A male patient presented to an orthopaedic consult with pain and deformity in the hallux after suffering a trauma to the foot several months prior. He delayed seeking medical attention. After observing a deformity of the great toe of the foot, radiography and MRI were ordered.
The radiography of the foot revealed a varus deformity of the great toe with partial medial subluxation of the first metatarsophalangeal joint (Figure 1).
MRI showed a non-acute tear of the plantar plate of the first metatarsophalangeal joint (Figure 2), accompanied by injury to the lateral capsular structures and collateral ligaments (Figures 3a and 3b), with oedema and thickening of lateral metatarsosesamoid ligament, probably by associated partial tear (Figures 4a and 4b). The adductor hallucis remained intact and the sesamoids were not proximally retracted due to the integrity of the sesamoid phalangeal ligaments, specifically the lateral one (Figure 5).
On the medial side, the collateral sesamoid phalangeal ligament was normal, and both sesamoids showed no oedema-like changes (Figure 5).
The extensor tendons and sagittal bands of the great toe remained normal (Figure 3a).
Regarding the metatarsophalangeal joint, imaging showed chondral irregularity of the articular surfaces, mostly on the base of the proximal phalanx, due to either post-traumatic changes or early degenerative manifestations (Figure 2).
Turf toe refers to an injury of the first metatarsophalangeal joint (MTPJ), with a hyperextension mechanism, often occurring during athletic activities, with a higher prevalence of these injuries in football players competing on artificial surfaces with softer soled shoes, allowing greater speed and traction [1]. It involves spraining the plantar structures of the greater toe, leading to a spectrum of injuries, from mild sprains to complete tears [2].
Unlike the lesser MTPJs, the first MTPJ lacks a single dominating fibrocartilaginous capsular thickening. Rather, the sesamoids are invested by the fibrocartilaginous pad at the plantar first MTPJ, which is inseparable from the musculotendinous structures, paired metatarsosesamoid ligaments (MTSLs), sesamoid phalangeal ligaments (SPLs), and plantar capsule. These work together to form the plantar plate complex, a functional unit [2].
In the current case, the trauma led to a disruption of the lateral capsular and collateral complex, as well as a partial lesion to the lateral metatarsosesamoid ligament, contributing to the development of hallux varus, where the proximal phalanx of the great toe deviates medially.
Patients often exhibit pain, oedema, and instability at the MTPJ at the time of the injury, albeit delayed presentation can mask early signs of damage. In these situations, imaging is essential since a physical examination might not be enough to determine the full extent of the injury. MRI is particularly useful for assessing soft tissue injuries, such as plantar plate and collateral ligament tears [3], which were present in this case. Radiographs can confirm deformities, such as hallux varus, as seen here.
From an imaging perspective, diagnostic pearls include evaluating for plantar plate integrity, sesamoid positioning, and morphology of the capsule and its ligamentous attachments on MRI [3]. These findings help confirm the extent of joint instability and deformity.
A common grading system proposed by Anderson [4] classifies turf toe injury into three different grades, ranging from stretching of and partial tears of the plantar complex to complete tears, each with their commonly associated signs and symptoms.
While these lesions occur due to a mechanism of hyperextension of the first MTPJ, hyperflexion injuries sustained during sports such as beach volleyball are termed “sand toe” and are associated with dorsal capsular injury of the first MTPJ [5].
Treatment typically involves conservative management with immobilisation, but in cases with significant deformity or instability, surgical intervention may be necessary [6].
Early imaging is crucial in guiding treatment and predicting outcomes since untreated or misdiagnosed turf toe can result in lasting deformities like hallux varus with degenerative changes [1,6].
Turf toe with hallux varus
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1. From the X-ray, there is an abnormality at the first metatarsophalangeal joint: the proximal phalanx (of the first toe) deviates medially, showing a certain degree of hallux varus deformity (Hallux Varus).
2. MRI indicates damage to the lateral capsule-ligament complex of the first metatarsophalangeal joint, specifically:
Based on the imaging findings, the patient’s trauma history, and clinical symptoms, the following diagnoses are considered likely:
Considering the patient’s youth, sports-related injury (hyperextension), delayed presentation with hallux varus deformity of the first toe, and the imaging evidence of lateral ligament and joint capsule injuries at the first metatarsophalangeal joint, the most likely diagnosis is:
“Turf Toe” leading to instability of the first metatarsophalangeal joint and hallux varus deformity.
Once acute inflammation is controlled or after any necessary surgery, a gradual rehabilitation program should be started. The following suggestions are for reference only and may be adjusted based on individual circumstances:
For this patient, special attention should be paid to the stability of the first metatarsophalangeal joint and pain feedback during rehabilitation. A brace may be used when necessary to ensure proper alignment and weight-bearing mechanics.
This report is based on the synthesis of available clinical and imaging data for reference only and cannot replace in-person consultations or professional medical advice and treatment. If you have any concerns or if symptoms worsen, please seek prompt medical attention and follow the recommendations of a qualified healthcare professional.
Turf toe with hallux varus
