AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Although several variations exist, the classic definition of turf toe is a hyperdorsiflexion injury of the first metatarsophalangeal (MTP) joint. Since approximately the 1980s, turf toe has received increased attention in the media because of its effect on college-level and professional athletes.

History of the Procedure

Prior to the advent of artificial playing surfaces in the late 1960s, sprains to the hallux MTP joint were relatively uncommon. As artificial turf became popular in sports such as football, the incidence of MTP joint injuries appeared to increase. During a roundtable discussion in 1975 regarding the benefits and drawbacks of artificial turf, Garrick first suggested the relationship between first MTP joint sprains and the use of synthetic playing surfaces.¹ One year later, Bowers and Martin introduced the term turf toe to describe a plantar capsuloligamentous sprain of the first MTP joint related to 2 predisposing factors: hard artificial surfaces and soft-soled shoes.²

The earliest synthetic surfaces contained a synthetic nylon ribbon that wore away over time. Beneath that was a foam underpad that quickly became packed down, leaving a virtual asphalt-carpet interface. As a consequence, the effect of surface hardness was originally thought to be responsible for turf toe injury.

After the development of artificial turf, many players complained of poor traction with traditional shoes designed for use on grass surfaces. Despite lower rates of injuries, the demand for increased speed and traction in sports (eg, football) led to the development of a more flexible shoe. A softer, soccer-style shoe replaced the traditional multicleated shoe containing a steel plate in the forefoot that was designed for grass surfaces. This shoe allowed a greater degree of motion in the MTP joints and placed significantly more stress across the forefoot.

In 1978, a major study from the University of Arkansas by Coker and colleagues cited turf toe as a major cause of missed games and practices.³ However, it was not until 1986 that Clanton and coauthors developed a classification scheme for describing the degree of severity for turf toe injury.⁴ With some minor revisions since its original publication, this system continues to help in guiding treatment, as well as in predicting return to play.

Problem

Turf toe injury is most commonly seen when an axial load is delivered to a foot that is fixed in equinus. The typical scenario, which often occurs in football linemen, involves the fixation of the forefoot on the ground in the dorsiflexed position with the heel raised. An outside force then pushes the foot into further dorsiflexion, resulting in traumatic hyperextension of the hallux MTP joint (see Image 1). Although turf toe is most frequently seen in football players, it can occur in athletes in any sport (eg, basketball, soccer, rugby).

Although turf toe was once thought to be a low-morbidity injury, significant disability can occur with damage to the periarticular structures of the MTP joint complex. Such damage often is accompanied by long- and short-term sequelae. As many as 50% of individuals with turf toe injuries have persistent symptoms after 5 years. In the short term, running and pushing off are compromised, and players frequently miss games and practices. Possible long-term sequelae include hallux rigidus, hallux valgus, hallux cock-up deformity, and failure to regain push-off strength.

Turf toe injury is not limited to damage from hyperextension of the MTP joint. Several variations have been described that account for damage to specific anatomic structures in the capsuloligamentous-sesamoid complex. These include hyperflexion injuries, as well as valgus- and varus-type injuries. Because each mechanism affects different structures, accurate diagnosis is crucial to understanding nonoperative and operative treatment modalities.

Frequency

The actual incidence of turf toe has never clearly been defined. In certain sports, such as football and rugby, a predisposition to turf toe injury is higher than it is in other sports. In a study among football players at the University of Arkansas, researchers estimated the incidence to be 6 cases per year. At Rice University, an average of 4.5 cases per year was found among all sports over a 14-year period.

Turf toe ranks as the third most common injury (after knee and ankle traumas) causing loss of playing time among university athletes.⁵ While ankle injuries are up to 4 times as common as turf toe, the latter may account for a significantly greater proportion of missed playing time.

