Chapter 45 

First Metatarsophalangeal Joint Sprain

(Turf Toe)

INTRODUCTION
Stephen Gould, MD, MPH, and Kenneth J. Mroczek, MD

Epidemiology Pathophysiology
• The term turf toe first appeared in literature in 1976 Intrinsic Factors
as reported by Bowers and Martin to describe plantar
capsuloligamentous sprain of the first metatarsopha- • Major contributors
langeal (MTP) joint related to hard artificial surfaces • Increased ankle dorsiflexion2
and insubstantial footwear.1 • Mean ankle dorsiflexion of the uninjured side in
injured players was 13.33° compared with 7.87°
in uninjured players.3
• Flattening of the first MTP2
Age and Sex
• Foot pronation2
• There are no age or sex predilections for this injury. • Minor contributors
• Mechanism of injury, playing surface, and individual • Decreased first metatarsophalangeal dorsiflexion is
biomechanics are predisposing factors to the injury.2 associated with turf toe injury (40.6 ± 15.1° in foot-
ball players with turf toe versus 48.4 ± 12.8° in
football players without history of turf toe)6
• Hallux degenerative joint disease2
Sport and Position
• Prior first MTP joint injury
• Football players (running backs, wide receivers, defen- • Pes planus
sive backs, offensive linemen, tight ends) have a • Athlete’s weight2
higher incidence of turf toe injury3 but the injury is • Number of years in professional football
also seen in other sports/activities such as soccer and • 5.2 years for injured versus 3.0 for controls3
dance.
• Forty-five percent of professional football players sur- Extrinsic Factors
veyed reported suffering from turf toe.3
• Turf toe can cause significant functional disability. • Playing surface
• Coker et al. reported a series of injuries in University • Artificial turf and playing surfaces.2 The introduc-
of Arkansas football players. The authors described the tion of these manufactured surfaces in the mid-1960s
severity of turf toe injury in terms of lost playing time resulted in a loss of shock-absorbing characteristics
and delayed return to play, even when compared with compared with grass turf.
more common, but debilitating injuries.4 • Eighty-three percent of patients report initial injury
• Hallux metatarsophalangeal joint sprains occur in on an artificial surface.3
other sporting activities such as dance (modern and • Footwear
classical) and beach volleyball. “Sand Toe” is the term • The forces the halluces experience are compounded
used to describe this injury in beach volleyball.5 by the friction between athletic shoe and turf.2
1571

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1572   FOOT INJURIES

Hyperextension Hyperflaxion Valgus loading

FIGURE 45-1.  Loading mechanisms that can result in turf toe injury.

• Lighter, more flexible shoes with increased toe box • Essentially, any activity that results in forced hyper-
flexibility and decreased number of cleats in the dorsiflexion on the great toe can result in damage to
shoe2 provide greater agility but offer less protection the first MTP. Additional examples include forced
to the halluces from impact. dorsiflexion due to tackling or due to impact of the
first MTP against the toe box of the shoe during
rapid deceleration.
Traumatic Factors
• The most common mechanism of injury, accounting for Classic Pathological Findings
85% of injuries, results from forced hyperdorsiflexion
at the first MTP.3 This occurs when the forefoot is • While initially used to describe only a sprain or strain
planted and the heel rises from the ground. If this stress of the soft tissue support structures of the first MTP,
causes the hallux to dorsiflex beyond its biomechanical the term turf toe has come to designate a spectrum of
limits, damage to the capsule at the neck of the first injuries from sprains to frank dorsal dislocation of the
MTP will occur.2 This is because the joint capsule toe.8
attachment is weaker at this site than at the proximal • Clanton et al developed a classification system to
phalanx.3 describe the severity of turf toe injuries. This system
• The biomechanics of this injury results from distal trac- remains utilized today to help dictate treatment and
tion on the medial and lateral sesamoids during forced return to play.9
hyperextension. This transfers the mechanical load to
the dorsal aspect of the metatarsal head. This stress can
cause partial or complete disruption of the plantar
plate. Injury to the plantar plate results in impaction
of the articular surfaces of the proximal phalanx to the
metatarsal head during extension of the MTP. This is
the most severe form of injury to the soft tissues of the
first MTP.5
• Eighty-five percent of turf toe injuries result from
hyperextension of the first metatarsophalangeal joint.3
Less common mechanisms of injury include plantar
flexion injury to the first MTP joint, and varus or
valgus stress injuries.7 Hyperplantarflexion injuries are
more commonly seen in dance and beach volleyball
(Figure 45-1).5
• Various football positions are susceptible to this injury.
• Offensive linemen when pushing off from a stance,
can hyperextend the first MTP.
• Running backs and receivers may be also be injured
if tackled from behind, with their forefoot planted
FIGURE 45-2.  Forced dorsiflexionflexion injury in football. (Redrawn
on the ground, if another player falls onto their leg from Rodeo SA, O’Brien S, Warren RF, Barnes R, Wickiewicz TL, Dillingham
causing hyperextension at the first MTP (Figure MF: Turf-toe: An analysis of metatarsophalangeal joint sprains in profes-
45-2). sional football players. Am J Sports Med 18(3):280–285, 1990.)

