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What is the diagnosis?

Turf Toe, a term used to describe an injury to the first MTP, can involve a number of structures that commonly result from a force applied to the dorsiflexed first phalanx of the foot.  Multiple ligaments, sesamoid bones, and surrounding structures which comprise the plantar plate can be injured.  Artificial playing surfaces and softer, more flexible cleats have contributed to increased risk of this injury [1]. Fig 1 does not show any appreciable structural damage.

Which imaging modalities can be used?

MRI imaging can be used, however it requires specialized protocols and equipment to obtain optimal coverage and imaging [2].  Radiographs may demonstrate avulsions, metatarsal-phalanx impaction, or joint diastasis.  Ultrasound may have value in uncovering more serious injuries on the turf toe spectrum.

1. Pearl: Ultrasound imaging may demonstrate hypoechoic soft tissue edema, a thickened and hypoechoic plantar plate, ligament thickening or discontinuity, a hypoechoic cleft between the plantar plate and proximal phalanx, or an avulsion fracture from the plantar plate insertion at the base of the proximal phalanx [3].

What is the prognosis, disposition, and management in the ED?

The Anderson clinical classification is one method of grading injuries and can assist in determining severity of injury.  Initial conservative management includes NSAID’s, RICE, immobilization (post op shoe or boot) or taping, and occasionally steroid injections or the use of orthotics.  Grade 1 and 2 injuries generally do well with conservative management and return to play as symptoms improve.  Grade 3 injuries may benefit from referral for surgical treatment.  There is little solid evidence for one treatment pathway over another and a recent systematic review did not find specific timelines for treatment [4].

When do you consult Orthopedics?

Turf toe can be appropriately managed in the outpatient setting with orthopedic follow up unless there is concern for open fracture or neuro vascular compromise.

• Pearl:  Indications for surgical referral on a non-emergent basis include traumatic hallux valgus, joint diastasis, proximal migration of sesamoid, sesamoid fracture, osteochondral injury, or large capsule avulsion.