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Gupta A, Singh PK, Xu AL, Bronheim RS, McDaniel CM, Aiyer AA. Turf Toe Injuries in the Athlete: an Updated Review of Treatment Options, Rehabilitation Protocols, and Return-to-Play Outcomes. Curr Rev Musculoskelet Med 2023; 16:563-574. [PMID: 37789169 PMCID: PMC10587038 DOI: 10.1007/s12178-023-09870-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE OF REVIEW 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. RECENT FINDINGS 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.
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Affiliation(s)
- Arjun Gupta
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287 USA
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 185 South Orange Ave, Newark, NJ 07103 USA
| | - Priya K. Singh
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287 USA
- Department of Orthopaedic Surgery, Montefiore Medical Center at Albert Einstein College of Medicine, 1250 Waters Place, Bronx, NY 10461 USA
| | - Amy L. Xu
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287 USA
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Rachel S. Bronheim
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287 USA
| | - Claire M. McDaniel
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287 USA
| | - Amiethab A. Aiyer
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287 USA
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Dimmick S, Reeve A, Linklater J. Presurgical Perspective and Postsurgical Evaluation of Plantar Plate and Turf Toe. Semin Musculoskelet Radiol 2022; 26:695-709. [PMID: 36791738 DOI: 10.1055/s-0042-1760221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Capsuloligamentous injury of the first metatarsophalangeal (MTP) joint (eponymously called "turf toe") mostly occurs in athletes and involves acute trauma, whereas tears of the lesser MTP joint plantar plate typically are an attritional-degenerative condition. This article reviews the anatomy, pathophysiology, mechanism and patterns of injury, grading and classification of injury, imaging appearances (pre- and postoperative), and management of first MTP joint capsuloligamentous injuries and lesser MTP joint plantar plate tears. These two distinct pathologies are discussed in separate sections.
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Seow D, Tengku Yusof TNB, Yasui Y, Shimozono Y, Kennedy JG. Treatment Options for Turf Toe: A Systematic Review. J Foot Ankle Surg 2020; 59:112-116. [PMID: 31882133 DOI: 10.1053/j.jfas.2018.12.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 12/03/2018] [Accepted: 12/16/2018] [Indexed: 02/03/2023]
Abstract
Turf toe is hyperextension injury of the plantar plate at the first metatarsophalangeal joint. Etiologies have often included sports/activities with excessive forefoot axial loading and/or violent pivotal movements. The purpose of the systematic review was to systematically review and present an overview for the current evidence-based treatment options of turf toe. Both authors systematically reviewed the PubMed and EMBASE databases from inception to April 2016 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The level of evidence and quality of evidence were assessed by using the Level of Evidence for Primary Research Question of the Journal of Bone and Joint Surgery, and the quality of evidence was assessed with use of the Newcastle-Ottawa scale. Data were collected and categorized into: case reports and case series. Eight studies (16 turf toes) met the aforementioned criteria and were included. Five case reports and 3 case series reported various treatment options for turf toe. Specifically, 3 studies reported solely conservative treatment (n = 5), 1 study reported solely surgical treatment (n = 1), and 4 studies involved patients in conservative and/or surgical treatments (n = 10). All studies were of level of clinical evidence 4 and quality of clinical evidence score 2 (poor quality). Conservative treatment included closed reduction and immobilization, and surgical treatment included plantar plate tenodesis. Restricted dorsiflexion was the most common complication reported. Turf toe is an underreported injury with no evidence-based treatment guideline to date. Future studies of higher level and quality of evidence with a specific classification system (Jahss or Anderson) consistently reported are warranted for the development of an optimal guideline to determine the most appropriate treatment for each specific severity in injury.
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Affiliation(s)
- Dexter Seow
- Research Fellow, Department of Orthopedic Surgery, NYU Langone Health, New York, NY.
| | | | - Youichi Yasui
- Assistant Professor, Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yoshiharu Shimozono
- Orthopedic Surgeon, Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan; Orthopedic Surgeon, Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - John G Kennedy
- Chief of Foot and Ankle Surgery, Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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Abstract
Turf toe is a term used to describe myriad injuries to the metatarsophalangeal complex of the great toe, which have been associated with the introduction of artificial turf surfaces in sport. If not diagnosed early and treated properly, these injuries can result in chronic pain and loss of mobility. Accurate injury grading through physical exam and advanced imaging is essential to guide treatment, thereby minimizing long-term complications and maximizing an athlete's recovery and return to play. Levels of Evidence: Level V.