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• Grade I injuries: least severe; strain of the capsulo-
ligamentous complex without loss of its functional
integrity.7,10,11
• Grade II injuries are more severe and represent
partial thickness tearing of the plantar plate and
capsular structures.7,10,11
• Grade III injuries are the most severe. This grade of
injury may be used to describe either chronic effects
of a disrupted capsule,7 or to describe an acute injury
with complete disruption of the capsuloligamentous
complex. With this grade of injury, the plantar plate
may be completely avulsed from the metatarsal neck,
resulting in impaction of the metatarsal head during
full extension of the joint.3,7,10,11
Clinical Presentation
History
• Typical presentation includes great toe pain in an
athlete whose sport exposes him or her to hyperexten-
sion of the toe on a hard surface. Football players,
soccer players, and dancers, among others may suffer
from this injury.
• The patient may complain of pain, swelling, and ten-
derness of the plantar aspect of the MTP, as well as
inability to push off with the great toe.7
Physical Examination
Key Elements of Exam
• Observe for general deformity of the toe, presence of
swelling and ecchymosis (ecchymosis indicates fracture
or disruption of tendon/ligament).11
• Palpate joint structures including dorsal metatarsal
head and neck, dorsal aspect of the proximal phalanx,
and the sesamoids to assess integrity and presence of
tenderness to palpation.11
• Stress tests
• Abduction stress test: assesses medial collateral liga-
ment, medial capsule, abductor halluces11
• Adduction stress test: assesses lateral collateral liga-
ment, lateral capsule, and adductor halluces11
• Lachman-type maneuver to assess plantar plate10,11
• Flexor hallucis brevis strength and integrity
assessment11
Abnormal Findings
• Grade I: Plantar or medial tenderness to palpation;
minimal to no swelling; minimal or no ecchymosis7,8,10
• Grade II: Diffuse tenderness to palpation; moderate
swelling and ecchymosis; painful and restricted range
of motion. Symptoms may progress and athletes can
lose up to 2 weeks of play.7,8,10
• Grade III: Severe tenderness to palpation; marked
swelling and ecchymosis, and restricted range of
motion. The patient usually will avoid weight bearing
due to pain. Athletes can miss up to 6 weeks or more
of play. Hallux plantarflexion weakness or frank insta-
bility of hallux MTP can occur.7,8,10,11
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FIRST METATARSOPHALANGEAL JOINT SPRAIN (TURF TOE)   1573
Pertinent Normal Findings
• Grade 1: no visible bruising. There is little change in
the range of motion and the patient can continue to
bear weight.7
Imaging
Grade I
• Radiographs are normal. An MRI may demonstrate
mild soft tissue edema surrounding the capsule;
however, all components of the capsule remain intact.7,10
Grade II
• Radiographs are typically normal. An MRI will show
adjacent soft tissue edema. Partial thickness disruption
may be seen as fluid signal intensity extending partially
through the plantar plate and capsular structures. The
sesamoid bones typically remain in normal position.7,10
Grade III
• Radiographs are abnormal and may demonstrate an
associated capsular avulsion, compression fracture;
sesamoid fracture, diastasis, or proximal migration.
Comparison films with the contralateral foot or prein-
jury radiographs may be helpful in detecting sesamoid
abnormalities.7,10,11
• A small fleck of bone might be found avulsed from the
proximal phalanx or the sesamoid, suggesting a capsu-
lar disruption.8
• An MRI will also demonstrate these findings and can
also reveal the extent of injury to each component of
the capsuloligamentous structure (Figure 45-3), includ-
ing the plantar plate, collateral ligaments, as well as
the flexor and extensor tendons.7,10,11
• An MRI can also assess the integrity of the articular
surface of the MTP joint.7
General Imaging
• Comparison radiographs of the contralateral foot are
mandatory as patients with a rupture of the plantar
plate will have proximal migration of one or both
sesamoids.8
• Forced dorsiflexion lateral radiographs should be
obtained if there is clinical suspicion for a plantar plate
disruption. If there is a complete disruption of the MTP
joint complex, the sesamoids will not track distally
with the hallux extension and will appear to be located
proximally.8
• An MRI is useful for both soft-tissue injury and osseous
damage. T2-weighted images will identify subtle inju-
ries. An MRI is recommended for all grade II or III
injures to help guide the treatment plan and return to
play.8
Differential Diagnosis
• Gout: differentiated by associated erythema and
warmth of joint; no ecchymosis present; severe pain
and restriction of motion
1574   FOOT INJURIES