Etiology

Bowers and Martin coined the term turf toe to acknowledge the predisposing factor of artificial synthetic surfaces on hallux MTP joint sprains. They found that injuries occurred most frequently in athletes playing on artificial turf who wore flexible, soccer-style shoes. The shoe-surface interface is probably responsible for the higher risk of injury in these athletes. In descending order of importance, causative factors are listed as follows: 

• Footwear - Throughout the past several decades, football shoes have evolved from the traditional 7-cleat shoe containing a metal plate in the sole designed for grass surfaces to a more flexible, soccer-style shoe designed for grass surfaces and, finally, to a shoe designed for artificial turf. These changes in shoe type have allowed increased speed at the expense of stability. The absence of a stiff sole places the forefoot, and specifically the MTP joints, at much greater risk of sustaining stress-type injuries. Athletes wearing flexible turf shoes are much more prone to injury than are those wearing shoes containing a stiff forefoot.
• Synthetic surfaces - Artificial grass contains a higher coefficient of friction and tends to lose some of its resiliency and shock absorbency over time. The combination of increased surface friction and a hard undersurface is believed to play a major role in the natural history of the injury. A higher coefficient of friction places the forefoot at greater risk of becoming fixed to the playing surface. Thus, the forefoot becomes more prone to an external force that places the hallux MTP joint in a position of extreme dorsiflexion.
• Ankle range of motion (ROM) - The risk of turf toe appears to be related to the range of ankle motion in the injured person. A greater degree of ankle dorsiflexion has been correlated with the risk of hyperextension to the first MTP joint.
• Miscellaneous - Other factors have been postulated to play a role in turf toe. These include a player's position, weight, and years of participation, as well as hallux interphalangeal degenerative joint disease, pes planus, and prior injury. For the most part, study results regarding these factors are largely inconclusive. Another point worth mentioning, however, is that a number of groups have, after researching the question, found no correlation between MTP joint ROM and the associated risk of turf toe.

Pathophysiology

The normal MTP joint functions with a smooth gliding motion except when in full dorsiflexion, when some compression occurs. Tears of the joint capsule occur at the metatarsal neck rather than at the proximal phalanx because the metatarsal neck is its weakest point of attachment. Once torn, unrestricted motion of the proximal phalanx results in severe compression of the dorsal articular surface of the metatarsal head. This produces the potential for fracture or possibly even for dislocation. Usually, the plantar portion of the ligamentous complex tears, while the plantar plate becomes detached distal to the sesamoids. Rarely, fracture of the sesamoid bone may occur (see Image 2).

Other mechanisms of turf toe injury include valgus and varus injuries, as well as hyperflexion-related damage. Valgus injury is a variant of the dorsiflexion-type injury in which the medial ligamentous structures and, in some cases, the medial sesamoid bone are damaged. This most often occurs in the setting of push-off, when internal rotation occurs on a fixed forefoot. Untreated, this may lead to bunion formation and contractures on the lateral side of the joint.

Rarer still, a varus injury may result from external rotation on a fixed forefoot. Patients may present with varus instability resulting from a torn lateral capsule as well as from rupture of the adductor hallucis tendon from the base of the proximal phalanx.

Hyperflexion occurs when the MTP joint is forced into exaggerated plantarflexion. This injury has been referred to as sand toe, as it often occurs in beach volleyball players. The injury has also been known to occur in football players and dancers. A plantar foot with the MTP joints driven into exaggerated hyperflexion can result in tearing of the dorsal capsule. The anatomic structures that are damaged and the injury treatment required are different from those of classic turf toe and should be recognized as such.

The table below shows the classification scheme for tears of the capsuloligamentous complex, including for hyperflexion and dorsiflexion injuries. (See Clinical for a discussion of injury grades.)

Classification Scheme for Tears of the Capsuloligamentous Complex

Clinical

Taking a detailed history is the first step in the treatment of all turf toe injuries. The clinician should determine the specific series of events leading to the injury.

Physical examination then follows, with attention to the presence and location of pain, swelling, and ecchymosis. The examination may be difficult in the acute stages because of pain; however, all structures, including the collateral ligaments, sesamoids, plantar plate, and dorsal capsule, should be palpated.

