TURF TOE
First MTP Plantar Plate Injury | Hyperextension Mechanism | Athletes | Sesamoid Complex
ANDERSON GRADING SYSTEM
Critical Must-Knows
- Hyperextension injury of first MTP with forefoot fixed on ground
- Plantar plate complex (plantar plate + sesamoids + FHB) is key structure
- Anderson Grade 3 with instability or sesamoid retraction may need surgery
- MRI essential for Grade 2-3 to assess soft tissue and surgical planning
- Turf toe plate (carbon fiber insole) essential for return to sport prevention
Examiner's Pearls
- "Flexible footwear on hard artificial surface is the classic mechanism
- "Sesamoid proximal migration over 50% suggests complete rupture requiring surgery
- "Loss of push-off strength correlates with plantar plate injury severity
- "Chronic turf toe can lead to hallux rigidus (traumatic arthritis)
Clinical Imaging
Imaging Gallery
Critical Turf Toe Exam Concepts
The Mechanism
Hyperextension of first MTP joint while forefoot is fixed on ground. Body momentum drives proximal phalanx into forced dorsiflexion beyond 45 degrees. Hard artificial turf + flexible shoes = high risk.
The Key Structure
Plantar plate complex includes: fibrocartilaginous plantar plate, medial and lateral sesamoids, flexor hallucis brevis (FHB) insertions, and plantar capsule. This complex provides 90% of plantar restraint to hyperextension.
The Critical Grade
Grade 3 injuries have complete plantar plate disruption with joint instability. Look for: sesamoid proximal migration over 50%, traumatic hallux valgus, positive vertical instability test. May need surgical repair.
The Prevention
Turf toe plate (carbon fiber/steel shank insole) limits MTP dorsiflexion and is mandatory for return to sport. Prevents recurrence in 85% of athletes. Also consider high-top cleats and stiffer shoe soles.
At a Glance
Turf toe is a hyperextension injury of the first MTP joint caused by forced dorsiflexion beyond 45° while the forefoot is fixed on the ground—classically occurring on artificial turf with flexible footwear. The plantar plate complex (plantar plate, sesamoids, FHB) provides 90% of plantar restraint and is the key structure injured. The Anderson grading system (1-3) guides management: Grade 1-2 are treated conservatively with rest and taping, while Grade 3 (complete rupture with instability or sesamoid retraction over 50%) may require surgical repair. A turf toe plate (carbon fiber insole) is mandatory for return to sport to prevent recurrence.
TURFTurf Toe Features
Memory Hook:TURF toe happens on TURF surfaces!
PLATESPlantar Plate Complex
Memory Hook:The PLATES under the great toe prevent hyperextension!
CRUSHGrade 3 Surgical Indications
Memory Hook:CRUSH injuries need surgery!
Overview and Epidemiology
Why Called Turf Toe
First described in 1976 by Bowers and Martin when American football changed from grass to artificial turf. The harder surface combined with flexible shoes allowed excessive MTP dorsiflexion. Incidence increased 5-fold on artificial surfaces.
Epidemiology
- Prevalence: 45% of NFL players report history
- Peak age: 15-35 years (athletic population)
- Sports: Football, soccer, rugby, basketball, wrestling
- Surface: 5x more common on artificial turf
- Gender: Males slightly more (contact sports)
Risk Factors
- Artificial turf (hard, less forgiving)
- Flexible-soled shoes (poor support)
- Previous turf toe (50% recurrence without prevention)
- Hallux rigidus (altered biomechanics)
- Hypermobility (first ray hypermobility)
Anatomy and Biomechanics
Critical Anatomy Concept
The plantar plate complex is NOT just the plantar plate - it includes the fibrocartilaginous plantar plate, both sesamoids, the FHB tendon insertions, and the plantar capsule. Injury to ANY component can cause turf toe syndrome.
Plantar Plate Structure
Composition:
- Fibrocartilaginous structure (Type II collagen)
- 8-10mm thick plantarly, thins dorsally
- Originates from metatarsal neck (plantar surface)
- Inserts on proximal phalanx base
Function:
- Primary restraint to MTP hyperextension
- Resists forces up to 45 degrees dorsiflexion
- Beyond this threshold, rupture occurs
- Contributes to 90% of plantar stability
Layers:
- Superficial layer blends with plantar fascia
- Deep layer attaches to sesamoids
- Integrates with collateral ligaments laterally
Understanding plantar plate anatomy is essential for surgical repair.
Pathophysiology and Mechanism
The Classic Mechanism
Turf toe occurs when the forefoot is fixed on the ground (e.g., by a tackler landing on the heel) while body momentum drives the proximal phalanx into forced dorsiflexion. The plantar plate is tensioned beyond its 45-degree threshold and tears.
