Turf Toe

Patients describe acute sharp plantar pain at the base of the great toe during a specific identifiable event - typically during a tackle, push-off, or deceleration when the foot was planted and a force drove the toe upward. Plantar 1st MTP pain is worse with push-off, dorsiflexion, and weight-bearing through the forefoot. Swelling ranges from mild (Grade I) to dramatic with ecchymosis (Grade III). Difficulty with push-off and gait significantly affects athletic performance even in mild turf toe. Always ask about the exact mechanism, surface type, footwear (flexible vs rigid sole), sport, previous 1st MTP injury, and ability to continue playing.

Examination: plantar tenderness at the 1st MTP joint is the most important finding. Palpate each sesamoid individually - focal tenderness at one sesamoid suggests sesamoid fracture or focal plantar plate injury. Dorsal tenderness and swelling are present in Grade II-III. Plantar ecchymosis tracking along the foot border suggests significant structural injury.

Assess active and passive 1st MTP dorsiflexion and plantar flexion compared with the contralateral side. Restricted and painful dorsiflexion is the key finding, and a soft or empty end-feel on dorsiflexion versus a firm contralateral end-feel suggests plantar plate disruption.

The vertical stress test is the key stability test: stabilise the first metatarsal head and translate the proximal phalanx dorsally. Increased dorsal translation compared with the contralateral side, with loss of a definitive end-point, indicates plantar plate laxity or rupture (Grade III). Valgus/varus stress assesses the collateral ligaments. Assess gait (antalgic, loss of push-off, lateral weight transfer) and footwear (flexible sole, lack of forefoot rigidity).

Differentials: gout (podagra) with no traumatic mechanism, hallux rigidus (chronic 1st MTP OA), sesamoiditis (chronic overuse without acute mechanism), sesamoid stress fracture (gradual onset, activity-related, MRI diagnostic), hallux valgus, plantar plate tear of lesser MTP joints, FHL tendinopathy, and sand toe (hyperflexion injuring the dorsal capsule).

Turf toe is primarily a clinical diagnosis. Normal plain radiographs do not exclude significant plantar complex injury. Imaging is used to grade severity, identify sesamoid pathology, and guide management.

Plain radiographs include weight-bearing AP, lateral, and the sesamoid axial view (particularly useful when sesamoid injury is suspected). On AP view, look for sesamoid fracture (irregular edges vs smooth rounded edges of a bipartite sesamoid) and intersesamoid diastasis (widening over 3 mm or asymmetric to the contralateral side). On the lateral weight-bearing view, look for sesamoid retraction (a proximal shift over 3 mm relative to the contralateral foot is highly suspicious for complete plantar plate disruption). Contralateral comparison is essential throughout.

MRI is the most informative advanced investigation. It directly demonstrates the plantar plate (tear, avulsion), sesamoid bone marrow oedema on fluid-sensitive sequences (STIR or T2 fat-suppressed) confirming acute fracture, intersesamoid ligament integrity, collateral ligament injury, flexor hallucis brevis tendon damage, and articular cartilage injury. Most useful for Grade II-III injuries, persistent symptoms, and pre-operative planning.

USS may help with dynamic plantar plate assessment and sesamoid position but is operator-dependent and usually less informative than MRI for significant structural injury. CT is useful for detailed sesamoid fracture characterisation when X-ray is equivocal.

Management is grade-dependent. Most Grade I and II injuries are managed non-operatively. Grade III injuries with instability, sesamoid displacement, or progressive deformity may require surgical intervention.

Grade I (plantar plate stretch, mild): relative rest and activity modification (no formal immobilisation needed), taping or strapping to limit painful hallux dorsiflexion, a stiff-soled shoe or carbon fibre footplate, ice/elevation/compression, simple analgesia (paracetamol, short-course oral NSAIDs), and continued weight-bearing as tolerated. Return to sport is often 1-3 weeks with taping and a stiff insole, criteria-based.

Grade II (partial plantar plate tear, moderate): a walking boot or stiff-soled shoe for a short period (often 2-4 weeks, varies with symptoms), protected weight-bearing with crutches for comfort as needed, taping when transitioning out of the boot, carbon fibre footplate or stiff insole when weight-bearing resumes, ice/elevation/compression, analgesia, and progressive rehabilitation once acute symptoms settle. Return to sport is typically 4-8 weeks, criteria-based.

