What you need to know about "Turf Toe"

Turf Toe

The simplest definition of turf toe is that it is a sprain of the main joint of the big toe. It happens when the toe is forcibly bent up into hyperextension, such as when pushing off into a sprint and having the toe get stuck flat on the ground.

Sprains of the big toe joint became especially prevalent in American football players after artificial turf became more common on playing fields - hence the term "turf toe." Artificial turf is a harder surface than grass and does not have much "give" when forces are placed on it.

Although often associated with football, turf toe occurs in a wide range of sports and activities.

The typical position of the foot when a turf toe injury occurs.

Anatomy

The big toe is made up of two joints. The largest of the two is the metatarsophalangeal joint (MTP), where the first long bone of the foot (metatarsal) meets the first bone of the toe (phalanx). In turf toe, the MTP joint is injured.

The MTP joint is the large joint closest to the base of the big toe.

The joint is surrounded by important structures that hold it in place and prevent it from dislocating. Together these structures are referred to as the "plantar complex."

• Plantar plate. This thick, fibrous tissue under the MTP joint prevents the big toe from bending too far (dorsiflexion).
• Collateral ligaments. Located on each side of the big toe, collateral ligaments connect the phalanx bone to the metatarsal and prevent the toe from going too far side-to-side.
• Flexor hallucis brevis. This tendon runs under the first metatarsal bone and attaches to the phalanx. It provides strength and stability to the big toe during push-off motions.
• Sesamoids. These two small bones are enveloped in the flexor hallucis tendon, and help it to move more easily. In addition, the sesamoids provide stability to the MTP joint by helping to bear weight placed on the forefoot.

Several structures work together to protect and stabilize the MTP joint.

Description

The term "turf toe" refers to an injury of any soft tissue structure in the plantar complex, such as the plantar plate or a collateral ligament. These injuries can vary in severity — from stretching of the soft tissue to partial tearing, and even total dislocation of the MTP joint.

To help them plan treatment for turf toe, doctors grade the injuries from 1 to 3 - mild to severe.

• Grade 1. The plantar complex has been stretched causing pin-point tenderness and slight swelling.
• Grade 2. A partial tearing of the plantar complex causes more widespread tenderness, moderate swelling, and bruising. Movement of the toe is limited and painful.
• Grade 3. The plantar complex is completely torn causing severe tenderness, severe swelling, and bruising. It is difficult and painful to move the big toe.

We have treated this injury on and off over the years with similar therapy. Rarely does this require surgery, and there is sparse literature which can be referenced to delineate whether grade 1 and grade 3 injuries are specifically nonsurgical or surgical.  We have used a combination of PRP injections with hallux extension BK casting for this injury and have found good success. This is a non surgical approach and has had with it some good short term success. But this may still be a devastating injury for most athletes. (Even notable pros such as Deion Sanders, have had career ending versions of this injury). 

Secrets of foot pain: Arthritis is PROGRESSIVE

The patient above was seen initially in this office back in 2011, and those images are on the right hand side. The left side images show 2013 radiographs. This demonstrates the progressive nature of the arthritic condition in the first toe joint. The left shows a joint space of 0.6mm versus 1.92 mm joint space on the right, and this implies cartilage thinning, a mainstay of osteoarthritis. On the side views, we see increased calcifications and spurring on top of the joint which is outlined with a red circle to the image on the left.

This can progress slowly, but whenever we see this sort of progression in 2 years time, we can be certain this patient may require surgical intervention. I always strive to treat with nonsurgical care, but in circumstances such as this, often times an arthrodesis or total joint replacement can be undertaken depending on nature of symptoms and activity level of the patient.

Joint supplementation, such as chondroiten sulfate,  along with flavanoids for anti oxidant nonsteroidal anti inflammatory relief may benefit for osteoarthritis pain as well.

Sometimes even cortisone injections (maximum of 3 in a 12 month period) may be useful for pain relief, along with orthosis with rigid first ray advancement.

Dr Timm

Diplomate American Board of Podiatric Surgery

Secrets of foot pain: Not all foot pain is arthritis!

"Doc, my foot and leg are cramping lately."

Do I have arthritis?

Probably. But in many cases, especially in diabetics and patients with a strong smoking history, that is not the root cause of the pain. We will listen to the pulses, and if there are abnormalities in this examination, I will order an on site screening dopplar to rule out extensive or significant arterial and venous disease.





Most people are aware that cholesterol is bad (especially LDL) because it leads to heart disease. Lesser known vascular diseases include peripheral arterial disease of the legs and feet. This is a common finding in our office which can be identified with on site arterial dopplar testing and on physical examination with the "claudication" history.






Often times patients will present with generalized leg and foot pains which are not very responsive to NSAIDs. There may be significant color changes like on the right, or none like on the left of the above pictures.




For significant enough findings, we will refer for angiography, and the vascular interventionalist may be able to open the vessels without open surgery in many cases, which reduces or eliminates much of the pain associated with vascular disease. This also effectively is a form of limb salvage, which ultimately prevents leg amputations.

Dr Timm, DPM FACFAS

Board Certified by the American Board of Podiatric Surgery 

Why is Podiatry Better?

Orthopedics versus Podiatrics

This is a common question that I will encounter, and I thought I would enlighten our readers about how I tend to answer this:

Who is better for foot and ankle treatment, a podiatric surgeon or orthopedic surgeon ?

This is a long debated topic which spans several other forums, and may actually not have a defined answer in general. I feel this question would be best answered in paragraphs headed, "it depends".

"It depends" on training.

I will offer several reasons for this statement. The first being that not all orthopedic surgeons have the same training. The same holds true for podiatric surgeons. Some podiatrists are not surgically trained, and a pathology may require such an intervention. Many orthopedic doctors tend to spend more time on knees and hips, some have fellowships in shoulders and foot and ankle surgery training is minimal as a general rule. Surgically trained podiatrists must have ABPS board qualification or certification for adequate credentials, especially for more complex surigcal needs of patients, such as ankle fusions or calcaneal fracture open reductions. These podiatrists spend 3 years doing complex foot and ankle surgery and some even have an additional year of fellowship training as well.

Most podiatrists feel comfortable treating forefoot deformities like bunions and hammertoes, and if they have surgical priveleges they may treat these conditions quite well. Many orthopedic surgeons will not routinely treat foot and ankle conditions that podiatrists see in their offices every day. The few that are fellowship trained in foot and ankle surgery are more apt to treat these various conditions without too much trouble. Overal, if you are researching a new doctor for your feet, I believe it is necessary to know the qualifications of your doctor prior to making the appointment.

"It depends" on your problem.

If you suffer from heel pain, or nail issues, most podiatrists are able to effectively treat these conditions quite efficiently without surgical interventions. Again, if a blade is part of the treatment protocol needed to relief painful symptoms, it may be necessary to know what boards your doctor is part of. All of the podiatrists at FFLC are ABPS qualified, and that means we are able to surgically treat any foot and ankle condition. If you choose to go the orthopedic route for your care, you may need to know whether the physician has a fellowship in foot and ankle and is commonly seeing people for their feet issues.

We see the most common problems for foot and ankle pain here, as well as some of the most complex problems. We do this every day and that's all we do. Experience and volume speaks well for the abilities of our doctors to not only treat these conditions well, but treat them often.