In this series of articles we’ll be discussing sesamoid injuries, hallux rigidus and hallux limitus, turf toe, and other, similar first metatarsophalangeal (MTP) joint injuries. We’ll be starting with a quick overview of mild to moderate turf toe.

A properly functioning first metatarsophalangeal joint is critical for running.

Ardipithecus Ramidus

Ardipithecus Ramidus

In evolution, the abduction of the first ray, disappearance of an opposable hallux, and realignment of the first metatarsophalangeal joint and first metatarsocuneiform joint marked a complete change from arboreal living to obligate bipedalism. Ardipithecus ramidus, the oldest known hominid, had an adducted first metatarsal, opposable hallux, and was able to walk in a bipedal manner (Lovejoy, Latimer et al. 2009). When Australopithecus evolved with a more modern alignment of the great toe, hominids became obligate bipeds and as evolution continued further, Homo habilis and Homo erectus gained the ability to run.

The first metatarsophalangeal joint includes 4 bones. The most readily apparent portion of the joint is the articulation between the concave shaped base of the proximal phalanx and the convex, rounded head of the first metatarsal. The plantar surface includes the two sesamoid bones (fibular or lateral and tibial or medial) and the joint capsule. The joint capsule is reinforced on its plantar aspect by both a fibrocartilagenous plate and the plantar accessory ligament. The flexor hallucis longus and flexor hallucis brevis attach on the plantar aspect, along with the abductor hallucis muscle and the adductor hallucis muscle.

Dorsally the tendons of the extensor hallucis longus and the extensor hallucis brevis muscles insert.

Turf toe, sesamoiditis, and hallux rigidus are a functionally interconnected set of injuries. These problems can impair the ability to run. In severe cases a runner may consider giving up their sport permanently. We’ll examine these entities individually and review treatment.

Turf Toe: A quick look

Turf toe is the term applied to what is commonly termed a “sprain” of the first metatarsophalangeal  (MTP) joint. Early in its history it was applied only to those participating in American style football and occurring on artificial turf. In reality it occurs in many other sports including soccer, basketball, volleyball, dancers, and occasionally among runners. In runners, pure sesamoid injuries are more often seen, as is hallux limitus (limited upward motion of the big toe).

Turf toe is a complex injury. It is caused by a sudden dorsiflexion (bending upwards) of the great toe on the first metatarsal head. Attention is often directed to the dorsal aspect (top) of the first metatarsal, which has often been jammed. There is usually an injury to the cartilage on the dorsum, and almost always a limitation of motion in dorsiflexion after the injury.

Much of the injury, however, occurs below the first metatarsophalangeal joint (MTP). In assessing this injury much attention should be paid to the sesamoid area. As the toe moves up, the sesamoids are forced into the first metatarsal bone and subject to severe and sudden forces which injure the cartilage of the sesamoids and the plantar surface of the metatarsal head. Sometimes the sesamoids may fracture from these forces. Often the soft tissue attachments are also injured. The flexor hallucis brevis and abductor hallucis and adductor hallucis muscles all have an intimate attachment with the sesamoid bones.

“... much of the injury occurs below the first metatarsophalangeal join. ... pay attention to the sesamoid area...”

If the plantar portion of the joint is injured (which in reality, it always seems to be) there will be a limitation of motion. Attempts to increase the range of motion while the plantar structures are injured, and the dorsal structures are not in much better condition, does not seem to be a wonderful idea. I'd rather support, stabilize and limit motion while the problem is in an acute stage.

Classification Systems

Jahas in 1980 classified sprains of the 1st MTP joint as follows:

Type I - inter-sesamoid ligament and sesamoids remain intact.
Type II sprain - disruption of the intersesamoid ligament and an associated transverse fracture of the sesamoids.

Clanton and Ford devised a revised classification for 1st MTP sprains or Turf Toe in 1993:

Grade 1 - Stretch injury or slight tearing of the capsule and ligaments of the first MPJ. Findings include local plantar or plantar medial tenderness, mild swelling, minimal loss of range of motion, able to bear weight with only mild symptoms. Some pain on continuation of play.

Grade 2 - Partial tear of the capsule and ligaments of the first MP Joint. Findings include moderate swelling, bruising and moderate restriction of first MP Joint range of motion. Limp noted.

Grade 3 - Complete tear of the capsule and ligaments. Possible tear of the plantar plate

When things are "awful", swollen, tender, and painful with every step,  an AirCast Pneumatic Walker (or cam walker as a substitute) should be used by the patient. Do not force the injured toe to move, since it is going to cause pain and reinjure the damaged area. The purpose of the pneumatic walker is to prevent or limit the loading of the forefoot, and to limit the dorsiflexion motion of the great toe at this early stage of healing. This device limits the movement far better than a "postoperative shoe". By limiting the forward motion of the tibia over the foot and stopping the relative dorsiflexion of the foot on the leg, forces at the first metatarsophalangeal joint and concomitantly, the sesamoid bones, will be lessened.

