6/19/2018

Turf Toe

Turf Toe

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

  • Turf toe is actually a form of hallux limitus.
  • Hallux limitus is typically 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 as well as subsequent repetitive jamming of the first 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 osteoarthritis, external physical has a bearing on 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 terms is the patient population that they affect. Turf toe is a term used in athletic bags talking about any injuries of the great toe shared. Consequently, discussions regarding turf toe will 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 end result is actually a load that is applied to the subchondral bone that is greater than what are the bone tissue can tolerate. As the damage progresses, a series of small 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' underlying support and becomes susceptible to damage. 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 joint.

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 harmed 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.

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 both. These are the stage two and three cases of turf toe (hallux limitus) that show visible change on x-ray. As the subchondral bone will become increasingly damaged, this will create a good uneven helping surface for the cartilage. An increase in activity results in uneven loading of the combined because of the compression injury of the subchondral bone.

The onset of turf toe usually the same? Turf toe that is the result of functional hallux limitus are going to be insidious in onset. Functional hallux limitus will most likely be seen in younger athletes as they attempt to improve their activity. It may not occur during the first sports season, or the second, but when it does start to cause pain, the onset will be more frequent and more severe, various 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 often distracted by the event or game in which they're involved. The onset of immediate injury to the joint may be unexpected, but also may end up being insidious becoming increasingly more painful as the season progresses. The joint pain will abate with rest only to recur along with increased activity. It's not unusual to see signs of turf toe resolve in the off season only to recur with renewed exercise.

Treatment of turf toe varies along with the kind of healthcare provider and includes the use of rest, shoe modifications, orthotics, steroid needles and surgery. The success of non-surgical attention will vary with the degree of injury, the rate at which the injury is healing and also how much osteoarthritis provides occurred. We see varying degrees of success with orthotics that promote plantarflexion of the very 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 in order to suggest surgical revision to address the problem whether it be revisions of the combined problem, shortening of a long first metatarsal or architectural 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 actually either synovial pain or bone pain. If all of us recognize that painful stage one turf toe hallux limitus) may be due to bone pain, we then realize that turf toe should be treated aggressively in order to make sure the long term viability of the joint.

Nomenclature:

First MPJ - the big toe joint Metatarsus primus elevatus - a practical or even structural position of the very first metatarsal First metatarsal - the foot bone making up the proximal part of the important toe joint Hallux - the great toe.

Anatomy:

The great toe joint, or first metatarsal joint consists of two bones. The proximal bone is the very first metatarsal and also the distal is known as 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 upon the plantarflexion of the first metatasal. If the first metatarsal is limitied in its' ability 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 often be seen in younger athletes as they make an effort to increase their activity. It may not occur during the first athletic season, or the second, but when it does start 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 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 these are frequently distracted by the event or game in which they're required.
  • The onset of direct injury to the joint might be abrupt, but also may be insidious becoming increasingly more painful as the season progresses.
  • The joint pain can 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.

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Differential Diagnosis:

The differential diagnosis of turf toe includes; ArthitisFracture Gout Joint an infection Joint or bone 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 Between 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 Rigidus Deformity. J. Foot Surg. 39:3,

About the Author:Jeffrey a

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

Domenic GoldenDomenic Golden
Domenic is a head content marketing specialist at musclenstress.com, a collection of articles on health issues. In the past, Domenic worked as a post curator for a well-known health site. When he's not writing posts, Domenic enjoys drawing and rock climbing.