ROM testing should be performed by carefully looking for instability, mechanical block, or hypermobility that may suggest tearing of the plantar plate. Instability is assessed by performing the varus or valgus stress test and the dorsoplantar drawer test of the MTP joint. A positive result with the former suggests collateral ligament damage, whereas a positive finding with the latter suggests a plantar capsuloligamentous tear. Finally, examination of all structures is aided by comparison to the contralateral side.

Injuries are graded as follows:

• Grade 1 injury - Localized tenderness with minimal swelling and no ecchymosis
• Grade 2 injury - More widespread tenderness with mild to moderate swelling and ecchymosis
• Grade 3 injury - Severe and diffuse tenderness and swelling, moderate to severe ecchymosis, and painful ROM

Although most cases are managed conservatively, the treating physician should be alert to the presence of hallux malalignment, traumatic bunion deformity, diminished flexor strength, clawing of the great toe, generalized synovitis, or advanced degenerative joint disease. Clinical findings such as these often indicate that surgical intervention is required.

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Most MTP joint injuries can be managed nonsurgically. However, in instances in which the injury is refractory to conservative treatment, surgery should be considered as an option.

Complications of turf toe injury that may necessitate surgical intervention include the following:

• Sesamoid fracture
• Separation of a bipartite sesamoid bone
• Proximal migration of the sesamoids
• Instability with accompanying persistent pain or synovitis
• Hallux rigidus
• Cartilage flap or loose body within the hallux MTP joint

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

To understand how turf toe injury occurs, a thorough understanding of all anatomic structures in and around the MTP joint is critical. Unlike a simple hinged joint, the hallux MTP joint functions more like a hammock or an acetabulum. It contains multiple centers of motion, including sliding, rolling, and compression.

Like the glenoid cavity of the shoulder, the shallowness of the articular surface of the proximal phalanx provides little stability to the joint. The capsuloligamentous-sesamoid complex contributes most of the stability observed in the MTP joint. This complex is made up of collateral ligaments, along with the plantar plate, flexor hallucis brevis, adductor hallucis, and abductor hallucis (see Image 3).

• The medial and lateral collateral ligaments are composed of an MTP and a metatarsosesamoid ligament. They originate on either side of the metatarsal head and fan out distally to attach to the proximal phalanx.
• The plantar plate is a strong, fibrous structure that is firmly attached to the proximal phalanx and is loosely attached to the metatarsal neck through the joint capsule. It blends with the sesamoids and tendons of the flexor hallucis brevis to provide structural support.
• The sesamoid bones play a crucial role in providing stability to the MTP joint complex and in enhancing the tendon moment arm of the flexor hallucis brevis.
• The flexor hallucis brevis originates on the cuboid and lateral cuneiforms before splitting into medial and lateral heads that extend beneath the first metatarsal bone. Tendon fibers envelop the sesamoid bones just proximal to an insertion point at the base of the proximal phalanx. The flexor hallucis brevis plays an integral role in providing push-off strength for the hallux.
• The abductor and adductor hallucis tendons contribute additional stability through their insertions on the medial and lateral plantar portions, respectively, of the capsuloligamentous complex.

Proper function of the MTP joint is essential to normal foot biomechanics. The great toe typically bears twice the load of the lesser toes, and during normal gait, it withstands 40-60% of the body weight. This load increases severalfold with running or jumping, and it may approach nearly 8 times an individual's body weight with a running jump.

The normal MTP joint is in approximately 16º of dorsiflexion relative to the longitudinal axis of the first metatarsal, and it has a passive arc of motion in the range of 3-43º plantarflexion and 40-100º dorsiflexion. During normal gait, this angle is 60º on average, but it may decrease to 25-30º dorsiflexion in a stiff-soled shoe without affecting gait. As mentioned earlier, in high-performance activities, such as professional and college-level sports, the drive has been to produce lighter, softer-soled shoes that provide increased MTP joint motion. An increase in speed and flexibility occurs at the expense ofstability,with greater stresses across the forefoot.

