6/2/2020

Turf Toe

Turf Toe

Turf toe gets no respect. Let's take a closer look at the causes of turf toe and find out how you can treat it more effectively.

  • Turf toe is actually a form of hallux limitus.
  • Hallux limitus is classically described as pain and progressive decrease in the range of motion of the first metatarsal phalangeal joint (MPJ).
  • The oncoming of hallux limitus is due to the following:

Functional hallux limitus - biomechanical function that results in metatarsus primus elevatus and also subsequent repetitive jamming of the initial MPJ.

  • Direct physical injury - injury to the articular cartilage or subchondral bone.
  • These injuries may be due impaction injuries or hyperextension/flexion of the first MPJ.

Other conditions - synovitis, crystal deposition diseases such as gout, systemic arthritis, external physical affects such as Dupytren's contracture, etc.

But before we go any further, we need to understand that the terms turf toe and hallux limitus aren't really synonymous. The fundamental difference between the two conditions is the patient population that they affect. Turf toe is a term used in athletic bags discussing any injuries of the great toe joint. Consequently, discussions concerning turf toe may focus on the first couple of causes of hallux limitus mentioned above; functional hallux limitus and direct physical injury. On the other hand, when we discuss hallux limitus, we're actually referring to a broader, non-athletic' patient population and need to include all three causes of hallux limitus.

Think of turf toe (hallux limitus) as an isolated case of osteoarthritis limited to the first MPJ. Whether the injury is acute or due to repetitive loading, the result is actually a lot that is applied to the subchondral bone that is greater than what are the bone fragments can tolerate. As the damage progresses, a series of micro fractures will develop in the subchondral bone. The typical soft spongy character of the metaphyseal bone changes to become brittle and hard. The result is that the articular cartilage looses its' fundamental support and becomes susceptible to injury. Juxtachondral eburnation, osteophytes, lipping, spurring; call them what you like, but what you see on your x-ray is the slow progressive destruction of the shared.

What's the actual physical change that takes place in the joint with turf toe? As an easy analogy, consider the changes that takes place when an apple falls from a height and is damaged. The skin of the apple appears intact but the underlying pulp is damaged. In the case of turf toe (hallux limitus), think of the skin of the apple since the cartilage of the joint and the broken pulp of the apple is the subchondral bone. Moderate cases of turf toe (hallux limitus), result in little damage to the subchondral bone and will merely exhibit signs of inflammatory change within the combined.

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Most Authors Would Refer to These Cases as Stage One Turf Toe (Hallux Limitus)

More severe cases result in damage to the joint surface, the subchondral bone or each. These are the stage two and three cases of turf toe (hallux limitus) that show visible change on x-ray. As the subchondral bone gets increasingly damaged, this will create an uneven helping surface for the cartilage. An increase in activity results in uneven loading of the combined due to the compression injury of the subchondral bone.

The start of turf toe constantly the same? Turf toe that is the result of functional hallux limitus will be insidious in onset. Functional hallux limitus will usually be seen in younger athletes as they attempt to improve their activity. It may not occur during the very first sports season, or the second, but when it does set out to cause pain, the onset will be more frequent and more severe, different with activity. This profile of onset is simply due to the fact that the athlete is recreating the injury with every step.

Turf Toe the Result of a Direct Injury to the Joint May or May Not be Obvious

Athletes may not remember an incident of pain since they're frequently distracted by the event or game in which they're involved. The onset of immediate injury to the shared may be sudden, but also may be insidious becoming increasingly more painful as the season progresses. The joint pain will abate with rest only to recur with increased activity. It's not unusual to see symptoms of turf toe resolve in the off season only to recur with renewed exercise.

Treatment of turf toe varies along with the sort of healthcare provider and includes the use of rest, shoe modifications, orthotics, steroid shots and surgery. The success of non-surgical treatment will vary with the degree of injury, the rate at which the injury is healing and also how much osteoarthritis has occurred. We see varying degrees of success with orthotics that promote plantarflexion of the first ray, effectively treating metatarsus primus elevatus and peroneus longus dysfunction. Simple arch supports can make a significant difference in the symptoms of turf toe.

Should our patient not respond to conservative care in a reasonable time period, we are not reluctant to suggest surgical revision to address the problem may it be revisions of the combined problem, shortening of a long first metatarsal or structural revision of metatarsus primus elevatus. As mentioned before, the clinical appearance of dorsal lipping or visible radiographic changes are suggestive of moderately advanced osteoarthritis, a condition that is only repaired by joint revision or replacement.

When treating turf toe be sure to recognize the fact that there is no neural innervation in articular cartilage. Pain associated with stage one turf toe (hallux limitus) is either synovial pain or bone pain. If all of us recognize that agonizing stage one turf toe hallux limitus) may be due to bone pain, we then realize that turf toe should be handled aggressively to make sure over time possibility of the joint.

Nomenclature:

First MPJ - the big toe joint Metatarsus primus elevatus - a practical or perhaps structural position of the initial metatarsal First metatarsal - the foot bone making up the proximal part of the large toe joint Hallux - the great toe.

Joint Pain,Gout

Anatomy:

The great toe joint, or first metatarsal joint consists of two bones. The proximal bone is the first metatarsal and also the distal is called the proximal phalanx or hallux. These two bone move against each other within an up and down motion through what we refer to as the sagital plane. Biomechanics: The motion of the great toe joint is dependant on the plantarflexion of the very first metatasal. If the first metatarsal is limitied in its' capability to plantarflex, the joint will jam leading to funtional hallux limitus, which as we know is one of the causes of turf toe.

Symptoms:

Turf toe that is the result of functional hallux limitus is going to be insidious in onset. Functional hallux limitus will most likely be seen in more youthful sports athletes as they try to increase their activity. It may not take place during the first athletic season, or the second, but when it does set out to hurt, the onset will be more frequent and more severe, varying with activity. This profile of onset is simply due to the fact that the athlete is recreating the injury with each and every step.

Turf Toe Caused by a Direct Injury to the Joint May or May Not be Obvious

Athletes may not remember an incident of pain since they are usually distracted by the event or game in which they're involved. The onset of immediate injury to the joint might be abrupt, but also may be insidious becoming increasingly much more painful as the season progresses. The joint pain can subside with rest only to recur with increased activity. It's not unusual to see symptoms of turf toe resolve in the off season only to recur with renewed exercise.

Differential Diagnosis:

The differential diagnosis of turf toe includes; ArthitisFracture Gout Joint an infection Combined or bone tissue tumor Synovitis.

References:

Lombardi, C.M., Silhanek, A.D., Connolly, F.G., Dennis, L.N.,Keslonsky, A.J. First Metatarsophalangeal Arthrodesis forTreatment of Hallux Rigidus: A Retrospective Study. J. FootSurg. 40:3, 137-143, 2001

Unger, K., Rahimi, F., Bareither, D., Muehleman, C. TheRelationship Among Articular Cartilage material Degeneration and BoneChanges of the very first Metatarsophalangeal Joint. J. Foot Surg.

Ronconi, P., Monachino, P., Baleanu, P.M.,Favilli, G. DistalOblique Osteotomy of the very first Metatarsal for the Correction ofHallux Limitus and also Rigidus Deformity. J. Feet Surg. 39:3,

About the Author:Jeffrey a

Oster, DPM, C.Ped is a board certified foot and ankle surgeon. Dr. Oster is also board certified in pedorthics. Dr. Oster is medical director of Myfootshop.com and is in active practice in Granville, Ohio.