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.
Jahas in 1980 classified sprains of the 1st MTP joint as follows:
Type I - inter-sesamoid ligament and sesamoids remain intact.
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.
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.
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.
Start with careful assessment of the entire first metatarsophalangeal joint including dorsal aspect and the sesamoid bones:
PRICE: Protection, Rest, Ice, Elevation.
Potential Predisposing Conditions:
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.
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
Copyright 2003-2009 Stephen M. Pribut