Turf Toe

First toe pain in a professional football player • Xray of the Week

First toe pain in a 30 y/o professional football player. What is the diagnosis?

Figure 1. Sagittal T1 (A) and "fat sat" (B) images show a tear of the tibial sesamoid phalangeal ligament (red arrow). The tear is a complete tear (grade III) with retraction of the tibial sesamoid.

Figure 2. Sagittal “fat sat” images show a normal (green arrow) and a torn (red arrow) sesamoid phalangeal ligament.

Figure 3. Axial “fat sat” images show a normal (green arrow) and a torn (red arrow) sesamoid phalangeal ligament.

Figure 4. This football player is at high risk for turf toe. Note the hyperextension of the first metatarsal phalangeal joint (insert) and the massive downward pressure by the opposing player.

Figure 5. Accelerated arthrosis in a 27 year old with chronic turf toe. Sagittal (A) and coronal (B) images show a shortened scarred sesamoid phalangeal ligament (red arrow) and a chronic osteochondral defect of the first metatarsal head (green arrows).

Discussion:

Turf toe is a tear of the sesamoid phalangeal ligament [Figs. 1-3]. The mechanism of injury in the acute setting is a hyperextension of the first metatarsal phalangeal joint when the hallux is fixed in equinus [Fig.4]. Chronic tear may occur with hyperextension or repeatedly pushing off when running or jumping. Playing football especially on artificial turf is a predisposing factor. Significant morbidity can occur with up to half of patients still symptomatic at 5 years. Most cases are managed conservatively with ice, elevation, and NSAIDS. Immobilization is used in higher grade injuries. However, surgery may be needed for failed conservative management or if there are complications such as sesamoid fracture, bipartite sesamoid separation, sesamoid proximal migration, instability with pain/synovitis, hallux rigidus, or an unstable chondral flap of the first metatarsal phalangeal joint [Fig.5].

References:

1. McCormick JJ, Anderson RB. The great toe: failed turf toe, chronic turf toe, and complicated sesamoid injuries. Foot Ankle Clin. Jun 2009;14(2):135-50.

2. Crain JM, Phancao JP, Stidham K. MR imaging of turf toe. Magn Reson Imaging Clin N Am. Feb 2008;16(1):93-103, vi.

3. Sanders TG, Rathur SK. Imaging of painful conditions of the hallucal sesamoid complex and plantar capsular structures of the first metatarsophalangeal joint. Radiol Clin North Am. Nov 2008;46(6):1079-92, vii.

4. Yao L, Do HM, Cracchiolo A, et al. Plantar plate of the foot: findings on conventional arthrography and MR imaging. Am J Roentgenol 1994;163:641-4.

5. Kubitz ER. Athletic injuries of the first metatarsophalangeal joint. J Am Podiatr Med Assoc. Jul-Aug 2003;93(4):325-32.

6. Resnick D, Kang HS. Internal derangement of joints: emphasis on MR imaging Philadelphia, Pa: Saunders, 2nd Ed. 2006. Buy it on Amazon

7. Linklater JM. Imaging of Sports Injuries in the Foot. AJR 2012; 199:500–508

8. Stoller D, Tirman P, Bredella M et-al. Diagnostic imaging. AMIRSYS. (2004) ISBN:0721629202. www.amazon.com/gp/product/0721629202

9. Ashman CJ, Klecker RJ, Yu, JS. Forefoot Pain Involving the Metatarsal Region: Differential Diagnosis with MR Imaging. RadioGraphics 2001; 21:1425–1440

10. http://radsource.us/clinic-turf-toe/

11. Allen LR, Flemming D, Sanders TG. Turf toe: ligamentous injury of the first metatarsophalangeal joint. Mil Med. 2004 Nov;169(11):xix-xxiv.

Phillip Tirman, MD is the Medical Director of Musculoskeletal Imaging at the Renaissance Imaging Center in Westlake Village, California. A nationally recognized expert in the applications of MRI for evaluating MSK and spine disorders, Dr. Tirman is the co-author of three textbooks, including Shoulder Magnetic Resonance Imaging and Diagnostic Imaging: Orthopedics. He is also the author or co-author on over sixty original scientific articles published in the radiology and orthopedic literature.

In 2018, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator.

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Kevin M. Rice, MD is the President of Global Radiology CME

Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances and as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator.

Follow Dr. Rice on Twitter @KevinRiceMD

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