Injury Mechanism Sequence
Foot planted on hard surface (artificial turf). Another player may land on the heel, forcing the foot into dorsiflexion while the forefoot remains fixed.
Body momentum continues forward. Proximal phalanx is driven into dorsiflexion beyond the 45-degree physiological limit. Plantar plate stretched.
Tensile failure of plantar plate - either stretching (Grade 1), partial tear (Grade 2), or complete rupture (Grade 3). Sesamoids may displace proximally.
Associated injury to capsule, collaterals, and surrounding soft tissues. Hemorrhage and edema develop. Functional loss of push-off.
Contributing Factors
- Hard artificial turf: Doesn't absorb energy
- Flexible shoes: Allow excessive MTP motion
- Cleats caught in turf: Fixed forefoot
- High-velocity sports: Football, soccer, rugby
- Direct blow: Another player landing on heel
Tissue Response
- Acute hemorrhage into plantar capsule
- Inflammatory response (swelling, edema)
- Scar formation (may cause stiffness)
- Sesamoid healing (may form nonunion)
- Chronic instability if not treated properly
Anatomical Variants Affecting Injury
First Ray Variants
| Variant | Prevalence | Effect on Turf Toe |
|---|---|---|
| Long first metatarsal | Variable | Increased leverage, higher risk |
| Bipartite sesamoid | 10-30% | May mimic fracture on imaging |
| First ray hypermobility | Common in females | Increased MTP dorsiflexion range |
| Hallux rigidus (prior) | Older athletes | Altered mechanics, may protect or predispose |
Classification - Anderson Grading System
Anderson Classification of Turf Toe
| Grade | Pathology | Clinical Findings | MRI Findings | Treatment |
|---|---|---|---|---|
| Grade 1 | Plantar plate STRETCH | Minimal swelling, localized tenderness, normal ROM | Edema around plantar plate, no tear | Rest 1-2 weeks, taping, early RTS |
| Grade 2 | Plantar plate PARTIAL TEAR | Moderate swelling, ecchymosis, pain with dorsiflexion, decreased ROM | Partial tear visible, sesamoid position normal | Walking boot 3-4 weeks, protected WB |
| Grade 3 | Plantar plate COMPLETE RUPTURE | Severe swelling, ecchymosis, joint instability, loss of push-off | Complete disruption, sesamoid migration over 50% | Immobilization 6-8 weeks, may need surgery |
Critical Grade 3 Features
Look for the "3 S's" of Grade 3 turf toe:
- Sesamoid migration (proximal over 50%)
- Sesamoid diastasis (intersesamoid ligament rupture)
- Stress test positive (vertical instability)
Distinguishing Features by Grade
Grade 1 vs Grade 2:
- Grade 1: Can walk with minimal discomfort
- Grade 2: Significant antalgic gait, difficulty push-off
- Grade 1: Return in days; Grade 2: Return in weeks
Grade 2 vs Grade 3:
- Grade 2: Swelling moderate, joint STABLE
- Grade 3: Swelling severe, joint UNSTABLE
- Grade 2: Sesamoid position NORMAL
- Grade 3: Sesamoid PROXIMAL MIGRATION over 50%
Vertical Instability Test:
- Stabilize metatarsal head
- Apply vertical force to proximal phalanx
- Positive if more than 2mm dorsal translation
- Pathognomonic for Grade 3
Accurate grading guides treatment and prognosis counseling.
Clinical Presentation and Examination
History
- Mechanism: Forced hyperextension during sport
- Onset: Immediate pain at great toe
- Sensation: May report "pop" or "tear" feeling
- Function: Difficulty with push-off, antalgic gait
- Sport: Football, soccer, rugby, basketball
- Surface: Often artificial turf
- Footwear: Flexible-soled shoes or cleats
Physical Examination
- Inspection: Swelling, ecchymosis (plantar > dorsal)
- Palpation: Tenderness plantar to first MTP
- ROM: Pain with passive dorsiflexion
- Stability: Vertical instability test (Grade 3)
- Sesamoids: Point tenderness over sesamoids
- Strength: Weakness of FHB (push-off test)
- Gait: Antalgic with toe-off avoidance
Special Tests
Examination Maneuvers
| Test | Technique | Positive Finding | Significance |
|---|---|---|---|
| Vertical instability test | Stabilize MT head, dorsally translate PP | Greater than 2mm dorsal translation | Grade 3 plantar plate rupture |
| Passive dorsiflexion test | Dorsiflex MTP with knee extended | Pain at 30-45 degrees | Plantar plate/capsule injury |
| Sesamoid compression | Direct pressure over sesamoids | Focal tenderness | Sesamoid fracture or contusion |
| Push-off test | Single leg heel raise, push off great toe | Weakness or avoidance | FHB dysfunction, functional loss |
Red Flags - Grade 3 Indicators
Clinical findings suggesting Grade 3:
- Massive swelling with ecchymosis extending to arch
- Unable to weight-bear on toes
- Palpable gap in plantar plate
- Positive vertical instability test
- Obvious great toe position change (traumatic hallux valgus)
Investigations
Plain X-ray Assessment
Standard Views:
- AP foot (weight-bearing if possible)
- Lateral foot (assess sesamoid position)
- Oblique foot (additional detail)
- Sesamoid view (axial projection)
Key Findings:
- Sesamoid fracture (sharp margins)
- Sesamoid proximal migration (compare to contralateral)
- Joint subluxation or diastasis
- Avulsion fractures (plantar phalanx base)
Sesamoid Assessment:
- Compare position to contralateral foot
- Proximal migration over 50% = complete rupture
- Diastasis = intersesamoid ligament rupture
Limitations:
- Cannot assess soft tissue injury
- Bipartite sesamoid may mimic fracture
Always compare sesamoid position to contralateral side.
