TURF TOE
( Volar Plate Rupture )
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related: foot fracture; broken toe; ankle sprain; flat foot; toe deformity
What is a Turf Toe?
A Turf Toe is an injury to the Volar Plate (an important ligament of your toes).
A Turf Toe occurs after hyperextending the big toe (it gets bent back too much). Hyperextension will overstretch the joint ( called the 1st metatarsophalangeal joint, say that 5 times fast), which causes the joint capsule, and/or the Volar Plate to be sprained (partially torn) or completely torn. The Volar Plate is important for stabilizing the big toe and preventing it from drifting upward.
The injury often occurs in athletes when they make a sudden acceleration movement on a hard surface (this is likely how the injury got its name: astroturf is not a very forgiving surface to play on). The big toe plays an important role in our "push off" when we start to sprint, and thats why it gets torn after a specific injury.
The smaller toes can also experience an injury to the Volar Plate, but they arent very involved in push-off during sprinting, and therefore the Volar Plate doesnt get torn in this way. Instead, the Volar Plate can just wear out over time (a process called "attenuation") and will become so loose it doesnt do its job (think of a rubber band that looses its elasticity with too much use). The vast majority of these "Chronic Volar Plate Injuries" happen to the 2nd toe. The result is the same: without anything holding the toe down at the joint (MCP joint), the toe will start to drift upward, and this causes pain at the base of the toe.
How is a Turf Toe diagnosed?
In cases of an acute Turf Toe in your Big Toe (like in athletes), people usually report experiencing a sharp pain while playing a sport. In cases of chronic Turf Toe, people report noticing that their 2nd toe has been slowly drifting upward over a few months or years.
Turf Toe at the Big Toe is typically very painful especially at the bottom of the foot at the joint (thats where the injured volar plate is located).
A Turf Toe sprain, the mild version, is diagnosed when there is pain in the big toe, yet it does not prevent weight bearing on the toe. Inability to stand on the foot, or significant pain when moving the toe suggests a complete tear of the joint capsule or worse, a torn Volar Plate.
A complete Volar Plate tear is suspected when theres severe pain with any big toe motion (or if seen a few weeks after the injury, if the big toe is hyper-mobile, indicating instability).
X-rays of the foot are important to rule out a broken bone, which can cause similar pain and swelling. A stress fracture (a broken bone that slowly develops over many weeks due to repetitive stress on a bone) should always be considered when people come in with these symptoms. X-rays are negative (dont show any injury) in a Turf Toe because its a soft tissue injury (x-rays are really best at showing injury to bone).
Oftentimes an MRI is ordered, which is the best way to see a tear in the Volar Plate (yet because this ligament is so small, it may be difficult to see even on MRI...that is why a detailed physical exam by the doctor is so important). .
How is a Turf Toe treated?
The good news is that Turf Toes are mostly treated without surgery.
If the injury is a sprain only then there are typically no activity restrictions, most doctors recommend turning to activity as you can tolerate. If the injury occurs during a game, the athlete can usually return to sports immediately with the toe taped to its neighbor ("buddy tape").
If the capsule is completely torn off but the Volar Plate is intact, then a two week rest from sports is recommended and the foot should be placed into a hard-sole shoe (or medical boot) to protect the toe while it hears. Rest from activity should be continued until the toe is painless when bent upward to 60 degrees.
If the capsule and volar plate is completely torn, as determined by MRI or by physical exam (see the diagnosis section), surgery may be required if the joint remains unstable after a few weeks in a boot. Meaning, even if everything gets torn, there is still a decent chance the injury heals and the toe remains stable. Only if the toe remains unstable and prevents someone from returning to their pre-injury function, is surgery recommended.
Sometimes, when the volar plate tears, it actually pulls off a small bone fragment (called an avulsion fracture) which can get stuck within the joint. In such cases, surgery should be performed sooner than later.
Sometimes a bunion can form after the injury because the joint is unstable and becomes progressively more unstable with time. In such cases, surgery is also recommended.
What is the long term outcome?
People often recover well from the acutely traumatic turf toe injury, however the chronic turf toe (referred to as a floating toe) does not heal as reliably because all of the toe ligaments and associated soft tissue is loose from years of wear-and-tear and so its difficult for surgeons to obtain a strong restoration of ligaments to prevent future recurrence.
Reference
1) Bowers KD Jr, Martin RB. Turf-toe: A shoe-surface related football injury. Med Sci Sports 1976; 8: 81-83. full article. first paper to coin term.
2) McCormick JJ, Anderson RB. Turf toe: Anatomy, diagnosis, and treatment. Sports Health 2010; 2: 487-494. full article.
3) McCornick JJ, Anderson RB. The great toe: Failed turf toe, chronic turf toe, and complicated seasmoid injuries. Foot Ankle Clin 2009; 14: 135-150. full article.
4) Frimenko RE et al. Etiology and biomechanics of first metatarsophalangeal joint sprains (turf toe) in athletes. Crit Rev Biomed Eng 2012; 40: 43-61. full article.
5) Drakos MC et al. Synthetic playing surfaces and athlete health. JAAOS 2013; 21: 293-302. full article. review.
6) Anderson RB et al. Management of common sports-related injuries about the foot and ankle. JAAOS 2010; 18: 546-56. full article. review.
7) Rodeo SA et al. Turf-toe: an analysis of metatarsophalangeal joint sprains in professional football players. Am J Sports Med 1990; 18: 280-5. full article. affects 45% of nfl players.
8) Anderson R. Turf toe injuries of the hallux metatarsophalangeal joint. Techniques in Foot & Ankle Surgery 2002; 1: 102-11. full article. most return to prior level after surgery.