First Metatarsophalangeal (MTP) Joint Sprain

The plantar aspect of the great toe metatarsophalangeal (MTP) joint is stabilized by the joint capsule, plantar muscles and tendons, as well as the sesamoid complex.

The mechanism of first MTP joint sprain is extreme dorsiflexion of the great toe MTP joint (more than 90°; eg, with the heel raised off the ground in pushing off to sprint). The injury is sometimes called turf toe because it was first described in American football players playing on artificial turf. Because it is a harder surface than grass, artificial turf increases the distraction force with toe dorsiflexion during push-off and increases the risk of hyperextension. However, first MTP joint sprain can occur in any sport with sprinting or jumping that causes forced hyperextension of the great toe (eg, baseball, soccer, gymnastics). It can also occur chronically with repetitive hyperextension of the great toe (eg, in dancing). Some sports medicine physicians contend that athletic footwear that has flexible soles increases risk of injury.

In addition to knee and ankle injuries, first MTP joint sprain is a common injury that causes athletes to lose playing time.

There is sudden pain in the great toe metatarsophalangeal (MTP) joint. Active and passive joint motion is painful, and the joint is swollen.

• History and physical examination

• Radiograph

Diagnosis is clinical, but radiographs should be performed to exclude fracture. Treatment typically depends on injury severity (1). Several classification system are used to grade the severity of a great toe MTP joint injury. One of them is the Anderson anatomic classification and is as follows (1):

• Grade 1: Stretching of the plantar capsular complex

• Grade 2: Partial tear of capsular complex

• Grade 3: Frank tear of the capsular complex

• Supportive measures (rest, buddy tape, ice, elevation, analgesics)

• Physical therapy

• Rarely, surgical repair

Patients should generally limit activity, apply ice, and buddy tape the great toe to the second toe to partially immobilize the affected metatarsophalangeal (MTP) joint. Over-the-counter nonsteroidal anti-inflammatory drugs may help reduce pain in the short term (1). Physical therapy aimed at increasing flexibility can help prevent chronic MTP joint stiffness. For grade 2 injury, limitation of joint motion during ambulation may help (eg, wearing a stiff-soled shoe, walking boot, or shoe with an orthotic insert). If symptoms, including limited joint motion, persist beyond several weeks (suggesting a grade 3 sprain), surgical repair by a foot and ankle specialist may be needed.

In grade 1 injuries, symptoms usually resolve in a week or two. In grade 2 injuries, symptoms last > 2 weeks. In rare grade 3 injuries (complete rupture of the plantar ligament complex), symptoms persist beyond several weeks and include continued difficulty moving the great toe.

Untreated first MTP joint injuries can result in chronic MTP joint stiffness.

• First metatarsophalangeal (MTP) joint sprain (turf toe) is a sprain of the great toe MTP joint and occurs with forced joint hyperextension.

• The injury can occur in any sport that requires sudden jumping or cutting, especially on artificial turf.

• Athletic footwear that is less supportive and flexible may increase risk of the injury.

• Accurate diagnosis and appropriate treatment are imperative to help prevent chronic great toe joint stiffness and pain.