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Contraindications to surgical intervention are nonspecific and include those that apply to any surgical procedure. Contraindications include active local infection or open dermatologic lesions, advanced dysvascularity, and minimal or absent pain and dysfunction.

Patients with turf toe injuries are typically young and healthy. Therefore, they are unlikely to have local or systemic conditions that preclude surgery.

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Imaging Studies

• Plain radiographs, including anteroposterior weight-bearing, lateral, and sesamoid axial views, are mandatory. Sesamoid impaction, avulsion, or diastasis may be observed on plain images.
• • Contralateral views are highly recommended. These allow comparison of the sesamoid-to-joint distances on each side. The distal sesamoid-to-joint distance should be no greater than 3 mm (tibial) and 2.7 mm (fibular) when compared with those on the contralateral side. A separation of 10.4 mm or more on the tibial side or 13.3 mm on the fibular side is 99% predictive of rupture of the plantar plate.
  • A forced dorsiflexion view also is recommended. Joint subluxation, sesamoid migration, separation of a bipartite sesamoid bone, or disruption of the medial or lateral capsuloligamentous complex (see Image 4) is better depicted on a forced dorsiflexion radiograph.
• The routine use of magnetic resonance imaging (MRI) is questionable. Currently, MRI is not recommended as part of the routine workup; however, some clinicians have begun using it to better define soft-tissue injury or osseous or articular damage. MRI may be particularly useful in the professional athlete who requires a high (ie, equal to preinjury) level of function.
• Arthrography is not part of a routine workup for turf toe.

Other Tests

• ROM testing is used to assess for instability, mechanical blockage, or hypermobility that may suggest tearing of the plantar plate.
• Instability is assessed by performing a varus or valgus stress test and the dorsoplantar drawer test of the MTP joint. Positive findings with the former suggest collateral ligament damage, whereas positive results with the latter suggest a plantar capsuloligamentous tear.

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Medical Therapy

Conservative management in the acute stages, regardless of grade, consists of rest, ice, compression, and elevation (RICE). Taping is not recommended in the acute stages because of swelling and the risk of vascular compromise. Nonsteroidal anti-inflammatory drugs (NSAIDs) may help minimize pain and inflammation. In some cases, a short leg cast with a toe spica in slight plantarflexion or a walker boot may be used for the first week to help decrease pain. Gradual range of motion begins in 3-5 days following injury.

After the acute stages, conservative management is based on the grade of injury, as follows:

• Grade I injuries are treated by taping the great toe to the lesser toes to prevent movement of the hallux MTP joint. Players may also consider using an insole containing a carbon fiber steel plate in the forefoot. As always, the overall goal is to restrict forefoot motion. Usually, persons with grade I injuries can return to play immediately, with only mild pain.
• Grade 2 injuries are treated in the same way as grade 1 injuries are, but athletes may lose significantly more playing time. Lost playing time can range from 3-14 days. Use of a fracture walker and/or crutches is preferred.
• Grade 3 injuries usually require long-term immobilization in a boot or cast rather than surgical intervention. Frequently, these injuries result in 2-6 weeks of missed playing time. Return to play is generally acceptable when 50-60º of passive dorsiflexion is possible without pain.

Surgical Therapy

When conservative treatment fails, as evidenced by persistent pain and difficulty with pushing off and with cutting or pivoting motions, surgical therapy may be indicated.

Although most cases are managed conservatively, the treating physician should be alert to the presence of hallux malalignment, traumatic bunion deformity, diminished flexor strength, clawing of the great toe, generalized synovitis, or advanced degenerative joint disease. Clinical findings such as these often indicate that surgical intervention is required.

Intraoperative Details

Open reduction and internal fixation should be used for diastasis of a bipartite sesamoid bone whenever possible. Severe fragmentation may necessitate complete sesamoidectomy. The surgical approach and repair is depicted in Images 8-9.

An ankle block is given in the usual fashion. The patient is placed prone, as this greatly facilitates the ease of operating. An ankle tourniquet is applied, and the foot is prepared and draped.