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Affiliation(s)
- Daniel Chiou
- Warren Alpert Medical School, Brown University, Providence, Rhode Island (DC).,Department of Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts (KLS, GW)
| | - Kristen L Stupay
- Warren Alpert Medical School, Brown University, Providence, Rhode Island (DC).,Department of Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts (KLS, GW)
| | - Gregory Waryasz
- Warren Alpert Medical School, Brown University, Providence, Rhode Island (DC).,Department of Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts (KLS, GW)
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Abstract
Turf toe injuries can be a disabling if not recognized and treated early. A high index of suspicion, based on the mechanism of injury and appropriate imaging, helps in the timely diagnosis. These injuries are frequently known to occur on artificial playing surfaces, because of the increased traction at the shoe-surface interface. Stress and instability testing are key components to assess the need for surgical intervention. Accurate timely diagnosis and treatment can allow full return to physical activities for most athletes, back to their pre-injury level.
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Kulessa DJ, Gollhofer A, Gehring D. The influence of football shoe characteristics on athletic performance and injury risk – a review. FOOTWEAR SCIENCE 2017. [DOI: 10.1080/19424280.2017.1284273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
| | - Albert Gollhofer
- Department of Sport and Sport Science, University of Freiburg, Freiburg, Germany
| | - Dominic Gehring
- Department of Sport and Sport Science, University of Freiburg, Freiburg, Germany
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Stefanyshyn DJ, Wannop JW. The influence of forefoot bending stiffness of footwear on athletic injury and performance. FOOTWEAR SCIENCE 2016. [DOI: 10.1080/19424280.2016.1144652] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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George E, Harris AHS, Dragoo JL, Hunt KJ. Incidence and risk factors for turf toe injuries in intercollegiate football: data from the national collegiate athletic association injury surveillance system. Foot Ankle Int 2014; 35:108-15. [PMID: 24334272 DOI: 10.1177/1071100713514038] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Turf toe is the general term for a sprain of the first metatarsophalangeal (MTP) joint complex. Previously attributed to shoe design and artificial turf, the incidence of turf toe injury has been thought to decline with the advent of newer turf designs. However, the current incidence and epidemiology remain unknown as the majority of the literature consists of small series and addresses diagnosis and treatment rather than epidemiology and prevention. METHODS We examined data from the NCAA's Injury Surveillance System (ISS) for 5 football seasons (2004-2005 through 2008-2009), including all preseason, regular season, and postseason practice and competition data. The incidence, epidemiology, and risk factors for turf toe injury, defined as injury to the connective tissue of the first MTP joint, plantar plate complex, and/or sesamoid fracture, were determined. RESULTS The overall incidence of turf toe injuries in NCAA football players was 0.062 per 1000 athlete-exposures (A-Es; 95% CI 0.052, 0.072). Athletes were nearly 14 times more likely to sustain the injury during games compared to practice, with a mean days lost due to injury of 10.1 (7.9, 12.4). Fewer than 2% of turf toe injuries required operative intervention. There was a significantly higher injury rate on third-generation artificial surfaces compared to natural grass (0.087 per 1000 A-E [0.067, 0.11] vs 0.047 per 1000 A-E [0.036, 0.059]). The majority of injuries occurred as a result of contact with the playing surface (35.4%) or contact with another player (32.7%), and running backs and quarterbacks were the most common positions to suffer turf toe injury. CONCLUSION Our data suggest a significantly higher incidence of turf toe injuries during games, a greater susceptibility among running backs and quarterbacks, and a significant contribution of playing surface to risk of injury. Though turf toe injuries may be less common that previously reported in elite football players, these injuries warrant appropriate acute and long-term management to prevent long-term dysfunction. LEVEL OF EVIDENCE Level IV, case series.
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Robinson D, Heller E, Garti A. Sesamoid complex disruption as a cause of hallux valgus: report of three cases. Foot (Edinb) 2012; 22:322-5. [PMID: 23140792 DOI: 10.1016/j.foot.2012.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Accepted: 09/29/2012] [Indexed: 02/04/2023]
Abstract
Hallux valgus is perhaps the most common forefoot deformity, usually related to genetic factors, gender and footwear habits. The current cases represent an unusual etiology of the syndrome due to sesamoid ligamentary damage and inter-sesamoid ligament rupture. One of the cases was treated surgically by excision of the non-united lateral sesamoid and reconstruction of the intermetatarsal ligament. Another one was treated by a Wilson-like osteotomy. The third one was conservatively treated by casting. In these cases the hallux valgus angle declined following treatment.
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Affiliation(s)
- D Robinson
- Tel Aviv University Medical School, Foot and Ankle Service, Hasharon Hospital, Rabin Medical Center, Petah Tikwa, Israel.
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