icing of the joint. Motion of the joint may be permitted

in several days as symptoms permit.7 Walking boot and
crutches as needed; may need taping on return to play.8
• Grade III: The athlete will lose a minimum of 4 to 6
Flexor weeks of playing time, and treatment may require pro-
hallucis longed immobilization or surgery.7
longus
Surgical Indications
Deep Relative
transverse
intermeta-
Sesamoid • Large capsular avulsion with unstable joint
tarsal • Diastasis of bipartite sesamoid
ligament components
• Diastasis of sesamoid fracture
Adductor • Retraction of sesamoid(s)
hallucis
• Traumatic hallux valgus deformity
• Vertical instability (positive Lachman test)
• Loose body
• Chondral injury
• Failed conservative treatment8,11
Absolute
Flexor Abductor • Irreducible joint dislocation
hallucis hallucis
brevis
Aspects of History, Demographics, or Exam
Findings that Affect Choice of Treatment
• Grade I injury, or sprain of the capsuloligamentous
FIGURE 45-3.  Anatomy of the capsuloligamentous structures. structures, allows athletes to return to competition as
(Redrawn from Rodeo SA, O’Brien S, Warren RF, Barnes R, Wickiewicz TL, tolerated. Taping in slight plantarflexion to diminish
Dillingham MF: Turf-toe: An analysis of metatarsophalangeal joint sprains
in professional football players. Am J Sports Med 18(3):280–285, 1990.)
motion at the first MTP may alleviate symptoms. In
addition, athletes can use orthotics or turf toe plates to
minimize hallux MTP extension.8
• First metatarsal stress fracture: differentiated by lack • Grade II injuries, or partial plantar capsular ligamen-
of erythema/ecchymosis; point tenderness and indolent tous rupture, will generally result in loss of playing
course time of at least 2 weeks. These injuries are treated with
• Soft tissue mass (bursitis, granuloma, Morton neuroma): a similar regimen of relative immobilization of the first
differentiated by minimal pain with palpation; lack of MTP, similar to that used for grade I injuries.7 Some
skin findings authors further advocate a 2-week period of non–
weight-bearing.11
• Grade III injury, or complete plantar capsular ligamen-
tous rupture, can have a prolonged recovery time. With
Treatment these injuries, a 4- to 8-week period of immobilization
followed by rehabilitation is appropriate before return
Nonoperative Management
to play.8,11
• Immobilization, cryotherapy, NSAIDS
• Nonsurgical treatment options involve limiting the Aspects of Clinical Decision Making
range of motion of the first MTP When Surgery Is Indicated
• Taping of the toe7,10,11 • Conservative treatment with immobilization, cryother-
• Orthotics or “turf toe plate” in the shoe7,11 apy, and NSAIDS is usually successful, so operative
• Rocker sole shoe10 management is rarely considered in acute injury.
• Walking boot and crutches as needed8,11 • However, operative intervention is required in the acute
• Long-term immobilization in boot or cast8,11 setting in the case of irreducible joint dislocation.
• Steroid injection is controversial; some authors believe • If conservative measures fail, surgical intervention
it may predispose to further soft tissue damage.11 should be considered. This is especially true if the
patients suffer loss of performance, such as loss of push-
Guidelines for Choosing Among off strength.8
Nonoperative Treatments • Because of the infrequency with which these injuries are
• Grade I: The prognosis for full recovery is good and surgically repaired, some authors recommend that they
the patient can usually continue to play with only mild should be referred to a foot and ankle specialist.8
discomfort.3,7,12 Grade I injuries may be treated with • Consideration should be given to surgical repair of the
taping of the toe and the use of a stiff insole in the ruptured capsuloligamentous complex (Grade III) in
shoe.7 Grade II: Treatment of grade II injuries is usually collegiate and professional athletes, particularly foot-
conservative with pain control, elevation, rest, and ball players.13

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 FIRST METATARSOPHALANGEAL JOINT SPRAIN (TURF TOE)   1575

Evidence 12. Clanton TO, Ford JJ: Turf toe injury. Clin Sports Med 13(4):731–
741, 1994.
13. Anderson R: Turf toe injuries of the hallux metatarsophalangeal
Bowers KD, Jr, Martin RB: Turf-toe: A shoe-surface related joint. Tech Foot Ankle Surg 1:102–111, 2002.
football injury. Med Sci Sports 8(2):81–83, 1976.
This paper is the first to describe turf toe injuries, or plantar
capsule-ligament sprains of the great toe metatarsophalangeal Multiple-Choice Questions
joint. Predisposing factors were noted to be playing surface
hardness and shoe stiffness. (Level V evidence) QUESTION 1. What biomechanical factor predisposes an
Brophy RH, Gamradt SC, Ellis SJ, et al: Effect of turf toe on athlete to a turf toe injury?
foot contact pressures in professional American football players. A. Decreased ankle dorsiflexion
Foot Ankle Int 30(5):405–409, 2009. B. Increased ankle dorsiflexion
In an assessment of 44 players on one National Football C. High arches
League team, this study showed that turf toe injury is associ- D. Prior anterior talofibular ligament injury
ated with decreased MTP motion, 40.6 ± 15.1° in football
players with turf toe versus 48.4 ± 12.8° in football players QUESTION 2. The most common mechanism of injury
without history of turf toe. (Level IV evidence) to the first metatarsal ligaments is
Coker TP, Arnold JA, Weber DL: Traumatic lesions of the A. hyperplantarflexion.
metatarsophalangeal joint of the great toe in athletes. Am J B. hyperextension/hyperdorsiflexion.
Sports Med 6(6):326–334, 1978. C. varus stress.
In a case series of injuries in University of Arkansas football D. valgus stress.
players over three seasons, turf toe injuries caused more lost
playing time and delayed return to play when compared to
QUESTION 3. Which grade of injury represents partial
ankle sprains. The authors noted an average of 6.0 turf toe thickness tearing of the plantar plate and capsular
injuries per season. (Level IV evidence) structures?
Rodeo SA, O’Brien S, Warren RF, et al: Turf-toe: An analysis
A. Grade 1
of metatarsophalangeal joint sprains in professional football B. Grade 2
players. Am J Sports Med 18(3):280–285, 1990. C. Grade 3
D. Grade 4
A case series of eighty active professional football players
with first metatarsophalangeal joint sprains found the primary QUESTION 4. Which of the following is not an indica-
mechanism of injury (85%) to be hyperextension. The major- tion for surgical repair?
ity of initial injuries (83%) occurred on artificial turf and
decreased range of motion of the first metatarsophalangeal A. Vertical instability
joint was a significant outcome after turf toe injury.) Level B. Loose body
IV evidence) C. Partial tear of the capsuloligamentous complex
D. Chondral injury
REFERENCES QUESTION 5. If treated conservatively, Grade 3 injuries
1. Bowers KD, Jr, Martin RB: Turf-toe: A shoe-surface related football are usually treated with immobilization for what
injury. Med Sci Sports 8(2):81–83, 1976. period of time?
2. Childs SG: The Pathogenesis and biomechanics of turf toe. Ortho-
paedic Nursing 25(4):276–280, 2006. A. 1 week
3. Rodeo SA, O’Brien S, Warren RF, et al: Turf-toe: An analysis of B. 2 weeks
metatarsophalangeal joint sprains in professional football players. C. 3 weeks
Am J Sports Med 18(3):280–285, 1990.
4. Coker TP, Arnold JA, Weber DL: Traumatic lesions of the metatar-
D. 4 or more weeks
sophalangeal joint of the great toe in athletes. Am J Sports Med
6(6):326–334, 1978.
5. Watson TS, Anderson RB, Davis WH: Periarticular injuries to the Answer Key
hallux metatarsophalangeal joint in athletes. Foot and Ankle
Clinics 5:687–713, 2000.
6. Brophy RH, Gamradt SC, Ellis SJ, et al: Effect of turf toe on foot QUESTION 1. Correct answer: A (see Pathophysiology,
contact pressures in professional American football players. Foot Major Contributors)
Ankle Int 30(5):405–409, 2009.
7. Allen LR, Flemming D, Sanders TG: Turf toe: Ligamentous injury QUESTION 2. Correct answer: B (see Pathophysiology;
of the first metatarsophalangeal joint. Mil Med 69(11):19–25, Mechanism of Injury)
2004.
8. McCormick JJ, Anderson RB: Rehabilitation following turf toe QUESTION 3. Correct answer: B (see Clinical
injury and plantar plate repair. Clin Sports Med 29(2):313–323,
2010.
Presentation)
9. Clanton TO, Butler JE, Eggert A: Injuries to the metatarsophalan-
geal joints in athletes. Foot Ankle 7(3):162–176, 1986. QUESTION 4. Correct answer: C (see Treatment; Surgi-
10. Frimenko RE, Lievers W, Coughlin MJ, et al: Etiology and biome- cal Indications)
chanics of first metatarsophalangeal joint sprains (turf toe) in ath-
letes. Crit Rev Biomed Eng 40(1):43–61, 2012. QUESTION 5. Correct answer: D (see Treatment)
11. VanPelt MD, Saxena A, Allen MA: Turf toe injuries. In Saxena A,
editor: Sports medicine and arthroscopic surgery of the foot and
ankle, London, 2013, Springer-Verlag, pp 13–27.

