries in athletes, but few researchers have detailed the operative and nonoperative treatments of plantar-plate disruption in these patients. We examine 3 cases that occurred over 4 seasons on a collegiate football team.

CONCLUSIONS

Turf toe represents a wide array of pathologic conditions involving the first metatarsophalangeal joint. Stress and instability testing are key components to assess in determining whether surgical intervention is warranted to restore optimal function. Stiffer-soled shoes or shoes with steel-plate insertions may help to prevent these injuries and are useful tools for protection during the rehabilitation period.

Epidemiology and imaging appearance of the normal Bi-/multipartite hallux sesamoid bone

BACKGROUND

Turf toe is a hyperextension injury of the hallux metatarsophalangeal joint that can be difficult to diagnose on physical examination and imaging. Diastasis of the bi- or multipartite sesamoid of the hallux has been implicated as 1 potential radiographic finding of turf toe injury, and when present may require operative management. However, the normal interval for the bi-/multipartite sesamoid has not yet been established.

METHODS

A total of 671 foot radiograph series were reviewed in effort to quantify the dominant interval of the bi-/multipartite sesamoid bone with respect to potential influencing factors including right versus left foot, medial and/or lateral sesamoid involvement, patient age and gender, and weight versus non-weight-bearing radiograph technique.

RESULTS

The prevalence of a bi-/multipartite hallux sesamoid was 14.3% in our population. The dominant sesamoid interval ranged from 0-2 mm, with an average of 0.79 mm.

CONCLUSION

We conclude that sesamoid diastasis should be considered, in the appropriate clinical setting, when the sesamoid interval is greater than 2 mm on a routine AP radiograph of the foot.

LEVEL OF EVIDENCE

Level III, comparative study.

Turf toe and sesamoiditis: what the radiologist needs to know

The first metatarsophalangeal (MTP) joint complex is a critical weight-bearing structure important to biomechanics. An acute dorsiflexion injury, named "turf toe," is common among American football and soccer players. "Sesamoiditis" is a name often given for pain arising from the hallux sesamoids in the absence of acute trauma, and may result from a variety of causes. The first MTP joint complex can also be affected by degenerative or inflammatory arthritis, infarct, and infection. This review article will cover the anatomy and biomechanics of the first MTP joint complex, its patterns of injury and pathology, imaging techniques, and management.

Case series of first metatarsophalangeal joint injuries in division 1 college athletes

Context:

Injuries of the first metatarsophalangeal (hallux MP) joint can be debilitating in the athletic population. Turf toe and plantar plate injuries are typically diagnosed similarly. However, variance in injury mechanism as well as compromised integrity of soft tissue and ligamentous structures make it difficult to accurately diagnose specific hallux MP injuries. Recent literature has supported the use of both radiographic imaging and the Lachman test as reliable indicators of joint instability in the presence of hallux MP injuries. To date, research supporting specific rehabilitation interventions and return-to-play decision making for hallux MP injuries has been limited to case studies and suggested guidelines from literature reviews. There is limited evidence suggesting specific criteria for surgical and nonsurgical decision making in conjunction with rehabilitation progressions to return an athlete to sport when managing hallux MP injuries.

Evidence Acquisition:

A literature search was performed using Medline, PubMed, and Google Scholar to find and review articles from 1970 to 2013 that addressed the basic anatomy of the plantar plate, injuries to this anatomical structure, and the evaluation, diagnosis, surgical and nonsurgical management, and rehabilitation of these injuries, specifically in the athletic population. Medical information for each case was gathered from electronic medical records from the individual athletes cited in this case series, which included imaging reports, rehabilitation documentation, and both evaluation and surgical reports. No statistical analysis was used.

Study Design:

Case series.

Level of Evidence:

Level 4.

Results:

Treatment plans for each case varied depending on surgical and nonsurgical intervention and rehabilitation outcomes. However, each athlete was able to return to sports-specific activities.

Conclusion:

Successful outcomes for hallux MP injuries are contingent on thorough evaluation, appropriate clinical decision making with regard to surgical versus nonsurgical treatment planning, and a multidisciplinary team approach for ensuring a safe return to sport.

Strength-of-Recommendation Taxonomy (SORT):

C.

The plantar plate of the first metatarsophalangeal joint: an anatomical study

The plantar plate of the first metatarsophalangeal (MP) joint is a critical structure of the forefoot that has been identified as a major stabilizer within the capsuloligamentous complex. Many studies have clarified and documented the anatomy of the lesser toe MP plantar plates, but few have looked closely at the anatomy of the first MP joint. Ten cadaveric specimens were examined to identify and document the objective anatomic relationship of the plantar plate, tibial sesamoid, and surrounding osseus structures. The average distance of the plantar plate distal insertion from the joint line into the proximal phalanx was 0.33 mm. The plantar plate was inserted into the metatarsal head on average 17.29 mm proximal from the joint line. The proximal aspect of the sesamoid was 18.55 mm proximal to the distal attachment of the plantar plate to the phalanx. The distal aspect of the sesamoid averaged 4.69 mm away from the distal attachment into the proximal phalanx. The footprint of the distal plate insertion was on average 6.33 mm in length in the sagittal plane. The authors hope that these objective data measures can aid in the understanding and subsequent surgical repair of this important forefoot structure.

