Etiology and biomechanics of first metatarsophalangeal joint sprains (turf toe) in athletes

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

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.

The Influence of Different Rope Jumping Methods on Adolescents' Lower Limb Biomechanics during the Ground-Contact Phase

As a simple and beneficial way of exercise, rope skipping is favored by the majority of teenagers, but incorrect rope skipping may lead to the risk of injury. In this study, 16 male adolescent subjects were tested for bounced jump skipping and alternating jump rope skipping. The kinematic data of the hip, knee, ankle and metatarsophalangeal joint of lower extremities and the kinetics data of lower extremity touching the ground during rope skipping were collected, respectively. Moreover, the electromyography (EMG) data of multiple muscles of the lower extremity were collected by Delsys wireless surface EMG tester. Results revealed that bounced jump (BJ) depicted a significantly smaller vertical ground reaction force (VGRF) than alternate jump (AJ) during the 11−82% of the ground-contact stage (p < 0.001), and the peak ground reaction force and average loading rate were significantly smaller than AJ. From the kinematic perspective, in the sagittal plane, when using BJ, the flexion angle of the hip joint was comparably larger at 12−76% of the ground-contact stage (p < 0.01) and the flexion angle of the knee joint was significantly larger at 13−72% of the ground-contact stage (p < 0.001). When using two rope skipping methods, the minimum dorsal extension angle of the metatarsophalangeal joint was more than 25°, and the maximum was even higher than 50°. In the frontal plane, when using AJ, the valgus angle of the knee joint was significantly larger during the whole ground-contact stage (p < 0.001), and the adduction angle of the metatarsophalangeal joint (MPJ) was significantly larger at 0−97% of the ground-contact stage (p = 0.001). EMG data showed that the standardized value of root mean square amplitude of the tibialis anterior and gastrocnemius lateral head of BJ was significantly higher than AJ. At the same time, that of semitendinosus and iliopsoas muscle was significantly lower. According to the above results, compared with AJ, teenagers receive less GRF and have a better landing buffer strategy to reduce load, and have less risk of injury during BJ. In addition, in BJ rope skipping, the lower limbs are more inclined to the calf muscle group force, while AJ is more inclined to the thigh muscle group force. We also found that in using two ways of rope skipping, the extreme metatarsophalangeal joint back extension angle could be a potential risk of injury for rope skipping.

A rare case of recurrent medial dislocation of the 1st metatarsophalangeal joint in a professional athlete

Dislocations of the first metatarsophalangealjoint are rare, and recurrent dislocations unique. A national-level Kabaddi player dislocated his right first metatarsophalangeal joint while playing a game bear footed. After self-manipulative reduction, the patient had multiple dislocations. The patient reported after a year of injury with complaints of recurrent medial dislocations of the first metatarsophalangeal joint. At surgery, reconstruction of deficient lateral capsule-ligamentous structures of the first metatarsophalangeal joint was done with Palmaris longus autograft. The patient returned to sports in six months and was followed up for more than two years. The case is unique in the form that recurrent medial dislocation of first metatarsophalangeal dislocation is not described. LEVEL OF CLINICAL EVIDENCE: Level V.

Turf Toe, Traumatic Hallux Valgus, and Hallux Rigidus -What Can I Do After an Metatarsophalangeal Fusion?

Turf toe injuries should be recognized and treated early to prevent long-term disability. The accurate clinical assessment and radiological evaluation of appropriate cases is important. Both conservative and surgical treatments play a major role in getting athletes back to their preinjury level. There are more recent reported case series and systemic reviews that encourage operative treatment as early as possible for grade III turf toe injury. If the patient presents late from a traumatic hallux injury with subsequent degenerative changes or has hallux rigidus from other etiologies, a first metatarsophalangeal arthrodesis should be considered to minimize pain and improve function.