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1576   FOOT INJURIES

NONOPERATIVE REHABILITATION OF FIRST

METATARSOPHALANGEAL SPRAIN (TURF TOE)
Smita Rao, PT, PhD, and Kenneth J. Mroczek, MD

• After surgical reconstruction, the patient is non-weight

GUIDING PRINCIPLES OF
NONOPERATIVE REHABILITATION
• Treatment of turf toe is based on the grade of injury
(Grade I, II, or III).
• Excessive dorsiflexion at the first metatarsophalan-
geal joint must be prevented.
• Return to activity decisions are sport- and
position-dependent.
Phase I (weeks 0 to 4):
Early Protection
Note: The duration of this phase depends on the Grade
of injury. Progression to Phase II is based on resolution
of symptoms.
• For Grade I injuries, minimal immobilization and early
progression to Phase II is recommended.
• For Grade II injuries, the Early Protection phase may
be expected to last 2 weeks.
• Grade III injuries, immobilization may be part of non-
surgical as well as postoperative management.
• As part of the initial nonsurgical treatment, immobili-
zation may last up to 4 weeks based on the severity of
symptoms.
bearing for 4 weeks. Although gentle range of motion
can be initiated 5 to 7 days postoperatively, immobili-
zation in a toe spica and joint protection is maintained
the remainder of the time.
Goals
• The main goals of Phase I (early protection) are to
reduce pain and swelling and facilitate the healing of
injured tissue.
Protection
• For Grade I injuries, immobilization with taping and
early progression to Phase II is recommended.
• Grade II injuries are treated with immobilization in the
form of taping, or a short leg walking boot with
crutches. A short leg walking cast may be used in lieu
of the walking boot. A toe extension spica may be
incorporated in the cast to prevent excessive dorsiflex-
ion of the first metatarsophalangeal (MTP) joint. The
patient is allowed to bear weight as tolerated.
• Grade III injuries usually require immobilization in
plantar flexion to facilitate healing of ruptured plantar
structures, consequently a short leg cast with toe spica
or walking boot with crutches is used.

TIMELINE 45-1:  Nonoperative Rehabilitation of First Metatarsophalangeal Sprain (Turf Toe)

PHASE I (weeks 0 to 4) PHASE II (weeks 4 to 12) PHASE III (weeks 12 to 16)
• Toe spica in 10° of plantarflexion, and (weeks 4 to 8) (weeks 8 to 12) • PT modalities as needed
walking boot (non–weight-bearing) • Active first MTP • DC walker, • PROM—full
• Elevation motion transition to • Mobilizations as needed
• PT modalities to address pain, swelling • Partial weight rocker sole shoe • Taping and/or Morton’s extension as
• Supervised passive motion initiated on bearing/ weight or stiff-sole shoe needed
day 5 to 7 bearing as • PT modalities as • Return to activity, sport-specific training
• Transition to removable splint with tolerated (WBAT) needed • Patient education: Full recovery may
walking boot • Weight bearing • PROM—full take from 24 to 52 weeks.
may be deferred • Mobilizations as • Injury surveillance and prevention
if osteochondral needed (maintain conditioning and form)
injury present • Therapeutic
• PT modalities to exercise (muscle
address pain, strengthening,
swelling, scar balance,
healing, and bicycling)
range of motion • Graduated
• Hydrotherapy if increase in
available intensity and
• Therapeutic duration of
exercise (muscle weight-bearing
strengthening, activity
balance) • Taping and/or
• Taping Morton’s
extension

