Turf Toe Injuries Research Articles

Outcomes of Surgical Management of Turf Toe: 12-Year Results.

Background "Turf toe" is a classical capsuloligamentous injury to the plantar surface of the metatarsophalangeal (MTP) joint of the great toe. The name is synonymous with injuries sustained on artificial turf or hard grounds. The classical injury pattern is a hyperdorsiflexion injury with an axial load. The outcomes of these injuries are unpredictable and there are no clear guidelines for the management of these injuries. These injuries are debilitating and can lead to long-term problems and inability to return to pre-injury activity level if missed. We present a long-term surgical follow-up of severe grade 3 turf toe injuries. Methods In the period from 2011 to 2022, we treated 20 patients with turf toe/MTP joint instability. There were 10 football injuries (50%), six running injuries (30%), two gymnastic injuries (10%), one motorcycle injury (0.5%), and one was a ballet dancer (0.5%). All the grade 1 and 2 injuries were treated conservatively with rest, ice application, and splinting of the toe. Grade 3 injuries were treated surgically and strict rehabilitation protocol was followed. Results The mean age at surgery was 32.7 years and the average patient follow-up was 7.5 months after surgery. The Manchester-Oxford Foot Questionnaire (MOXFQ) score showed a statistically significant improvement from a mean of 73.0 (median = 75) preoperatively to 28.1 (median = 28.6) postoperatively (median improvement = 46.4, P = 0.022). Similarly, there was a significant improvement in pain score, which showed an improvement from a mean of 72.9 (median = 70.0) preoperatively to a mean of 22.9 (median = 25.0) postoperatively (median improvement = 51.3, P = 0.022). Conclusion Turf toe is a serious injury that may prevent a high percentage of patients from resuming their previous physical activities. The correct identification, classification, and grading of the first MTP joint instability helps in decision-making and achieving good surgical outcomes.

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

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. 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.

Grade III Turf Toe Injury in a Cowboy.

Turf toe injuries are common, particularly in athletes competing on artificial turf. This debilitating injury and its associated sequelae can affect the long-term performance of athletes and others. In this case is presented an atypical cause for development of grade III turf toe. This case presents an acute injury with significant damage to the plantar first metatarsophalangeal joint, with plantar plate rupture and tibial sesamoid retraction secondary to injury involving working calves on a ranch. The anatomy, mechanism, and associated treatments are reviewed. The anatomical and functional interplay with this injury is discussed.

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.

Open Reduction and Screw Fixation of a Diastatic Bipartite Hallux Sesamoid in Turf Toe Injury: A Case Report

We present a case of a 25-year-old male professional soccer player who complained of severe pain over the first metatarsal head after opponent contact during a soccer game. Clinical findings showed swelling and tenderness. Initial radiographs showed a diastasis of a bipartite medial sesamoid between the fragments as compared to radiographs taken 4 years earlier of the same foot. A computed tomography scan was performed objectifying the widened interval and also showing an angulation of the proximal fragment. Open reduction and screw fixation were performed, leading to adequate positioning of the 2 bipartite fragments. The patient showed good clinical recovery and returned to the same performance level. Turf toe injury with diastasis of a medial bipartite sesamoid can be treated successfully with this operative technique.Levels of Evidence: Level V: Case report

Turf Toe and Sesamoiditis

Two of the more common sporting injuries involving the forefoot are acute capsuloligamentous injuries at the metatarsophalangeal (MTP) joint and overload injuries of the sesamoid complex. These terms are referred to as turf toe and sesamoiditis, respectively, neither of which is descriptive or specific for the underlying cause of the patient's pain. Turf toe injuries can range from mild sprains to complete disruptions of the plantar capsule, requiring a careful understanding of each patient's injury to facilitate a timely return to sport. Sesamoiditis in the athlete is commonly secondary to a stress fracture, osteonecrosis, or chondromalacia, and warrants nonoperative care prior to a surgical intervention. In the following section, we will review the pertinent anatomy, common presentations, and recommendations for treating these injuries.