For long term follow up, I will teat it primarily as an injury to the sesamoid apparatus and structures attached to the sesamoid bones. I try to offload it with a sesamoid accommodation pad (or a "dancers" pad) which is designed to shift weight and forces proximally and laterally. Then I'll make an orthotic of a semi-rigid or somewhat softer material with a pad like that built into it. I often use leather and like how the company I use to make them grinds out the sesamoid area.

On occasion the injury needs to be evaluated for sesamoid fracture and avascular necrosis. X-rays of fractured hallucal sesamoid bones do not usually show healing as in the long bones. The bone stays split, but fibrous connective tissue can make a firm union of the parts. An accommodation built into an orthotic usually helps, if well designed. Bone stimulators have been used to treat turf toe. Some find shoes with a stiff forefoot or a Rocker forefoot sole can be helpful.

Sometimes a splint is used below the first metatarsophalangeal joint. My personal preference is to off load the forces using a sesamoid pad. Incorporating this into an orthotic usually helps significantly in the long term. It directly removes pressure from the sesamoidal apparatus, places the great toe in a good functional position, and eliminates the early, rapid change in position of the great toe that takes place as the gait cycle passes through heel off.

...offloading... directly removes pressure from the sesamoidal apparatus, places the great toe in a good functional position, and eliminates the early, rapid change in position of the great toe that takes place as the gait cycle passes through heel off...

Anatomy:

The first metatarsophalangeal joint includes 4 bones including primarily the articulation between the concave shaped base of the proximal phalanx and the convex, rounded head of the first metatarsal. The plantar surface includes the two sesamoid bones (fibular or lateral and tibial or medial) and the joint capsule which is plantarly reinforced by a plantar fibrocartilagenous plate which includes the plantar accessory ligament. The muscles attaching here include the flexor hallucis longus and flexor hallucis brevis on the plantar aspect, accompanied by the abductor hallucis muscle and the adductor hallucis muscle. On the dorsum is the extensor hallucis longus muscle and the extensor hallucis brevis.

Treatment Summary:

Start with careful assessment of the entire first metatarsophalangeal joint including dorsal aspect and the sesamoid bones:

 

 

Acute Care:

PRICE: Protection, Rest, Ice, Elevation.

Offloading shoe
Rocker sole
Pneumatic Walker

Long Term:
Offloading Orthotic with Sesamoid Accommodation

Potential Predisposing Conditions:

  • Artificial turf and playing surfaces
  • Athlete's experience and years of sports participation
  • Flattened 1st MTP Joint
  • Cavus Foot Type
  • Football players (defensive and offensive running backs, wide receivers, linemen)
  • Foot pronation
  • Hallux degenerative joint disease
  • Increased ankle dorsiflexion
  • Increased friction between athletic shoe and turf
  • Excessive toe box flexibility
  • Prior 1st MTP joint injury
  • Sesamoiditis

The hallucal sesamoid bones are associated with the big toe and the first metatarsophalangeal joint. They function as as a fulcrum in a sense (although some describe the function as like a pulley) and mechanically increase the advantage of the muscles that plantar flex the big toe. The knee cap provides a similar function at the patellofemoral joint and increases the mechanical advantage of the quadriceps. The patella or knee cap is another sesamoid bone. Sesamoid bones by definition occur in tendons. We'll be looking at this condition in an upcoming article.

Treatment Summary for Turf Toe:

Careful assessment followed by the appropriate treatment:

Acute Care:

  • PRICE: Protection, Rest, Ice, Elevation.

  • Limit motion using:

    • Offloading shoe
    • Rocker sole
    • Pneumatic Walker

Long Term:

  • Off loading orthotic with sesamoid accomodation.
  • Gentle Range of Motion exercises or Physical Therapy as needed.
  • Rocker sole or stiff forefoot on footwear.

Selected References:

Clanton TO, Ford JJ., Turf toe injury. Clinics in Sports Med 13(4):731-735, Oct. 1994

Coker, T. P, Arnold, J. A., & Weber, D. L. (1978). Traumatic lesions of the metatarsophalangeal joint of the great toe in athletes. The American Journal of Sports Medicine, 6(6), 326-334.

Lovejoy, C. O., B. Latimer, et al. (2009). "Combining prehension and propulsion: the foot of Ardipithecus ramidus." Science 326(5949): 72e71-78.

Rodeo, S., O'Brien S., Warren,R., et. al "Turf-toe: An analysis of metatarsophalangeal joint sprains in professional football players". 1990 18: 280 Am J Sports Med

Clanton, T. O., & Ford, J. J. (1994). Turf toe. Clinics in Sports Medicine, 13(4), 731-741.

Williams, B How To Treat Turf Toe Injuries. Podiatry Today. . VOL 21 Sep 01 2008