A turf toe injury refers to a sprain of the ligamentous structure of the first metatarsophalangeal joint (MTPJ).
The mechanism of turf toe injuries involves hyper-extensive force delivered to the first MTPJ resulting in a disruption of the plantar joint complex. This is caused when axial load passes through the heel with the foot in a fixed equinus position.
If dorsiflexion of the first MTPJ remains uninterrupted, the base of the proximal phalanx impacts the central dorsal articular surface of the metatarsal head leading to further injuries of the joint surface.
The term “turf toe” was first coined by Bowers and Martin in 1976 when they observed an increase in the incidences of sprains in the plantar capsule-ligament complex of the first MTPJ among players, after the installation of an artificial turf on West Virginia University’s football field.
The authors noted that the combination of a relatively flexible football shoe with a hard artificial surface predisposed the players to turf toe injuries, necessitating the use of firm-soled football shoes.
According to McCormick and Anderson, turf toe injuries can be categorised as – hyperextension, hyperflexion and dislocation injuries – distinguished by history and physical examination.
Hyperextension turf toe includes any stretching or tear of the plantar capsular ligamentous complex causing tenderness, swelling and ecchymosis. This occurs when a player’s leg is injured on the field with the foot plantar flexed at the ankle and the hallux in full extension.
Hyperflexion (sand toe) refers to an injury of the hallux MTPJ or any of the lesser MTP joints. This is less common and occurs when a tackle from behind pushes the player’s knee forward, while the foot is plantar flexed and the body is in continuous movement.
A dislocation involves a disruption of the hallux with the sesamoids, or an associated disruption of the intersesamoid ligament. There could also be a transverse fracture of any of the sesamoids or a complete disruption of the intersesamoid ligament with fracture of one of the sesamoids.
The risk associated with a compromised medial longitudinal arch is the additional stress placed on the foot which predisposes a player to a valgus or varus injury of the first MTPJ.
In the case of hyperextension injuries, a stiff-soled shoe paired with customised orthotics such as MASS4D® can help limit hallux MTPJ extension, improve plantar flexion of the first ray and enable a smooth transition of the player to pre-injury performance level.
As part of an active rehabilitation programme, customised orthotics with added rigidity would be beneficial in reducing dorsiflexion stress to the MTPJ and supporting the peroneal and tibialis posterior muscles which are responsible for the stabilisation of the foot in motion.
This will help restore the medial longitudinal arch and improve range of motion of the foot and ankle, helping enhance the player’s performance on the field.
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Repetitive plantarflexion can lead to pain and mechanical limitation in the posterior ankle joint which is known as posterior ankle impingement syndrome. This pathology commonly occurs in ballet dancers and football players.