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Management of Pain and Swelling
• Although taping is recommended for Grade I and II
injuries, it should be noted that taping is not used in
the acute setting because of the risk of circulatory
compromise.
• Rest, ice, compression, and elevation (RICE) are used
in the acute stage to manage pain and swelling. Addi-
tional modalities such as cryotherapy (in the form of
cold packs), contrast baths, pulsed ultrasound, and
interferential electrical stimulation may be used if
needed.1
• When swelling is well controlled and there is no within 3 to 7 days following the initial injury.
risk of circulatory compromise, taping may be
instituted.
Techniques for Progressive Increase
in Range of Motion
• With the first MTP joint immobilized and protected
from excessive dorsiflexion, the patient is encouraged
to perform ankle circles and ankle pumps.
Other Therapeutic Exercises
• Strength training for the core, upper extremities, and
the contralateral extremity should continue.
• Aerobic conditioning can be maintained using an upper
extremity bicycle ergometer.
• Open chain exercises for the proximal muscles of the
involved lower extremity are allowed (hamstring curls,
leg extensions)
Activation of Primary Muscles Involved
• In this phase, activation of the flexor hallucis longus
and extensor hallucis longus is minimized.
• To minimize loads at the forefoot and hallux, the
patient is advised to limit activities involving strong
push-off phase and strong contraction of the calf
muscles.
Open and Closed Kinetic Chain Exercises
• CKC exercises are limited to the contralateral limb.
• Resisted OKC exercises of the proximal muscles (ham-
strings, quadriceps, glutei) are recommended.
• Ankle circles and ankle pumps (OKC ankle exercises)
are used to reduce swelling and maintain range of
motion.
Sport-Specific Exercises
• Aerobic fitness should be maintained
cross-training.
Milestones for Progression to
the Next Phase
• Resolution of symptoms (pain and swelling) is the chief
criterion used to progress to the Phase II (activity
progression)
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FIRST METATARSOPHALANGEAL JOINT SPRAIN (TURF TOE)   1577
Phase II (weeks 4 to 12):
Activity Progression
Note: The duration of this phase depends on the grade of
injury. Resolution of swelling and pain serve as criteria
for progression from Phase I (early protection) to Phase
II (activity progression).
• For Grade I injuries, Phase II rehabilitation may begin
as soon as swelling is well controlled and the risk of
circulatory compromise is ruled out.
• Grade II injuries may begin Phase II rehabilitation
• For Grade III injuries, Phase II rehabilitation may be
initiated at 3 to 4 weeks following injury in the initial
nonsurgical management. In the postsurgical manage-
ment of turf toe reconstruction, Phase II rehabilitation
may being on the fifth to seventh postoperative day.
Goals
• The chief goal of Phase II is to restore pain-free range
of motion and ability to walk without pain.
Protection
• Taping provides minimal mechanical restraint.
• For Grade I and II injuries during Phase II rehabilita-
tion, the use of rigid, stiff-soled, steel-shanked shoes is
recommended to limit excessive first MTP dorsiflexion
during weight-bearing activities.
• Alternatively patients may prefer to use an orthotic
device like a carbon graphite shoe insert or Morton’s
extension (Figure 45-4). These devices may be full
length (extends from the posterior heel to the tip of the
great toe) or three-quarter length, available over the
counter or through custom fabrication. They are
intended to be rigid and limit the amount of the dor-
siflexion experienced at the first MTP joint. They are
available in varying grades of carbon graphite and
through
FIGURE 45-4.  Over the counter orthotic devices. From right to left:
full-length carbon graphite shoe insert (contoured); full-length carbon
graphite shoe insert (flat), and three-quarter length Morton’s exten-
sion (flat).
1578   FOOT INJURIES
polypropylene. Thicker grades are stiffer. For patient
comfort, a soft, viscoelastic insole can be used over the
carbon graphite shoe insert or Morton’s extension.
• For Grade III injuries, Phase II rehabilitation includes
protection in a toe spica and walking cast or walking
boot with crutches.
• If required a toe spacer or separator is used to maintain
frontal plane alignment of the hallux and prevent
hallux valgus.
• Gentle passive range of motion is instituted by the fifth
to seventh postoperative day.
• Four weeks postoperatively, active range of motion and
weight bearing as tolerated are initiated.
• Eight weeks postoperatively, the patient is allowed to
transition to rigid shoes. In protective footwear, gradual
activity progression is encouraged.
Management of Pain and Swelling
• As in Phase I, principles of RICE (rest, ice, compres-
sion, elevation) are used to achieve pain control and
reduce swelling. Additional modalities may be added if
required.
Techniques for Progressive Increase
in Range of Motion
• Gentle passive plantarflexion to prevent adhesions and
loss of sesamoid mobility is encouraged with the overall
goal of maintaining joint motion required for gait
while avoiding excessive dorsiflexion.
• Manual therapy in the form of joint mobilizations can
be used for pain relief and to restore range of motion.
Initially, distraction and/or Kaltenborn Grade I antero-
posterior glides with oscillations are recommended. As
the patient progresses and range of motion improves,
Kaltenborn Grade II and III glides (Figure 45-5) and
mobilizations with movement (MWM) are appropriate.
• Tender points or trigger points in the calf muscles may
be treated with ischemic compression and soft tissue
mobilization techniques.
A B
FIGURE 45-5.  Manual therapy techniques may involve distraction (gray arrow, A) and anterior-posterior glides (white arrow, A) of the first MTP
joint. Manual therapy to facilitate distal sesamoid glides (white arrow, B) may also be used to improve first MTP joint dorsiflexion.
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• Non–weight-bearing stretches for the gastrocnemius
and soleus muscles should be prescribed, with progres-
sion to weight-bearing stretches.
Other Therapeutic Exercises
• Based on sport and/or activity, other therapeutic exer-
cises are continued to maintain lower limb and core
strength and flexibility. These include gastrocnemius,
hamstrings, rectus femoris, iliotibial band, and ilio-
psoas stretches.
• Open chain resisted exercises like hamstring curls and
quadriceps exercises are appropriate.
• Closed chain exercised like squats should be performed
with the first MTP joint maintained in plantarflexion
in a toe spica.
• Exercise performance should be supervised to ensure
that the flexor and/or extensor hallucis longus muscles
are not activated.
• Exercises such as the lunge that involve extreme first
MTP dorsiflexion are contraindicated at this stage.
Activation of Primary Muscles Involved
• Starting with passive and then active first MTP plan-
tarflexion, the patient starts to activate his or her flexor
hallucis longus in open chain exercises.
• Over time, open chain first MTP dorsiflexion using the
extensor hallucis longus is initiated, taking take to
avoid impingement and avoid forcing the joint into
excessive dorsiflexion.
Sensorimotor Exercises
• Hydrotherapy and whirlpools are useful adjuncts. Water
aerobics and walking in the pool can be initiated.
Open and Closed Kinetic Chain Exercises
• Towel crunches are commenced for the toe flexors and
extensors (Figure 45-6). Marble or rubber band pickups,

