WHAT IS TURF TOE?
Turf toe was initially termed back in 1976 by Bowers and Martin out of West Virginia University. They first described it as a sprain of the plantar plate, the strongest stabilizer within the great toe metatarsophalangeal (MTP) joint. The injury occurs after a forceful hyperextension of the joint. It can be broken down into three grades according to the Anderson classification system:
- Grade 1: Sprain of plantar plate – can fully weight bear with full ROM
- Grade 2: Partial tear of the plantar plate – painful ROM, ecchymosis, swelling, and pain weight-bearing
- Grade 3: Complete rupture of plantar plate – marked tenderness to palpation, decreased ROM, swelling, ecchymosis, difficulty weight bearing, and migration of sesamoid bone
WHY IS IT CALLED TURF TOE?
An injury to the plantar plate ligament can occur during all different types of athletic activities. A common injury pattern of athletes playing contact sports on rigid surfaces with footwear that allows the greater toe MTP joint to hyperextend was seen.
When astroturf was the standard for football an increased prevalence of the injury was seen and determined to be from the harder, less compliant surface placing more strain on the players’ feet compared to grass.
TREATMENT OPTIONS
Regardless of severity, initial treatment will consist of the RICE principle with the first goal of recovery being stabilization. A stiff soled shoe or rocker bottom will limit motion. Burrow was seen exiting the stadium Sunday in a CAM boot and single crutch. Once stabilized, progressive ROM is introduced. A corticosteroid injection is not advised for this injury.
- Grade 1: Typically out 1-2 weeks before return to play as tolerated. Brock Purdy exited the game vs Seattle during Week 1 after having Julian Love land on his heel while in a plantarflexed position with the 1st MPJ hyperextended. Purdy has not been placed on IR meaning they expect him to be back within 4 weeks with conservative treatments. Average return for the NFL is typically about 10 days.
- Grade 2: Typically out 4-6 weeks before returning to play as tolerated with taping to resist greater toe MTP joint hyperextension.
- Grade 3: Immobilization in CAM boot for 4-6 weeks before progressive ROM rehabilitation. Ambulation should be done in modified footwear or carbon fiber inserts to restrict motion. A grade 3 sprain is typically repaired with surgery.
- Surgical options: With Adam Schefter’s report confirming Burrow will require surgery let’s explore the options. If the plantar plate tissue is inadequate suture anchors are most likely to be used. In the case there is still healthy tissue available, sutures shuttled through drill holes in the proximal phalanx and tied over the bone bridge. A 2018 study done by Smith and Walldrop found that the average return to play time for an elite athlete after a grade III injury was 16.5 weeks with all participating with a custom carbon fiber footplate and one requiring another surgery. The timeframe being tossed around the media currently is at least 3 months, however this is extremely optimistic compared to the data presented and Burrow will likely be out for the remainder of the Bengal’s season.
COMPLICATIONS
Acute complications include: infections, scar formation secondary to hypertrophy, and plantar nerve neuroma development. Longer term complications can possibly include hallux rigidus, cock-up deformity, joint fibrosis, bunion deformity, and loose bodies in the joint space.
Athletic ability is impaired due to limitation of ROM in triple extension position and as a result decreased push off strength is the most noted detriment. As for Quarterbacks, if the injury is suffered on the main plant foot during the throwing motion there is an average decrease in performance with a high risk of further injury or re-injury during scramble situations.