Novel treatment for hallux rigidus using a temporary metal interpositional device

BACKGROUND

The aim of this prospective study is to evaluate the results of a consecutive series of patients suffering from grade II-III hallux rigidus who underwent a mobility preserving surgical technique consisting of resection arthroplasty with implantation of a temporary metal spacer.

METHODS

Thirty consecutive patients, 18 female and 12 male with a diagnosis of a grade II-III hallux rigidus, not responding to conservative treatment, underwent a minimal resection arthroplasty followed by the implantation of a temporary metal interpositional device by the same surgeon. All spacers were removed after 6 months through a minimal incision under regional anaesthesia. Patients were clinically and radiographically evaluated at 3, 6, 12 months, and 5 years after spacer removal.

RESULTS

The clinical AOFAS scores improved already at first follow-up and continued to improve over time with a statistically significant change until the first year. At 3, 6, and 12 months follow-ups, the number of patients with severely limited ROM (i.e. under 30°, that means grade II-III according to Coughlin and Shaurnas classification) significantly decreased. There were only two minor complications, so defined as both of which resolved spontaneously and did not affect the procedure's effectiveness.

CONCLUSIONS

We observed good to excellent results with the use of this mobility preserving surgical technique for the treatment of symptomatic grades II and III hallux rigidus. The never before published procedure is easy to perform and inexpensive.

LEVEL OF EVIDENCE

Level IV.

Influence of forefoot bending stiffness on American football performance and metatarsophalangeal joint bending angle

Changes in forefoot bending stiffness have been shown to affect metatarsophalangeal peak bending angles as well as athletic performance. Increasing bending stiffness tends to reduce peak bending angles, which could potentially reduce hyperextension injuries such as turf toe. Limited information is available, however, on the efficacy of increasing forefoot bending stiffness on large-sized athletes such as those that participate in American Football, with prior studies being conducted on smaller athlete populations. Therefore, the purpose of this study was to determine the influence of increased forefoot bending stiffness on metatarsophalangeal joint extension and athletic performance of grid-iron football players. Ten varsity grid-iron football players performed four National Football League combine movements in a motion capture laboratory in three footwear conditions of varying bending stiffness: Soft (12.7 N/mm), Control (23.8 N/mm), Stiff (42.2 N/mm). None of the footwear conditions significantly altered the maximum metatarsophalangeal bending. Therefore, to reduce metatarsophalangeal hyperextension injuries in American football players a greater amount of forefoot bending stiffness may be required. Performance differences were present only during the five-metre sprint acceleration, with athletes having an improved performance in the Control and Stiff conditions. This improved performance was due to an increased horizontal impulse and improvements in power generation at the ankle joint.

First MTP joint instability - Expanding the concept of "Turf-toe" injuries

BACKGROUND

Although 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.

METHODS

In 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.

RESULTS

After 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).

CONCLUSIONS

Turf-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.

Properties and Function of the Flexor Hallucis Capsularis Interphalangeus Tendon

INTRODUCTION

The fibrocartilagenous plantar plates of the forefoot are biomechanically important, forming the primary distal attachment for the plantar aponeurosis. They are integral to the function of the windlass mechanism in supporting the arches of the foot in gait. Dissection of the cadaveric hallux revealed an organised sagittal thickening of the dorsal side of the flexor hallucis longus (FHL) sheath, which attached the interphalangeal plantar plate to the metatarsophalangeal (MTP) plantar plate. A description of a similar structure was made in 1984 when it was termed the flexor hallucis capsularis interphalangeus (FHCI) - however, it has not been researched since, and we aim to study it further and identify its characteristics.

METHOD

Eight specimens were dissected from four cadavers. Two were stained and examined under magnification in both polarized and non polarized light. The remaining 6 were subjected to micrometer testing of their tensile properties.

RESULTS

Both the histological features and mechanical properties were consistent with tendon; with cross sectional area, ultimate tensile strength and stiffness varying between specimens.

