Clinical Tips for Assessing 1st MTPJ Sprain (aka "Turf Toe")

During football season, it's not uncommon to see a spike in acute 1st MTPJ injuries.

Today I want to share some clinical tips when it comes to the assessment of Turf Toe injuries, including the utilisation of diagnostic imaging.

Given the complex anatomy of the 1st MTPJ, there are a range of clinical tests and diagnostics we need to have an understanding of in order to arrive at a prompt diagnosis, deliver effective management, and facilitate a timely return-to-activities.

What is "Turf Toe"?

"Turf toe" is a term used to describe a hyperextension injury of the metatarsophalangeal-sesamoid complex of the hallux (2,6).

It is often seen in sports or activities that involve high degrees of forefoot axial loading and/or pivoting movements (6).

In turf toe injuries, both dorsal and plantar structures of the hallux metatarsophalangeal joint can be affected, involving various musculoskeletal structures.

Mechanisms of Injury

High-range &/or high-velocity 1st MTPJ dorsiflexion + axial loading.

Despite understanding the mechanisms of these injuries, often the articular and ossesous elements of higher-grade turf toe injuries can be overlooked.

We are familiar with the tensile/traction/distraction forces at the plantar joint complex in these injuries. All of which can result in connective tissue sprains, strains, plantar plate tears, sesamoid fractures &/or dorsal dislocation of the joint.

In injuries where the forces are high enough to cause disruption to the plantar aspect of the joint, there are also compressive forces acting on the dorsal aspect. Structures that may be impacted via this mechanism at the dorsal aspect of the joint include; the base of the proximal phalanx & dorsal aspect of the 1st metatarsal, potentially resulting in an articular injury &/or fracture.

Clinical Assessments

Palpation & Physical Tests

Given the complex anatomy of the 1st MTPJ, we need to consider all musculoskeletal structures in the region that may be injured. This includes; articular surfaces, joint capsules, sesamoids, ligaments, tendons and neurovascular structures.

1st MTPJ ROM

We need to consider the range of motion, quality of motion and the inter-limb symmetry of movement.

Articular Surfaces

1st MTPJ ROM testing (flexion & extension).

Applying tensile & compressive loads to a joint will give an indication of the location(s) of an injury.

For example, pain at the dorsal aspect of the 1st MTPJ during 1st MTPJ extension applies compressive loads to the region, potentially indicating a dorsal articular cartilage injury or presence of a fracture.

Whereas, if there was no dorsal pain during this movement and the pain was only located on the plantar aspect, it may indicate plantar plate, plantar joint capsule, sesamoid, and/or tendon injury.

Collateral Ligaments

Varus and valgus stress tests.

Dorsal + Plantar Capsule

Tested via applying tensile loads (1st MTPJ flexion / extension).

Plantar Plate

Metatarsophalangeal "drawer" test.

"With the head and neck of the metatarsal bone fixed by one hand, the examiner attempts to dislocate the proximal phalanx dorsally with the other hand." (Fernandes et al, 2015).

Active extension & flexion at the MTPJ & IPJs

Tests dynamic flexion & extension tolerance, in addition to testing integrity of extensor & flexor tendons.

Plantar Sesamoid Complex

Palpation & Passive Axial Compression Manoeuvre (PAC test) - described in Martinez? & Morales (2022).

An in-depth overview of clinical assessments for Turf Toe injuries will be covered in an upcoming 2024 Progressive Podiatry Project webinar.

Diagnostic Imaging

Diagnostic imaging is often required for higher-grade injuries, with both x-ray and ultrasound providing a cost-effective and timely method for assessment, especially in regions in which other modalities may be difficult to access.

Below are some recommendations and clinical pearls regarding x-ray & MRI imaging.

X-Ray

Despite x-ray imaging being often considered only useful for assessing osseous structures, observable signs of soft tissue disruption can be determined in the case of 1st MTPJ injuries.

Should you refer for plain radiographs, obtaining comparison films are encouraged, as this can identify proximal migration (retraction) of the sesamoids in higher-grade plantar plate injuries in AP view. (Hainsworth & McKinley, 2018).

Recommended X-Ray Films

Standard weight-bearing AP, Lateral and Axial Sesamoid.

X-ray films are often normal/NAD in GI & II.

MRI

Recommended for higher-GII & GIII injuries, due to the likely involvement of multiple connective & osseous tissues.

T2-weighted images can demonstrate soft tissue disruption &/or articular injury.

MRI may demonstrate high T2 signals (Hillier et al, 2004)

In the presence of a fracture, CT can be effective at monitoring progress following fracture diagnosis (Ribbans & Hintermann, 2016)

I hope you've found this insight article helpful.

If you'd like to learn more, one of our upcoming webinars for 2024 as part of the Progressive Podiatry Project's GFM: Gait | Footwear | Movement monthly CPD subscription covers the assessment, management & rehabilitation for "Turf Toe" injuries.

Including;

• In-depth overview of above ↑ information.
• Injury grading & return-to-play timeframes.
• Rehabilitation considerations, exercises & progressions.
• Orthomechanical interventions (orthoses, footwear, carbon fibre plates etc).

For more information on GFM, click HERE

To save 15% on your first 12 months of GFM: Gait | Footwear | Movement, enter Code HAYLEY at checkout before 30th June 2024

References

1. Eloy de Avila Fernandes, Tania Szejnfeld Mann, Andrea Puchnick, Franklin de Freitas Tertulino, Camila Testoni Cannato, Caio Nery, Artur da Rocha Corrêa Fernandes, Can ultrasound of plantar plate have normal appearance with a positive drawer test?, European Journal of Radiology, Volume 84, Issue 3, 2015, Pages 443-449, ISSN 0720-048X, https://doi.org/10.1016/j.ejrad.2014.11.036.
2. Hainsworth, L. and McKinley, J. (2017) ‘15?the management of turf toe – a systematic review’, Day 3 Poster presentations [Preprint]. doi:10.1136/bjsports-2017-098966.19.
3. McCormick JJ, Anderson RB. Turf toe: anatomy, diagnosis, and treatment. Sports Health. 2010 Nov;2(6):487-94. doi: 10.1177/1941738110386681. PMID: 23015979; PMCID: PMC3438874.
4. Ribbans, W., & Hintermann, B. (2016). Hallucal Sesamoid Fractures in Athletes, Diagnosis and Treatment. Sports Orthopaedics and Traumatology, 32(3), 295-303. https://doi.org/10.1016/j.orthtr.2016.04.001.
5. Rodeo, S.A. et al. (1990) ‘Turf-toe: An analysis of metatarsophalangeal joint sprains in professional football players’, The American Journal of Sports Medicine, 18(3), pp. 280–285. doi:10.1177/036354659001800311.
6. Seow, D. et al. (2020) ‘Treatment options for turf toe: A systematic review’, The Journal of Foot and Ankle Surgery, 59(1), pp. 112–116. doi:10.1053/j.jfas.2018.12.041.