11/14/2018

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 discussing any injury of the great toe joint. Consequently, discussions regarding turf toe can focus on the first two 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 will be lots that is put on the subchondral bone that is greater than what the bone fragments can tolerate. As the injury 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' fundamental 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 as 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.

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, that will create a good 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.

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The oncoming 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 often be seen in younger athletes as they attempt to increase their activity. It may not occur during the initial fitness season, or the second, but when it does begin to cause pain, 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 well not remember an incident of pain since they're frequently distracted by the event or game in which they are involved. The onset of direct injury to the combined may be abrupt, but also may be 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 the signs of turf toe resolve in the off season only to recur with renewed exercise.

Treatment of turf toe varies with the sort of healthcare provider and includes the use of rest, shoe modifications, orthotics, steroid injections and surgery. The success of non-surgical treatment will vary with the degree of injury, the rate at which the injury is healing and how much osteoarthritis offers 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.

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  • Should our patient not necessarily answer conservative care in a reasonable time period, we are not reluctant in order to suggest surgical revision to address the problem whether revisions of the joint 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 lack of feeling innervation in articular cartilage. Pain associated with stage one turf toe (hallux limitus) is actually either synovial pain or bone pain. If we all recognize that unpleasant stage one turf toe hallux limitus) may be due in order to bone pain, we then recognize that turf toe should be taken care of aggressively to be able to insure the long run stability of the joint.

    Nomenclature:

    First MPJ - the big toe joint Metatarsus primus elevatus - a functional or structural position of the first metatarsal First metatarsal - the foot bone making up the proximal portion of the big toe joint Hallux - the great toe.

    Anatomy:

    The great toe joint, or first metatarsal joint consists of two bones. The proximal bone is the initial metatarsal as well as 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' power to plantarflex, the joint will jam causing funtional hallux limitus, which as we know is one of the causes of turf toe.

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    Joint Pain,Gout

    Symptoms:

    Turf toe that is the result of functional hallux limitus is going to be insidious in onset. Functional hallux limitus will usually be seen in younger sports athletes as they try to improve their activity. It may not occur during the first athletic season, or the second, but when it does set out to injure, 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're frequently distracted by the event or game in which they're included. The onset of immediate injury to the joint could be abrupt, but also may be insidious becoming increasingly a lot more painful as the season progresses. The joint pain may 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 Shared or bone fragments 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 Normal cartilage Degeneration and BoneChanges of the 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. 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 which is in active practice in Granville, Ohio.