Management Algorithm
Rehabilitation and Return to Sport
Rehabilitation Phases
Goals: Control pain, protect healing tissue
- RICE protocol, protected weight-bearing
- Gentle ROM exercises (within pain limits)
- Maintain cardiovascular fitness (upper body)
- Avoid push-off activities
Goals: Restore ROM, begin strengthening
- Full ROM exercises (active and passive)
- FHB strengthening (towel scrunches, marble pick-up)
- Pool therapy for protected gait
- Balance and proprioception exercises
Goals: Sport-specific preparation
- Progressive resistance exercises
- Single-leg heel raises, push-off drills
- Agility training (cutting, pivoting)
- Turf toe plate in athletic shoes
Goals: Full sport participation
- Sport-specific skills without restriction
- Full-contact practice clearance
- Must pass functional testing
- Turf toe plate mandatory for competition
Return to Sport Criteria
Clearance Criteria
| Criteria | Grade 1 | Grade 2 | Grade 3 |
|---|---|---|---|
| Pain-free ROM | Full | Full | Near-full (90%) |
| Push-off strength | Full | 90% contralateral | 85% contralateral |
| Single-leg hop test | Pass | Pass | Pass |
| Sport-specific drill | Pass | Pass | Pass |
| Timeline | 1-2 weeks | 3-6 weeks | 3-6 months |
Prevention of Recurrence
All athletes with turf toe must use a turf toe plate (carbon fiber or steel shank insole) for return to sport. This limits MTP dorsiflexion to under 30 degrees and prevents recurrence in 85% of cases. Also consider stiffer-soled shoes and high-top footwear.
Complications
| Complication | Incidence | Risk Factors | Prevention/Management |
|---|---|---|---|
| Chronic pain/stiffness | 20-30% | Grade 3, delayed treatment | Adequate healing, proper rehabilitation |
| Hallux rigidus | 10-15% | Cartilage injury, repeated trauma | Protect joint, may need fusion long-term |
| Cock-up deformity | 5% | Grade 3 without repair | Surgical repair if unstable |
| Recurrence | 10-15% | Return too early, no prevention | Turf toe plate, proper timing |
| Sesamoid nonunion | Rare | Displaced fracture | Excision if symptomatic |
| Chronic instability | 5-10% | Grade 3 not repaired | Late surgical stabilization |
Long-Term Sequelae
Hallux rigidus (first MTP arthritis) is the most significant long-term complication. Occurs in 10-15% of Grade 3 injuries due to cartilage damage. May eventually require cheilectomy or fusion. Prevention involves adequate initial treatment and protection.