A B
FIGURE 45-6.  Exercises like towel crunches can be used to promote full range active first MTP joint dorsiflexion (B) and plantarflexion (A).
in which the patient is asked to pick up marbles from
the floor and put them into a bowl using their toes, can
also be instituted for the same purpose.
• Ankle circles and ankle pumps (OKC ankle exercises)
are used to reduce swelling and maintain range of
motion.
• As in Phase I, resisted CKC exercises are limited to the
contralateral limb.
• Resisted OKC exercises of the proximal muscles (ham-
strings, quadriceps, and glutei) are recommended.
• As pain and swelling subside, the patient is allowed to
transition to weight bearing as tolerated, and finally to
full weight bearing.
Techniques to Increase Muscle Strength,
Power, and Endurance
• OKC resisted ankle plantarflexion using a Thera-Band
can be initiated (Figure 45-7). Ankle dorsiflexion-
plantarflexion and inversion-eversion can be performed
with Thera-Band. Progression involves increasing the
number of repetitions and sets, and also increasing the
stiffness of the Thera-Band used.
• With the foot protected in a stiff-soled shoe, carbon
graphite shoe insert, or Morton’s extension, the patient
can start using a stationary bicycle with instructions to
avoid excessive first MTP dorsiflexion.
• Seat height needs to be adjusted and the main goal is
to increase lower extremity muscle endurance while
protecting the first MTP joint from excessive
dorsiflexion.
Neuromuscular Dynamic Stability Exercises
• When the patient can tolerate bilateral stance with
equal weight bearing, dynamic neuromuscular exer-
cises that involve standing on surfaces of varying stabil-
ity and stiffness should be commenced.
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FIRST METATARSOPHALANGEAL JOINT SPRAIN (TURF TOE)   1579
• Bilateral activities such as squats and heel raises should
be initiated in the pain-free range and progress to mul-
tiple repetitions over the full range.
• During these exercises, it is important to flag and
correct asymmetry in exercise performance and weight
bearing.
Functional Exercises
• One of the chief goals of Phase II is to restore pain-free
ambulation.
• When the patient is able to sustain unilateral single
limb stance (see balance and neuromuscular stability
exercises), walking should be attempted.
• Pool walking may be used to help with graduated
weight bearing.
• Overground or treadmill walking should be initiated
with protective footwear and/or shoe inserts.
• Pain-free and symmetrical ambulation is the primary
goal. As patient progresses, speed and duration can be
increased.
Sport-Specific Exercises
• Sport-specific upper limb activities such as throwing
can be resumed in Phase II.
• Any weight-bearing activity should be performed with
protective footwear and/or shoe inserts.
• Sport- and position-specific tasks such as the three-
point stance for defensive linemen will be incorporated
in Phase III.
Milestones for Progression to the Next Phase
• Pain-free range of motion (60° first MTP dorsiflexion,
measured passively with a goniometer) and pain-free
weight bearing (standing and walking) serve as criteria
for progression to Phase III (Return to Sport).
1580   FOOT INJURIES

A B

C D
FIGURE 45-7.  Open chain ankle dorsiflexion (A), plantarflexion (B), inversion (C), and eversion (D) using Thera-Band. Progression will involve
increasing the number of repetitions, as well as sets and stiffness of the Thera-Band used.

Techniques for Progressive Increase

Phase III (weeks 12 to 16):
Return to Sport
• When the patient is able to walk without pain at the
first metatarsophalangeal joint and demonstrates pain-
free range of motion on clinical testing, they are ready
to progress to Phase III.
• This phase may last 4 weeks to 3 months based on the
severity and chronicity of the original injury, and
demands of the sport and position he or she plays.
Protection
• Morton’s extension or rigid sole shoes are used during
high-demand activities.
in Range of Motion
• Manual therapy, in the form of soft tissue and joint
mobilizations, is used to ensure full range of motion
and good tissue extensibility. In addition to glides and
distraction at the first MTP joint, sesamoid mobiliza-
tion may be employed to achieve full range of first
MTP dorsiflexion.
• In addition to weight bearing and non–weight-bearing
stretches for the gastrocnemius and soleus, a plantar
fascia stretch may also be incorporated.
• Joint and soft tissue mobilization may be indicated to
achieve full range of motion at proximal and contra-
lateral lower extremity joints, including tarsometatar-
sal, talonavicular, subtalar, ankle, tibiofibular, knee,
and hip joints.