CONCLUSIONS

Based on its location and properties, the FHCI tendon may be involved in limiting dorsiflexion of the first MTP joint and could have clinical relevance in pathological processes around both the first and second MTP joints. Clin. Anat., 33:689-695, 2020. © 2019 Wiley Periodicals, Inc.

How to classify plantar plate injuries: parameters from history and physical examination

Objective

To find the best clinical parameters for defining and classifying the degree of plantar plate injuries.

Method

Sixty-eight patients (100 metatarsophalangeal joints) were classified in accordance with the Arthroscopic Anatomical Classification for plantar plate injuries and were divided into five groups (0 to IV). Their medical files were reviewed and the incidence of each parameter for the respective group was correlated. These parameters were: use of high heels, sports, acute pain, local edema, Mulder's sign, widening of the interdigital space, pain in the head of the corresponding metatarsal, touching the ground, “drawer test”, toe grip and toe deformities (in the sagittal, coronal and transversal planes).

Results

There were no statistically significant associations between the degree of injury and use of high-heel shoes, sports trauma, pain at the head of the metatarsal, Mulder's sign, deformity in pronation or displacement in the transversal and sagittal planes (although their combination, i.e. “cross toe”, showed a statistically significant correlation). Positive correlations with the severity of the injuries were found in relation to initial acute pain, progressive widening of the interdigital space, loss of “touching the ground”, positive results from the “drawer test” on the metatarsophalangeal joint, diminished grip strength and toe deformity in supination.

Conclusions

The “drawer test” was seen to be the more reliable and precise tool for classifying the degree of plantar plate injury, followed by “touching the ground” and rotational deformities. It is possible to improve the precision of the diagnosis and the predictions of the anatomical classification for plantar plate injuries through combining the clinical history and data from the physical examination.

Acute forefoot and midfoot injuries

Forefoot and midfoot injuries in the athlete are common. Injuries of the digits include subungual hematomas and fractures. Metatarsal fractures occur frequently in sports, and their treatments range greatly. Hyperflexion and extension injuries about the first metatarsophalangeal joint can be very debilitating. Midfoot sprains and fractures require a high index of suspicion for diagnosis.

Development of an injury risk function for first metatarsophalangeal joint sprains

INTRODUCTION

Sprains of the first metatarsophalangeal (1MTP) joint, also known as turf toe, are debilitating athletic injuries. Because 85% of 1MTP sprains result from excessive hallux dorsiflexion, interventions that limit motion to subinjurious levels would greatly benefit athletes. Hallux dorsiflexion range of motion (hdROM) cannot be overly constrained, however, lest athletic performance be compromised. Therefore, the tolerance of the 1MTP joint to excessive dorsiflexion injury must be quantified before appropriate hdROM limitations may be developed. The purpose of this study was to develop a quantitative injury risk function for 1MTP sprains on the basis of hallux dorsiflexion angle.

METHODS

Twenty cadaveric limbs were tested to both subinjurious and injurious levels of hallux dorsiflexion. Motion capture techniques were used to track six-degree-of-freedom motion of the first proximal phalanx, first metatarsal, and calcaneus. Specimens were examined by physicians posttest to diagnose injury occurrence and ensure clinical relevance of the injuries.

RESULTS

A two-parameter Weibull hazard function analysis reveals that a 50% risk of injury occurs at 78° of dorsiflexion from anatomical zero.

CONCLUSION

Methods presented here drove cadaveric 1MTP joints to various degrees of dorsiflexion, resulting in both noninjurious and injurious trials, which were formed into an injury risk function.

Incidence and risk factors for turf toe injuries in intercollegiate football: data from the national collegiate athletic association injury surveillance system

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.

Turf toe repair: a technical note

Turf toe injury typically describes an injury to the metatarsosesamoid complex of the hallux generally caused by a hyperextension force to the great toe. This injury may be accompanied by pain, deformity, and decreased athletic performance. Operative treatment to repair the damaged tissue can be difficult, and we present a technique description that may help simplify the surgical reconstruction.