Dynamic Imaging Evaluation in Turf Toe Injuries: A Prospective Protocol in 18 Patients

CategorySports; TraumaIntroduction/Purpose:Turf Toe remains a diagnostic challenge for the orthopedic surgeon. A high index of suspicion is needed, in addition to adequate imaging strategies to characterize the broad spectrum of injuries involving this pathology. MRI imaging provides excellent static soft-tissue details and it has become widely used to determine the anatomical structures damaged.However, defining the stability of the 1st metatarsophalangeal (MTP) plantar plate complex is difficult without proper dynamic evaluation and this is crucial to define between conservative or operative management. Since there is no current consensus regarding the optimal imaging assessment to optimize turf toe diagnosis we present the results of an imaging protocol, including dynamic fluoroscopy and ultrasound (US), to enhance the identification of unstable Turf Toe injuries.Methods:A prospective imaging protocol consisting of bilateral comparative weightbearing x-rays, US examination, and mobilization under fluoroscopy was designed. The inclusion criterion was any patient with clinical findings consistent with plantar plate injury after forced hyperextension of the hallux. All studies were informed and performed by trained musculoskeletal radiologists. Location and symmetry of the sesamoids under the metatarsal, increased distal sesamoid-to-phalanx distance and proximal migration of one or both sesamoids were suggestive findings of unstable plantar plate rupture on weightbearing x-rays. Ultrasound examination was performed to address soft tissue injuries, characterize the magnitude of the plantar plate rupture and for dynamic/comparative stability assessment. A comparative dynamic fluoroscopic evaluation was performed to evaluate the behavior of the sesamoids under maximal dorsiflexion and plantarflexion of the hallux on the lateral view. MRI was also done in all of the patients with positive findings of instability.Results:Eighteen patients (11M/7F) were evaluated under suspicion of turf toe injury from August 2016 to November 2019. The mean age was 31 years old (range:14-50). Weightbearing X-rays were positive for sesamoid complex instability in one patient.Four patients (22,2%) had positive findings for instability in fluoroscopy and US. The agreement between US and fluoroscopy was excellent (kappa coefficient 1). Assuming fluoroscopy examination as the gold standard for instability, the US was highly effective at detecting unstable injuries (Sensitivity 100%, Specificity 100%, PPV 100%, NPV 100%). Four patients positive for instability received operative treatment.Conclusion:In our series, dynamic ultrasound and fluoroscopy allowed detection of 4/18 unstable turf toe injuries compared to Weightbearing X-rays that detected only one unstable injury. US examination is highly sensitive for instability being comparable to fluoroscopic examination. Dynamic testing, with either US or fluoroscopy, in turf toe may improve the diagnosis of severe injuries, leading to higher detection of patients requiring surgical stabilization of the plantar complex.

Return to Play Following High-Grade Turf Toe Injuries in National Football League Athletes

Category:Sports; Midfoot/Forefoot; TraumaIntroduction/Purpose:Return-to-play (RTP) rates of National Football League (NFL) athletes following surgical intervention for numerous foot and ankle injuries has been reported. To our knowledge, no studies have reported on RTP rates of NFL athletes after non-operative and operative treatment of high-grade turf toe injuries. The purpose of this study was to evaluate the RTP rates in NFL athletes who sustained high-grade turf to injuries. We hypothesized that NFL athletes requiring operative intervention for high-grade turf toe injuries would have lower RTP rates and longer recoveries than athletes treated non- operatively. Additionally, we hypothesized that regardless of treatment, NFL athletes would demonstrate equal productivity following RTP.Methods:Publicly available NFL injury data was reviewed to identify athletes who sustained high-grade turf toe injuries, as indicated by surgical intervention or missed playing time of 2 weeks or more. Athletes were excluded if RTP was prevented for reasons unrelated to the injury. Demographic and performance data was obtained including a player’s injury, date of injury, date of surgery, RTP, time to RTP, number and percentage of games played, and performance.Results:53 NFL athletes were identified with high-grade turf toe injuries that met inclusion criteria. 28 of these athletes were treated non-operatively and 25 were treated with surgery. The overall RTP rate was 91%. Athletes who were treated non- operatively had a RTP rate of 100% while athletes who underwent surgery had a RTP rate of 80% (P = 0.011). The mean time to RTP for all athletes was 140.9+-111.9 days. The mean time to RTP for non-operatively treated patients was 75.8+-99.0 days, compared with 221.4+-81.6 days for operatively treated athletes (P = 0.002). In skill position athletes who achieved RTP, 78% treated non-operatively were able to return to their prior level of performance compared to only 27% for athletes treated surgically (P = 0.032).Conclusion:There is a significant difference in return to play following surgical versus non-operative management of high-grade turf toe injuries, with only 80% of athletes achieving return to play after surgery. No athletes were able to return the same season as surgery and the mean time to RTP following initiation of treatment was significantly shorter for players who underwent non- operative management. Postoperative performance was also significantly worse in players who underwent surgical intervention compared to non-operative management. This study provides important prognostic information to high level athletes in regards to recovery following high-grade turf toe injuries

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

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. 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. 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. 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.