A plantar, gently curved, concave, medial incision is made. This incision is slightly C shaped, with the proximal and distal limbs being more medial than is the central portion, which is just lateral to the lateral sesamoid bone. The soft tissues are split bluntly and longitudinally to avoid injury to the digital nerves. In the case depicted in Images 8-9, the long flexor sheath was intact, and marked intrafracture fibrosis required resection. The retracted proximal aspect was tethered after 8 months; therefore, moderate, blunt dissection of the soft tissue was required to mobilize it.

In this case, the fragments were temporarily held with bone-holding clamps and then fixed with headless screws (Acutrak, 14 mm, Mini). A substantial amount of soft tissue remained, and this was closed with polydioxanone (PDS-20; Ethicon) or a similar long-acting, absorbable suture. This process may be likened to the repair of a displaced, transverse midpatellar fracture with suture of the torn medial and lateral retinaculum. The instruments, especially the cannulated drill bit, must be sharp; if not, the result will be compromised, as shown in a postoperative radiograph (see Image 9) indicating less-than-perfect reduction. Perfect reapproximation of the skin edges with 4-0 nylon minimizes the potential for a painful incision.

If the volar plate is avulsed from the distal poles and the sesamoids are intact, the plate can be reattached through drill holes or by using a tapered, threaded anchor with a suture attached. This is analogous to a repair for a ruptured quadriceps tendon.

Postoperatively, the sutures are removed in 2 weeks, and the patient is advised to avoid dorsiflexion moments of the hallux for about 8 weeks. The site is protected in plaster with a toe extension. Once the cast is removed, further protection with a stiff sole shoe, with or without a rocker bottom, is needed for an additional 4-6 weeks.

Claw toe may be repaired through flexor-to-extensor tendon transfer if the MTP joint is passively correctable (see Images 5-6). If an interphalangeal contracture is present, arthrodesis of that joint is added.

Joint synovitis or osteochondral defect often requires debridement or cheilectomy.

Traumatic progressive hallux valgus is treated with release of lateral soft-tissue contractures and reconstruction of plantar and medial structures.

Postoperative details

Immediate postoperative care consists of external mobilization at 5-10° of plantar flexion for a minimum of 4 (preferably 6) weeks. This is followed by protective passive ROM under direct supervision of an athletic trainer or physical therapist. Active and passive dorsiflexion are avoided. When the patient is not participating in physical therapy, protection of the hallux MTP joint is imperative.

Non–weight-bearing ambulation is continued for 4 weeks in a removable posterior splint or fracture walker. Another possible option is a Darco Wedge shoe. This allows weight bearing on the hindfoot and simultaneous protection of the forefoot (see Image 7). ROM is gradually increased. After that time, protected ambulation is allowed in a cast boot. Active ROM begins at 2 months. The patient may wear an athletic shoe with a stiffened forefoot that limits MTP joint dorsiflexion.

Follow-up

After approximately 3-4 months, many patients are able to return to athletic activity. Equipment modification is essential. Patients should use an orthosis or insole that contains a stainless steel or graphite plate in the forefoot. Some insoles may be custom molded and contain a Morton extension to decrease MTP joint motion.

It may be 6-12 months before preinjury level of function is achieved.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Sprains and Strains Center. Also, see eMedicine's patient education articles Broken Toe and Sprains and Strains.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Joint stiffness or persistent pain, especially with running, is the most common complication. Loss of push-off strength, hallux rigidus, traumatic bunion deformity, cock-up deformity, arthrofibrosis, and loose joint bodies also may occur.

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

In many cases, if adequate compliance is achieved, conservatively and surgically treated patients can return to their preinjury level of function. However, some disability is possible with either form of treatment.

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

At present, the incidence of persistent symptoms and late-onset sequelae requires further understanding. In the literature, the incidence of persistent symptoms is as high as 50% after 5 years.