Outcomes and Prognosis
Prognostic Factors
Favorable Factors
- Grade 1-2 injury
- Early diagnosis and treatment
- Stable MTP joint
- No sesamoid migration
- Compliant with rehabilitation
- Proper prevention (turf toe plate)
Unfavorable Factors
- Grade 3 with instability
- Sesamoid proximal migration
- Traumatic hallux valgus
- Delayed presentation
- Premature return to sport
- Cartilage injury on MRI
NFL Player Outcomes (George et al., 2014)
- Grade 1: 100% return to play, minimal missed games
- Grade 2: 87% return to play, average 4 games missed
- Grade 3: 68% return to play, season-ending in some cases
- Career impact: 15% reported career-altering symptoms
Evidence Base and Key Studies
Anderson Grading System Validation
- Grade 1-3 system validated retrospectively
- Grade correlates with treatment and prognosis
- MRI improves accuracy of grading
- Surgical criteria established for Grade 3
NFL Player Outcomes
- Retrospective review of NFL turf toe injuries
- Grade 1: 100% RTS, minimal impact
- Grade 2: 87% RTS, average 4 games missed
- Grade 3: 68% RTS, some career-altering
MRI Correlation with Surgery
- MRI correlates well with surgical findings
- Essential for surgical planning in Grade 3
- Identifies associated injuries (sesamoid, FHL)
- Helps determine conservative vs surgical management
Surgical Outcomes
- Early series of surgical turf toe repair
- Good outcomes with plantar plate repair
- Early mobilization beneficial
- Long recovery 4-6 months
Turf Toe Plate Effectiveness
- Carbon fiber insole limits MTP dorsiflexion
- Reduces recurrence by 80-85%
- Recommended for all grades during RTS
- Combined with taping for optimal prevention
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Acute Turf Toe in NFL Player
"A 24-year-old NFL wide receiver hyperextended his great toe during a tackle on artificial turf. He has significant swelling, ecchymosis extending to the arch, and plantar MTP tenderness. He cannot push off. X-rays show no fracture but the tibial sesamoid appears proximally migrated compared to contralateral. What is your diagnosis and management?"
Scenario 2: Grade 2 Turf Toe Decision Making
"A 19-year-old university footballer presents 2 days after hyperextending his great toe. Examination shows moderate swelling, ecchymosis, tenderness plantarly, and pain with passive dorsiflexion beyond 30 degrees. The MTP joint is STABLE on vertical instability test. X-rays normal. MRI shows partial tear of plantar plate distal to the sesamoids with edema but sesamoids are in normal position. He has an important match in 2 weeks. How do you manage him?"
Scenario 3: Chronic Turf Toe with Hallux Rigidus
"A 32-year-old former professional rugby player presents with 2 years of progressive great toe pain and stiffness. He had multiple turf toe injuries during his career, including one Grade 3 injury treated conservatively. X-rays show first MTP joint space narrowing, dorsal osteophytes, and subchondral sclerosis. He has 15 degrees dorsiflexion (normal 70 degrees). What is your diagnosis and management?"
MCQ Practice Points
Mechanism Question
Q: What is the mechanism of turf toe? A: Hyperextension of the first MTP joint with the forefoot fixed on the ground. Body momentum drives the proximal phalanx into forced dorsiflexion beyond 45 degrees.
Key Structure Question
Q: What is the primary structure injured in turf toe? A: Plantar plate (plantar capsular-sesamoid complex). This includes the plantar plate, sesamoids, and FHB insertions - provides 90% of plantar restraint to hyperextension.
Grade 3 Indicator
Q: What finding on X-ray suggests a complete (Grade 3) plantar plate rupture? A: Sesamoid proximal migration greater than 50% compared to contralateral foot. Also look for sesamoid diastasis (intersesamoid ligament rupture).
Surgical Indication
Q: What are the surgical indications for turf toe? A: CRUSH: Complete rupture with instability, Retraction of sesamoid over 50%, Unstable MTP joint, Sesamoid diastasis, Hallux valgus (traumatic).
Prevention Question
Q: What is the most important preventive measure for return to sport after turf toe? A: Turf toe plate (carbon fiber insole). Limits MTP dorsiflexion to under 30 degrees and prevents recurrence in 85% of cases.
TURF TOE
High-Yield Exam Summary
DEFINITION
- •First MTP hyperextension injury
- •Plantar plate complex injury
- •Artificial turf + flexible shoes = risk
- •Sesamoid complex is key stabilizer
- •FHB insertions form plantar restraint
ANDERSON GRADING
- •Grade 1: Stretch - 1-2 wks RTS
- •Grade 2: Partial tear - 3-6 wks RTS
- •Grade 3: Complete rupture - 3-6 months
- •Grade based on clinical + MRI findings
- •Instability distinguishes Grade 2 vs 3
GRADE 3 INDICATORS
- •Sesamoid migration over 50%
- •Positive vertical instability test
- •Sesamoid diastasis
- •Traumatic hallux valgus
IMAGING
- •X-ray: sesamoid position, fracture
- •MRI: grade confirmation, surgical planning
- •Compare sesamoids to contralateral
- •Forced dorsiflexion views for instability
- •T2 shows plantar plate edema/tear
SURGICAL INDICATIONS (CRUSH)
- •Complete rupture + instability
- •Retraction sesamoid over 50%
- •Unstable joint on exam
- •Sesamoid diastasis
- •Hallux valgus (traumatic)
KEY POINTS
- •Turf toe plate ESSENTIAL for RTS
- •MRI for all Grade 2-3
- •Grade 3: 50-70% return same level
- •Long-term: hallux rigidus risk