Forefoot Injuries in Sports

Forefoot injuries are common injuries in high-impact sports. The forefoot experiences a large amount of stress during the late stance phase of the gait cycle. Repetitive load applied to the forefoot without adequate rest can lead to tissue breakdown, resulting in injury. Forefoot sporting injuries can deteriorate gait function, sporting performance, and quality of life. In this article, we review the typical presentation, approach, and treatment modalities of the commonest forefoot sporting injuries. These include metatarsal stress fractures, second metatarsophalangeal joint (MTPJ) instability, turf toe injury, sesamoid pathologies, as well as hallux valgus and rigidus. Metatarsal stress fractures are frequent overuse injuries. They can be managed conservatively with activity modification and protected weight-bearing or surgically with open internal fixation. Second MTPJ instability typically involves disruption of the second MTPJ ligamentous joint capsule. Management of this condition includes customized orthotics, physiotherapy, hydrocortisone and lignocaine (HL7(2):50–56.

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.

Outcome of Turf Toe Injuries in NFL Players

Category:Midfoot/Forefoot, Sports, TraumaIntroduction/Purpose:“Turf toe” is an injury to the great toe’s metatarsophalangeal joint capsule. The increase in artificial turf in the 1970’s was thought to have contributed to increased incidence of this injury in players of the National Football League (NFL). To our knowledge, there are no publications that have critically analyzed the impact of this injury on player performance. The goal of this study was to quantify the impact a turf toe injury has on NFL players, specifically in time to return to competition and their performance post-injury compared to pre-injury.Methods:This is a retrospective review of NFL players who sustained a turf toe injury between the 2011-2014 seasons. Online resources including NFL injury reports, player registries, game summary sites, NFL news articles, fantasy football sites and NFL blogs were used to identify players with this injury. Additionally, an injury database from theFantasyDoctors.com was used to further identify injured players. Recorded variables included player age, position, games missed, and type of playing surface on which the injury occurred. The performance of each offensive skill player was analyzed separately by calculating their power rating (total yards divided by 10 plus touchdowns multiplied by 6) for the 3 seasons prior to injury, the injury season (index season) and the 2 seasons immediately following. Injured offensive skill players were then compared to a control group consisting of all running backs and wide receivers without a turf toe injury who competed in the 2012 season.Results:71 turf toe injuries in 67 players were identified. Players’ average age was 26.4 years old. Injury by playing surface: 29 grass, 29 turf and 13 unidentified. The average time missed was 3.2 games. 9 players were placed on injured reserve and 8 required surgery. 16 offensive skill players were at or above 200 total points during the 6 observed seasons. The average power rating prior to injury was 105.7 per season (7.3 per game), 87.3 (6.9 per game) during the injury season and 115.5 (8.1 per game) for post-injury seasons. The power rating per season (p=0.53) and per game (p=0.4) was not significantly different after a turf toe injury compared to before. Power ratings were not significantly different from uninjured control players (p=0.24, p=0.27).Conclusion:”Turf toe” is a term used for an injury that has a wide spectrum of consequence depending on injury severity. A mild sprain of the great toe should respond well to conservative treatment with rest, taping and possibly an orthotic while a complete tear of the metatarsophalangeal joint capsule typically is season-ending and requires surgical repair. We were unable to show a statistically significant difference in NFL players’ performances after turf toe injury based on power ratings.

Return to Sport Following Turf Toe Injuries: A Systematic Review and Meta-Analysis