Management of Pain and Swelling Other Therapeutic Exercises

• Ice, in combination with RICE if needed, is used to • As previously detailed, core, upper extremity and con-
control pain and swelling, and is particularly useful to tralateral lower extremity strength training and stretch-
limit post-workout symptoms. ing regiments should continue.

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 FIRST METATARSOPHALANGEAL JOINT SPRAIN (TURF TOE)   1581

• In addition, weight-bearing closed chain exercises of
the involved limb should be initiated.
• Lunges without and with additional resistance should
be used. These are extremely provocative and the pres-
ence of pain and impingement should be monitored
before and after each workout.
Activation of Primary
Muscles Involved
• By Phase III, activation of great toe (flexor hallucis
longus, extensor hallucis longus) and ankle muscles
(gastrocnemius, soleus, peronei, tibialis anterior, tibi-
alis posterior, flexor digitorum longus) should be sym-
metric and free from deficits.
Sensorimotor Exercises
• The patient should be able to walk barefoot without
pain at the start of Phase III.
• Balance and proprioception training should begin with
activities involving single limb stance (Figure 45-8).
Activity-specific positions may need to be incorporated;
for example, stork stance from martial arts training.
• More dynamic tasks such as the star excursion and
balance test (SEBT) should be used, with cueing so the
patient does not overuse the flexor hallucis longus
muscle. Overuse of the flexor hallucis longus muscle
will manifest as excessive flexion of the first MTP and/
or interphalangeal joints. Single limb stance should be
commenced in front of a mirror or with other visual
feedback. Cues such as “relax the toe” should be used
to prevent excessive use of the flexor hallucis longus.
• Appropriate activation of proximal muscles such as the
hip rotators and abductors should be emphasized. In
single limb stance, attention should be paid to main-
taining proper form and balance (see Figure 45-8).
Progression will involve increasing the duration (for
example, three sets of 30 seconds each). Additionally
balance can be challenged by presenting unstable sur-
faces and by adding dynamic activities (see Figure 45-8).
During balance and proprioception training, a mirror
or other visual feedback should be used to prevent
overuse of arms, excessive trunk lean, dynamic knee
valgus, and/or calcaneal pronation (see Figure 45-8).
Open and Closed Kinetic Chain Exercises
• In this phase, the patient should progress from walking
to stair climbing. Stair ascent and descent place signifi-
cant demands on the first MTP joint and are more
challenging than straight-ahead gait.
• Bilateral graduated weight bearing in increasing
amounts of first MTP dorsiflexion can be initiated
using exercises like the heel raise.
• Progression involves performing single limb heel raises,
first without then with additional free weights.
• When the patient can perform full range unilateral heel
raises and negotiate stairs without pain, additional uni-
lateral resisted exercises (lunges) can be instituted. Pro-
gression will include multidirectional lunges with
added weights.

A B C
FIGURE 45-8.  Single limb stance on a foam surface with good mechanics is depicted (A). Note the alignment of the knee over the second toe;
the stance knee is not locked (“soft knee”) and there is an absence of any trunk lean. Inability to maintain posture and balance in single limb
stance (B) will manifest as excessive knee valgus, calcaneal pronation, first MTP flexion, trunk lean, and/or excessive use of arms for balance.
Training to improve posture and balance in single limb stance starts with the patient barefoot on a stable surface, and progression involves
increasing the duration, unstable surfaces (e.g., foam, BOSU ball), and dynamic activities (e.g., ball toss on BOSU ball) (C).

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1582   FOOT INJURIES

A B C
FIGURE 45-9.  Single limb squats can be used in Phase III to promote closed kinetic chain function because they require activation of both
proximal and distal muscles of the stance leg. Attention to good mechanics is crucial. In the frontal plane, note alignment of knee over second
toe, hips and knees are level, no trunk lean is present (A). In the lateral view, the knee should be over the toes and arms extended (B). Markers
of poor mechanics include excessive toe out, arch collapse, dynamic knee valgus, pelvic drop, and/or trunk lean (C).

• Single limb squats can also be useful in this phase
(Figure 45-9).
Techniques to Increase Muscle Strength,
Power, and Endurance
• See Open and Closed Kinetic Chain Exercises.
Neuromuscular Dynamic Stability Exercises
• Standing with balance and proprioception training, the
patient should progress to performing more dynamic
tasks such as single limb squats, single limb hops and
agility drills (Figures 45-10 to 45-12).
• Progression should involve cutting and rapid changes
in direction.
Plyometrics
• Eccentric exercises targeting the calf muscles in par­
ticular and the lower extremity in general are
indicated.
• In athletes involved with sports such as gymnastics and
martial arts, plyometrics are particularly important for

A B C D E
FIGURE 45-10.  Drills such as the side shuffle should be used to regain agility. Panels A through E depict symmetrical performance and ideal
form. Visual biofeedback using a mirror can be used to ensure good mechanics, reflected in symmetrical performance, absence of trunk lean,
dynamic valgus, and arch collapse. Audio feedback in terms of curing the patient to the sound of footfalls can be used to encourage him or
her to maintain a light and quick cadence.

