How To Treat Turf Toe Injuries

By Bruce E. Williams, DPM

Keys To Evaluating And Grading Turf Toe Injuries

Clanton and Ford set up a grading system for turf toe.8 Grade 1 sprains involve a stretch injury or slight tearing of the capsule and ligaments of the first MPJ. Symptoms would include local plantar or medial tenderness, minor swelling, no bruising, minimal loss of range of motion, the ability to bear weight with minimal symptoms, and some pain on continuation of play. Clanton and Ford also felt that these were the usual symptoms one would see for chronic turf toe sprains as well.
   Grade 2 sprains reflect a partial tear of the capsule and ligaments of the first MPJ. Clinicians will note moderate swelling and bruising as well as moderate restriction of first MPJ range of motion. The tenderness of the joint will be increased over a grade 1 sprain and the patient will usually limp on weightbearing. Most of the symptoms will become worse over the first 24 hours and the athlete cannot play at a normal functioning level.
   Grade 3 sprains will display a complete tear of the capsule and ligaments. Physicians may also detect a tear of the plantar plate of the first MPJ where it originates at the metatarsal head and neck. An impaction injury of the proximal phalanx into the metatarsal head dorsally is also usually present. Many of these injuries will be associated with a sesamoid fracture or a separation of a bipartite sesamoid that is already present. Sometimes the tear of the capsule can result in proximal migration of the sesamoids. These patients will display severe pain, swelling and bruising. These patients will also have severe restriction of range of motion. The athlete cannot perform or bear weight on the medial aspect of the first MPJ.
   An X-ray is the best initial modality for evaluation of turf toe. When viewing the X-ray, note the position of the sesamoids on comparison views of the opposite foot. Watch for proximal migration of both or individual sesamoids, and/or separations medially to laterally within the sesamoid complex. One can also use X-rays to rule out sesamoid fractures, capsule avulsions, separated bipartite sesamoids and impaction injuries of the first metatarsal head.
   Computed tomography (CT) scans are fantastic when physicians suspect a sesamoid injury or separation as the three-dimensional reconstruction detail is truly unique. Bear in mind that MRIs and/or ultrasound may provide more detail regarding a potential soft tissue ligamentous or capsular injury, especially of the plantar plate.
   Research suggests utilizing MRI for grade 2 and 3 turf toe injuries as this will show the severity of soft tissue damage and allow evaluation of the articular and bony injury as well.9 Magnetic resonance imaging is a great adjunctive diagnostic technique for differentiating these conditions.10,11

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