Category:SportsIntroduction/Purpose:The prevalence of turf toe injuries has increased in recent years due to heightened awareness and the large number of athletes participating in sports today. Uncertainty remains, however, as to how to properly treat turf toe and the prognosis for these injured athletes. The purpose of this study was to systematically review the literature to provide recommendations on treatment of turf toe and expectations for outcomes and return to play.Methods:Following PRISMA criteria, a systematic review and meta-analysis using the PubMed/Ovid Medline/PMC databases was performed (May 1964 – August 2018). Studies evaluating non-turf toe injuries, biomechanical studies, and those written in non- English language were excluded. Return to sport, treatment, severity of injury, athletic position, and sport were recorded and statistically analyzed.Results:12/944 studies met criteria, which included 112 athletes and 120 turf toe injuries. The athletes played a variety of sports: football (111), basketball (2), soccer (1), and track (3). 58 of these injuries were treated non-operatively, while 62 required surgery. There was one grade 1 injury, ten grade 2 injuries, and fifty-four grade 3 injuries. Fifty-five injuries were unclassifiable and excluded. Return to sport for patients treated non-operatively was 5.9 weeks versus 19.2 weeks in patients treated operatively (p=0.007). Patients with a grade 2 injury returned to sport quicker (11.7 weeks) than patients with grade 3 injuries (19.9 weeks) (p=0.016). Return to play was different according to the athlete’s level of play (13.9 weeks high school, 16.8 weeks college, 14.4 weeks professional) (p=0.018).Conclusion:Return to sport in patients suffering from a turf toe injury can be affected by either the severity of injury and/or level of competition of the athlete. However, this study also acknowledges the limited number of high level studies evaluating turf toe in the athletic population. Further research is necessary to clearly define appropriate treatment and return to play protocols based on sport, position, and level of play.

First MTP joint instability — Expanding the concept of “Turf-toe” injuries

BackgroundAlthough 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. MethodsIn 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. ResultsAfter 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). ConclusionsTurf-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.

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

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. 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. 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. 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 IV, case series.

Fracture of the Medial Sesamoid Bone in a professional soccer player

The incidence of medial sesamoid bone fracture is rare. Clinically they are often misdiagnosed as soft tissue injuries and often missed. Thus generates an important morbidity for the patient. Objectives: We present a case of turf-toe injury: plantar-plate rupture with medial sesamoid bone fracture in a contact athlete. Methods: A 19-year-old professional soccer player injured his left toe when he planted his foot during a sprint. He had an hyperextension and axial overload traumatism in his toe. On physical examination he had pain, swollen, ecchymosis, instability and loss of plantar-flexion strength. Radiographs showed a transverse medial sesamoid bone fracture with retraction &gt; 3 mm. Magnetic resonance imaging confirmed a subluxation of the proximal phalange and a plantar plate disruption. Because of the completely deficient flexion, the sesamoid retraction, and the articular subluxation, surgery was recommended to restore the MTPJ anatomy. Reduction of the fracture and Repair of the plantar plate was performed using non-absorbable 2-0 Fiber wire sutures through a medial approach. Postoperatively, the patient was placed in a cast, for a total of 2 weeks. After that he began a rehabilitation program. Results: The patient had a complete recovery. He returned to participation in his team at 3 months. At final follow-up, his dorsiflexion ROM was 60 in the involved toe. Conclusion: Turf-toe and disorders of the sesamoid complex is an important injury, often misdiagnosed and usually undertreated. They had an incidence of 25% to 50% of residual pain and limited dorsiflexion in those cases. Despite the incidence of surgical treatment of 2%, we have found hopeful results with the open reduction and internal fixation of the fracture. Accurate and timely diagnosis and treatment can allow for full return to activity for these athletes.

THE MANAGEMENT OF TURF TOE – A SYSTEMATIC REVIEW

Background. Turf toe is used to describe an injury occurring at the plantar aspect of the metatarsophalangeal- sesamoid complex of the hallux. Typically seen in athletes, it occurs due to hyperdorsiflexion and axial loading of the hallux metatarsophalangeal joint with the foot fixed in equinus. The injury causes pain and joint instability, missed athletic activity and potentially end careers. Turf toe can be managed conservatively or operatively, with controversy regarding the indications for operative intervention. This study aims to conduct a systematic review to determine whether and in what circumstances operative intervention is superior to conservative management of turf toe in adults. Methods. A systematic review of the literature was performed using PubMed, Embase, Cochrane and Scopus databases. The search terms used were “turf toe”, “first metatarsophalangeal joint injury”, “conservative”, “nonoperative”, and “operative”. All articles published in English reporting on the management of turf toe were reviewed. The primary outcome measure was the time to return to pre-injury activity with the secondary outcome of the time to symptom resolution. Results. Seven studies met the inclusion criteria. Three patients were successfully managed conservatively returning to athletic activity, on average at 12 weeks. Seventeen patients underwent surgical intervention with an average return to athletic activity at 18 weeks. Conclusion. Operative intervention was shown to give a successful outcome in patients with grade three turf toe injuries or those who have failed conservative management. However, there is insufficient evidence to determine whether operative intervention is superior to conservative management.