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 FIRST METATARSOPHALANGEAL JOINT SPRAIN (TURF TOE)   1583

A B C D E
FIGURE 45-11.  Return to sport (Phase III) should include sport-specific training such as jumping. Feet, knees, and hips should be symmetrical
during takeoff (A, B, C) and landing (D, E).

proper technique and biomechanics during takeoff and
landing.
• Motor learning and imagery techniques should be used
to cue proximal muscles (core and hip muscles) and
reduce the shock absorption and eccentric demand
placed on distal extremity muscles like the flexor hal-
lucis longus (e.g., the cue “pretend you’re landing on
marshmallows” is used to train landing in gymnasts
and dancers).
Functional Exercises
• See Open and Closed Kinetic Chain Exercises and Sen-
sorimotor and Neuromuscular Stability Exercises.
Sport-Specific Exercises
• For sports involving explosive starts and rapid through joint mobilization should be used to facili-
changes in direction (baseball, football), agility drills
incorporating these elements with are essential ele-
ments of sport-specific training.
• Additionally these drills should be performed on the
playing surface with footwear used during competition
to approximate realistic conditions.
• For activities involving jumping and landing (volley-
ball, dance), jumping drills with changes in direction
should be included.
Tips and Guidelines for Transitioning
to Performance Enhancement
• Prophylactic taping, the use of stiff-soled shoes (Figures
45-13 and 45-14) or Morton’s extensions may facilitate
the transition to performance.
• Post-game ice and maintenance of range of motion
tate recovery.

FIGURE 45-12.  A, Poor mechanics during takeoff

may manifest as an asymmetrical or staggered stance,
which in turn may lead to asymmetry or obliquity at
the knees and/or hips. B, Poor mechanics during
landing may result in one limb contacting the floor A B
before the other.

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1584   FOOT INJURIES

FIGURE 45-13.  Athletic shoe (A) with high toe-break

A B C flexibility (B). Walking shoe with minimal toe-break
flexibility (C).

Performance Enhancement and Specific Criteria for Return

Beyond Rehabilitation: Training/
Trainer and Optimization of
Athletic Performance
• Surveillance for impingement and/or osteochondral
injuries should continue after return to performance.
• Communication with patient and trainer is essential to
set realistic expectations for recovery and return to
sport.
• Upon complete resolution of symptoms, taping and
shoe inserts can be discontinued.
A B
FIGURE 45-14.  Athletic shoe (A) with high torsional flexibility (B).
to Sports Participation:
Tests and Measurements
• Pain-free and full range of motion
• Pain free during weight bearing activities
• Complete resolution of symptoms
Evidence
Limited objective data are available to guide the nonsurgical
management of turf toe. The following annotated bibliography
highlights recent comprehensive reviews that present retrospec-
tive data and/or clinical cases.
Chinn L, Hertel J: Rehabilitation of ankle and foot injuries in
athletes. Clin Sports Med 29(1):157–167, 2010.
This review comprehensively covers current nonsurgical
options available for foot and ankle injuries, including turf
toe. (Level IV evidence)
Coughlin MJ, Kemp TJ, Hirose CB: Turf toe: Soft tissue and
osteocartilaginous injury to the first metatarsophalangeal joint.
Phys Sportsmed 38(1):91–100, 2010.
This review highlights the importance of identifying and man-
aging osteocartilaginous injury in turf toe. (Level IV
evidence)
Maglaya CL, et al: Return to division 1A football following a
metatarsophalangeal joint dorsal dislocation. NAJSPT
5(3):131–142, 2010.
This case study follows the rehabilitation protocol of a Divi-
sion 1A football player following a turf toe injury. (Level IV
evidence)
McCormick JJ, Anderson RB: The great toe: failed turf toe,
chronic turf toe, and complicated sesamoid injuries. Foot Ankle
Clin 14(2):135–150, 2009.

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 FIRST METATARSOPHALANGEAL JOINT SPRAIN (TURF TOE)   1585

McCormick JJ, Anderson RB: Rehabilitation following turf toe QUESTION 2. For a patient with a Grade II turf toe
injury and plantar plate repair. Clin Sports Med 29(2):313–323, sprain, criteria for progression from Phase II to Phase
ix, 2010. III are:
This recent review provides an overview of the rehabilitation A. Duration since injury—progress to Phase III in
of turf toe as well as provides specific examples of interven- 4 weeks
tions used in current clinical practice. (Level IV evidence) B. Duration since injury—progress to Phase III in
Nihal A, Trepman E, Nag D: First ray disorders in athletes. 2 weeks
Sports Med Arthrosc 17(3):160–166, 2009. C. Pain free full range of motion
This review emphasizes the role of relative rest, activity modi- D. Pain free on full weight bearing
fication, and insoles in the rehabilitation of individuals with
turf toe injuries. (Level IV evidence)
QUESTION 3. A Morton’s extension or turf toe plate is
used to prevent
A. excessive dorsiflexion of the first
REFERENCE metatarsophalangeal joint.
1. Maglaya CL, et al: Return to division 1A football following a B. excessive plantarflexion of the first
metatarsophalangeal joint dorsal dislocation. NAJSPT 5(3):131– metatarsophalangeal joint.
142, 2010.
C. excessive impact and cushion plantar sesamoids.
D. arch collapse by complementing the windlass
effect.
Multiple Choice Questions
QUESTION 1. For Grade 1 turf toe injuries, which of the Answer Key
following is appropriate?
A. Immobilization in a toe spica in the acute QUESTION 1. Correct answer: C (see Phase I)
postinjury phase
B. Manual therapy in the form of soft tissue and QUESTION 2. Correct answer: D (see Phase III)
joint mobilization is the modality of choice in
the acute postinjury phase. QUESTION 3. Correct answer: A (see Phase II)
C. Immobilization with taping and early
progression to Phase II are the main goals in the
acute postinjury phase.
D. Manual therapy should only be instituted after
swelling subsides.

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