Originally described as occurring on artificial turf surfaces, turf toe injuries involve a primarily hyperdorsiflexion force to the first metatarsal phalangeal joint.14 Varus and valgus forces may also play a role and may increase the likelihood of late instability. These injuries occur in football, soccer, dance, and other sports that involve great toe dorsiflexion activity. The injury involves primarily the plantar plate; the sesamoid complex and the collateral ligaments are injured depending on the severity and direction of the forces involved.
Clinically, patients present with pain, swelling, ecchymosis, and a history consistent with the injury. Physical examination of the foot should be complete, with careful attention to neu-rovascular evaluation. Additionally, examination of the great toe should include an evaluation of range of motion and medial, lateral, and anteroposterior stress testing. The injury has been classified into three grades: grade 1, stretching of the capsule; grade 2, partial capsule tear; grade 3, complete tear.15 The physical examination will show increasing swelling, ecchymosis, tenderness, and instability with each grade. In the most severe cases of irreducible dislocation, the metatarsal phalangeal joint is usually dorsiflexed, and the distal interphalangeal joint is plantar flexed in a "claw toe" position.
Radiographic evaluation is necessary in all injuries. Careful attention should be paid to the presence of fractures of the base of the phalanx, sesamoids, and symmetry of the joint. In severe injuries, the sesamoid complex may be disrupted, and there may be an irreducible dislocation (Fig. 71-5). Rarely, especially in late presentations, magnetic resonance imaging may be useful to define injured structures.
In most injuries, conservative treatment is optimal. Patients with grade 1 and 2 injuries are treated with taping, activity modification, and a stiff orthotic support in their athletic shoe. They may return to play in 2 to 4 weeks when symptoms resolve. Grade 3 injuries involve instability of the joint and require cast immobilization with the hallux in a neutral position and prolonged rest. They may return to play at 6 to 8 weeks if the joint is stable. For an unstable or irreducible joint, surgery is indicated. There are no large series regarding acute operative treatment of severe turf toe injuries, but surgery should be directed toward the affected structures. Sesamoid fracture fixation or excision and collateral ligament and plantar plate repair are performed as indicated.15
Orthotic modification is often necessary for a prolonged duration if patients are to remain active. A simple over-the-counter turf toe insert is often sufficient. Alternatively, a steel plate may be inserted into the sole of the shoe or a custom insert made with steel or carbon fiber reinforcement under the hallux. Long-term sequelae of this injury may include hallux valgus, claw toe, stiffness, and degenerative arthritis. Late surgical treatment of these problems may involve osteotomy, chilectomy, or arthrodesis.
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