Surgical Outcomes of Severe Turf Toe Injuries in High-Level Football Players

Category: Sports Introduction/Purpose: 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 surgical intervention, there are instances where surgery is required to allow the athlete to return to play. Surgical turf toe repair restores the continuity of the plantar plate structures, re-establishes stability, and simultaneously addresses any sesamoid pathology or cartilage lesions. Although there is extensive literature on turf toe injuries and its nonoperative management, there are currently no reports on surgical outcomes in athletes larger than three to four patients. Methods: After obtaining Institutional Review Board approval, we attained 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. Our patient population consisted of thirteen patients. Their charts were reviewed for age, BMI, level of competition, injury mechanism (if known), football position, setting of injury (practice or game) and playing surface. In addition, we recorded the specifics of the surgical procedure, a listing of all injured structures, the surgical implants used and the great toe range of motion at final followup visit. In addition, a followup survey was administered to all patients. Results: The average patient was 19.5 years old with an average followup time of 21.4 months. Our group consisted of six linemen and seven skill position players. There was one semiprofessional player, ten collegiate players and two high school players. Eight of the 13 patients had complete rupture of both fibular and tibial phalangeal sesamoid ligaments while five patients had a partial injury. Seven of the patients had a suture only primary repair while in six patients suture anchors were utilized. The average playing time missed was 16.4 weeks. No patient had to stop playing football or change positions due to the injury or surgery. At final followup, the average patient had a VAS pain score of 0.21. Conclusion: Severe turf toe injuries are often debilitating and may require operative management to restore a pain-free, stable, and functional forefoot. The injuries sustained and procedures performed were variable in our patient population but every player was able to return to play at a high level with the use of a custom orthotic placed inside their cleat. This study represents the largest cohort of operatively treated severe turf toe injuries in the literature and demonstrates that good clinical outcomes can be expected with surgical repair.

The influence of gearing footwear on running biomechanics

The influence of nonlinear bending stiffness footwear, which alters the metatarsophalangeal (MTP) joint bending as a function of forefoot bending stiffness, has been postulated to improve athletic performance and reduce injury risk during many sports. As the shoe moves through greater amounts of bending, forefoot stiffness should increase nonlinearly, to shift the centre of pressure forward (improving performance), while restricting forefoot bending in regions where turf toe injury may result. Recently, materials which allow for stiffness modifications as a function of forefoot flexion angle have been developed; however, the efficacy of this technology is unknown. Therefore, the purpose of this project was to evaluate the influence of gearing technology (a variable bending stiffness shoe) on biomechanics during running and sprinting. Ten male recreational athletes performed running and sprinting in two footwear conditions consisting of an altered US 10 adidas 16.4 FXG cleat. The footwear was altered by placing carbon fibre insoles with variable (nonlinear stiffness) into the shoes creating two different conditions: Control (no insole) and the variable stiffness (varStiff) shoe (gearing insoles). Kinematic (joint angles) and kinetic (ground reaction force and 3D joint moments) data of the lower extremity were recorded during each movement. The results of the study indicate that the variable stiffness insoles did positively influence athlete lower extremity biomechanics. At the MTP joint, as running speed increased (and normal MTP bending range of motion increased), the variable stiffness insoles reduced the amount of MTP bending of the shoes and reduced the medial–lateral movement of the point of force application. Additionally, the variable stiffness insoles reduced key biomechanical injury risk variables, such as non-sagittal plane joint loading at the knee and ankle joint.

Turf Toe: 40 Years Later and Still a Problem

“Turf toe,” originally described in literature by Bowers and Martin in 1976, is an injury to the capsuloligamentous complex of the first metatarsophalangeal joint. This injury is common in football players. Up to 45% of National Football League (NFL) players have suffered from turf toe during their professional career. Turf toe injuries have been attributed to playing on hard, artificial surfaces with soft, flexible cleats; 83% of the turf toe injuries occurred on artificial turf. For most turf toe injuries, nonoperative treatment is the preferred approach, even in some cases with associated fracture of the sesamoids. Operative intervention should be considered after nonoperative management has failed or in cases of clear instability or sesamoid retraction. Good functional outcomes with high rates of return to play can be expected with appropriate management. Despite this, persistent symptoms of stiffness and great toe pain are not uncommon following initial injury, surgery or both. Due to limited availability of high-level evidence regarding the outcomes of turf toe injuries, particularly for surgical management of high-level athletes, this article will combine what is available with level V evidence based on the senior author’s experience over 34 years and his discussions with other experts in the unique subspecialty of foot and ankle sports medicine.