Grade III (complete plantar plate tear with or without sesamoid injury, severe): walking boot or below-knee cast for 4-8 weeks with strict avoidance of dorsiflexion, non-weight-bearing or very limited protected weight-bearing initially. Consider surgical referral for marked instability on vertical stress testing, displaced sesamoid fracture, sesamoid retraction or dislocation, dorsal subluxation or dislocation of the proximal phalanx, progressive hallux valgus developing after injury, or failed structured conservative management. Surgical options include direct plantar plate repair, sesamoid fixation, sesamoidectomy for severely comminuted non-repairable sesamoid fractures, and capsular reconstruction. Total sesamoidectomy (removing both sesamoids) is strictly avoided because it leads to devastating loss of push-off and cock-up deformity. Return to sport is typically 3-6 months for surgically managed injuries, often with a carbon fibre plate long-term.

Lower-limb immobilisation in a walking boot or cast should prompt VTE risk assessment per NICE NG89. Prophylactic LMWH should be considered when VTE risk outweighs bleeding risk.

Long-term complications: hallux rigidus (post-traumatic 1st MTP OA - the most important long-term complication), chronic instability, progressive hallux valgus, cock-up deformity, sesamoid non-union, and chronic pain/stiffness.

Rehabilitation is graded to injury severity. The goal is to restore 1st MTP range of motion (particularly dorsiflexion), push-off strength, and sport-specific performance while protecting the healing plantar plate.

Phase 1 (acute protection): immobilisation per grade. Ice, elevation, compression. Protect the plantar plate by avoiding forced dorsiflexion. Gentle isometric toe flexion within the boot. Maintain overall fitness with upper-body conditioning and (later) cycling if tolerable; avoid push-off from the wall in swimming initially. Calf and proximal lower-limb strengthening to prevent deconditioning.

Phase 2 (progressive ROM and strengthening): transition from boot to stiff-soled shoe with a carbon fibre footplate. Gentle progressive 1st MTP ROM with active dorsiflexion within comfortable limits. FHB and intrinsic foot strengthening (toe curls, marble pick-ups, towel scrunches, short-foot/arch doming). Calf strengthening from double-leg to single-leg heel raises. Proprioception and balance work. Taping during weight-bearing activity for protection.

Phase 3 (functional rehabilitation and return to sport): progressive push-off activities (walking on varied terrain, single-leg heel raises with great toe dorsiflexion), jogging (straight-line then multidirectional), cutting and pivoting, and sport-specific drills (sprinting, acceleration, deceleration, kicking). Continue taping and/or carbon fibre footplate during sport.

Return-to-sport criteria: pain-free 1st MTP dorsiflexion approaching functional range (at least 50-60 degrees for sport; normal 65-75), adequate push-off strength (single-leg heel raise), pain-free sport-specific function, functional testing (hopping, cutting), and psychological readiness.

Long-term maintenance: a carbon fibre footplate or stiff insole during sport may be used indefinitely; ongoing intrinsic foot and calf strengthening; monitor for developing hallux rigidus (progressive dorsiflexion loss, dorsal osteophyte).

• •Anderson classification (Anderson, 1990) - Three-grade system for turf toe (I stretch, II partial tear, III complete rupture +/- sesamoid injury) remains the standard staging used in UK SEM and orthopaedic practice.
• •BOFAS Hyperbook: Turf toe - UK foot and ankle specialist consensus on grading, imaging pathway, and indications for surgical referral.
• •Smith & Reischl (2013, Sports Health) - The vertical stress test is the most useful clinical sign for identifying Grade III instability requiring specialist review.
• •Anderson et al. (2018, Foot Ankle Clin) - Surgical repair of Grade III turf toe is indicated for marked instability, sesamoid retraction or dislocation, displaced sesamoid fracture, or progressive deformity; total sesamoidectomy is contraindicated.
• •NICE NG89 - VTE risk assessment is mandatory in any patient immobilised in a walking boot or cast; prophylactic LMWH should be considered where VTE risk outweighs bleeding risk.

• •Turf toe = forced hyperextension of the 1st MTP injuring the plantar capsuloligamentous complex; the plantar plate is the primary restraint to hyperextension.
• •Grade I stretch, Grade II partial tear, Grade III complete tear with or without sesamoid fracture/diastasis/dislocation. The vertical stress test identifies Grade III instability.
• •Bipartite sesamoid (smooth bilateral edges) vs acute fracture (irregular edges) - compare contralateral. Intersesamoid diastasis over 3 mm on AP indicates intersesamoid ligament disruption; sesamoid retraction over 3 mm on lateral indicates plantar plate avulsion.
• •Normal plain radiographs do NOT exclude significant plantar complex injury. MRI is the most informative advanced investigation.
• •A carbon fibre footplate or stiff insole limits 1st MTP dorsiflexion and is the most important protective device for return to sport. Hard surface plus flexible shoe is the highest-risk scenario.
• •Hallux rigidus is the most important long-term complication. Total sesamoidectomy (removing both sesamoids) is strictly avoided because it causes devastating loss of push-off and cock-up deformity. VTE risk assessment per NICE NG89 when immobilised.