Further insight into the usefulness of imaging methods such as MRI is necessary. Some surgeons believe that MRI allows for grading of the injury, the appreciation of findings not evident on physical examination or plain radiographs, and the development of a treatment plan. Above all, turf toe clearly represents a significant injury that deserves adequate recognition and treatment, especially in light of the complications that may occur when the condition is mismanaged.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  Typical mechanism of turf toe injury. The foot is fixed on the ground in equinus position while an external force drives the metatarsophalangeal (MTP) joint into hyperextension.
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Media file 2:  Metatarsophalangeal (MTP) joint hyperextension with tearing of the plantar plate complex. Unrestricted motion of the proximal phalanx results in severe compression of the articular surface of the metatarsal head along with separation of the sesamoid components.
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Media type:  Image

Media file 3:  The capsuloligamentous-sesamoid complex of the hallux. Top, medial view. Bottom, plantar view.
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Media file 4:  Typical method for obtaining a stress radiograph.
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Media file 5:  Techniques for reconstructing a passively correctable claw-toe deformity.
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Media file 6:  Techniques for reconstructing a passively correctable claw-toe deformity.
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Media type:  Image

Media file 7:  Protection of the hallux metatarsophalangeal (MTP) joint is imperative after surgical intervention. The Darco Wedge shoe allows weight bearing on the hindfoot and simultaneous protection of the forefoot.
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Media type:  Photo

Media file 8:  A 55-year-old man sustained this injury while attempting to prevent his large motorcycle from falling; he presented 8 months after the injury. Note the normal medial bipartite sesamoid bone on the opposite hallux.
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Media type:  X-RAY

Media file 9:  Three months after surgery, the patient in Image 8 was pleased with the results despite less-than-perfect approximation.
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Media type:  X-RAY

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

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2. Bowers KD Jr, Martin RB. Turf-toe: a shoe-surface related football injury. Med Sci Sports. 1976;8(2):81-3. [Medline].
3. Coker TP, Arnold JA, Weber DL. Traumatic lesions of the metatarsophalangeal joint of the great toe in athletes. Am J Sports Med. Nov-Dec 1978;6(6):326-34. [Medline].
4. Clanton TO, Butler JE, Eggert A. Injuries to the metatarsophalangeal joints in athletes. Foot Ankle. Dec 1986;7(3):162-76. [Medline].
5. Clanton TO, Ford JJ. Turf toe injury. Clin Sports Med. Oct 1994;13(4):731-41. [Medline].
6. Childs SG. The pathogenesis and biomechanics of turf toe. Orthop Nurs. Jul-Aug 2006;25(4):276-80; quiz 281-2. [Medline].
7. Clanton TO, Eggert KE, Pivarnik JM. First metatarsophalangeal joint range of motion as a factor in turf toe injuries. Am J Sports Med. 1992.
8. Nigg BM, Segesser B. The influence of playing surfaces on the load on the locomotor system and on football and tennis injuries. Sports Med. Jun 1988;5(6):375-85. [Medline].
9. Rodeo SA, O'Brien S, Warren RF, et al. Turf-toe: an analysis of metatarsophalangeal joint sprains in professional football players. Am J Sports Med. May-Jun 1990;18(3):280-5. [Medline].
10. Rodeo SA, Warren RF, O'Brien SJ, et al. Diastasis of bipartite sesamoids of the first metatarsophalangeal joint. Foot Ankle. Oct 1993;14(8):425-34. [Medline].
11. Athletic injuries to the soft tissues of the foot and ankle. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle. 7^th ed. St Louis, Mo: Mosby-Year Book; 1999.
12. Tewes DP, Fischer DA, Fritts HM, et al. MRI findings of acute turf toe. A case report and review of anatomy. Clin Orthop Relat Res. Jul 1994;(304):200-3. [Medline].
13. Watson TS, Anderson RB, Davis WH. Periarticular injuries to the hallux metatarsophalangeal joint in athletes. Foot Ankle Clin. Sep 2000;5(3):687-713. [Medline].

Article Last Updated: Sep 5, 2007