Incidence and risk factors for turf toe injuries in intercollegiate football: data from the national collegiate athletic association injury surveillance system

BACKGROUND

Turf toe is the general term for a sprain of the first metatarsophalangeal (MTP) joint complex. Previously attributed to shoe design and artificial turf, the incidence of turf toe injury has been thought to decline with the advent of newer turf designs. However, the current incidence and epidemiology remain unknown as the majority of the literature consists of small series and addresses diagnosis and treatment rather than epidemiology and prevention.

METHODS

We examined data from the NCAA's Injury Surveillance System (ISS) for 5 football seasons (2004-2005 through 2008-2009), including all preseason, regular season, and postseason practice and competition data. The incidence, epidemiology, and risk factors for turf toe injury, defined as injury to the connective tissue of the first MTP joint, plantar plate complex, and/or sesamoid fracture, were determined.

RESULTS

The overall incidence of turf toe injuries in NCAA football players was 0.062 per 1000 athlete-exposures (A-Es; 95% CI 0.052, 0.072). Athletes were nearly 14 times more likely to sustain the injury during games compared to practice, with a mean days lost due to injury of 10.1 (7.9, 12.4). Fewer than 2% of turf toe injuries required operative intervention. There was a significantly higher injury rate on third-generation artificial surfaces compared to natural grass (0.087 per 1000 A-E [0.067, 0.11] vs 0.047 per 1000 A-E [0.036, 0.059]). The majority of injuries occurred as a result of contact with the playing surface (35.4%) or contact with another player (32.7%), and running backs and quarterbacks were the most common positions to suffer turf toe injury.

CONCLUSION

Our data suggest a significantly higher incidence of turf toe injuries during games, a greater susceptibility among running backs and quarterbacks, and a significant contribution of playing surface to risk of injury. Though turf toe injuries may be less common that previously reported in elite football players, these injuries warrant appropriate acute and long-term management to prevent long-term dysfunction.

LEVEL OF EVIDENCE

Level IV, case series.

Radiographic evaluation of plantar plate injury: an in vitro biomechanical study

BACKGROUND

The term turf toe has been generally applied to athletic dorsiflexion injuries of the hallux metatarsophalangeal (MTP) joint. Variations in injury patterns coupled with the complexity of the MTP joint makes the diagnosis of more severe injuries challenging and may lead to a failure in recognition of an unstable joint and a subsequently prolonged recovery. Although the proximal migration of one or both sesamoids has been previously identified with a plantar plate disruption, the current study proposes a quantitative grading system based on dorsiflexion stress radiographs, providing a predictable and reproducible test for evaluating the extent of injury to the first MTP joint.

METHODS

Twenty-four nonpaired fresh-frozen foot/ankle specimens with no history or physical evidence of prior injury were used in this study. The specimens were randomly assigned into 4 cutting groups, and the 4 main distal ligaments of the plantar plate were identified and sectioned. Lateral dorsiflexion fluoroscopic stress images were obtained in the intact state and with each subsequent cut. With each image, measurements from the distal margin of the sesamoids to the most proximal margin of the proximal phalanx were taken. Images were obtained at 45 degrees with both a fibrous loop wrapped around the interphalangeal joint and applying 15 N and also with a manual dorsiflexion stress. Statistical testing performed was a repeated-measures analysis of variance with Tukey post hoc to compare measurements between each group to determine if movement of the sesamoid bones relative to the phalanx quantitatively increased with each structure that was cut.

RESULTS

Our results demonstrate a relationship between the number of ligaments injured in the turf toe simulation and an increase in sesamoid phalangeal distance. We found that an increase of 3 mm in the distance from the sesamoids to the proximal phalanx was significant and predictive of a severe injury to the plantar plate.

CONCLUSION

Injuries producing differences of 3 mm or greater from the intact state have a high likelihood of having sustained injury to at least 3 of the 4 ligaments of the plantar plate complex. This study is the first to establish a quantitative grading scale for evaluating turf toe injuries radiographically based on changes in movement of the sesamoids relative to the intact state.

CLINICAL RELEVANCE

In assessing a turf toe injury, historically the evaluation has been qualitative, but our study provides quantifiable data for evaluation of the severity of plantar plate injuries, which may provide guidance to physicians for treatment decisions.

Turf toe: anatomy, diagnosis, and treatment

Context:

Despite an increasing awareness of turf toe injury, confusion still exists regarding the anatomy, mechanism, diagnosis, and treatment of this hyperextension injury to the hallux metatarsophalangeal (MTP) joint.

Evidence Acquisition:

This article reviews the anatomy, diagnosis, and treatment algorithm for turf toe injury by reviewing relevant studies and presenting information useful to clinicians, therapists, and athletic trainers. A literature search was performed by a review of PubMed and OVID articles published from 1976 to July 2010.

Results:

Grade I injury is a sprain or attenuation of the plantar capsular ligamentous complex of the hallux MTP joint; athletes are typically able to return to play as tolerated. Grade II injury is a partial rupture of the plantar soft tissue structures of the hallux MTP joint, typically requiring about 2 weeks to recover. Grade III injury is a complete rupture of the plantar structures of the hallux MTP joint, requiring at least 10 to 16 weeks to recover. Some complete ruptures require surgical repair.

Conclusion:

With accurate diagnosis, athletes can have an appropriate treatment plan, and their expectations can be tempered to the degree of injury. Careful management may allow successful return to play at a preinjury level of participation.

Fifth toe plantar plate repair in a professional soccer player: case report

Level of Evidence: V, Expert Opinion