1st Metatarsophalangeal Joint Capsular Injury

Injuries to the 1st metatarsophalangeal joint


In 1976, Bowers and Martin coined the term “turf toe” to describe an increasingly prevalent injury to the 1st metatarsophalangeal joint in athletes competing on artificial surf. 

In fact this injury represents a simple hyperextension injury to the 1st metatarsophalangeal joint and may occur on any athletic surface. 

The injury occurs when the 1st metatarsophalangeal joint is dorsiflexed beyond its physiological range during weight bearing, resulting in initial stretching of the 1st metatarsophalangeal joint capsule and plantar plate. 

If the injurious load is maintained, these structures may tear as represented in figure 9.6.

Hyperflexion of the 1st metatarsophalangeal joint may result in a similar injury to the dorsal capsule. 

Chou (2000) reports this injury may have associated avulsion fracture of the base of the proximal phalanx, osteochondral fracture of the metatarsal head, or even frank dislocation of the 1st metatarsophalangeal joint.



Figure 9.6: Diagrammatic and graphic demonstration of the mechanism for turf toe injury

In most cases of turf toe, the patient will recall an incident of forced dorsiflexion of the 1st metatarsophalangeal joint, although the condition may present as an overuse injury in runners.  Gait studies reveal an antalgic pattern with lack of propulsion and external rotation of the injured side, to minimise loading through the 1st metatarsophalangeal joint. 

Swelling and ecchymosis around the joint may be present, but will vary according to the severity of the injury.  There will be a reduction in both the active and passive joint range of motion at the 1st metatarsophalangeal joint, with reflex pain inhibition (Churchill and Donley 1998).  Active resisted dorsiflexion/plantarflexion will elicit pain.  Clanton et al (1986) and later Bowman (1997) classified turf toe injuries according to table 9.1



Table 9.1


Grade 1 injuries can be effectively managed with RICE (Rest, Ice, Compression, Elevation).  Restriction of 1st metatarsophalangeal joint extension is achieved with taping as demonstrated in figure 9.7, or shoe modification incorporating increase sole stiffness in the forefoot.

Grade 2 injuries necessitate the athlete resting from athletic activities for one to two weeks (Churchill and Donley 1998).  A rigid orthotic device, with an extension beyond the 1st metatarsophalangeal joint (Morton’s Extension) may be most beneficial in reducing symptoms and preventing recurrence. 

Grade 3 injury may require a period of non weight bearing rest, and cessation of sporting activities for up to six weeks. 


Figure 9.7: Taping for turf toe

A comprehensive discussion on turf toe is available at https://www.bartoldclinical.com/articles/turf-toe

The same principles apply as for a grade 2 sprain, however if conservative measures fail, occasionally surgery for capsular repair or loose body removal may be indicated.  In all cases, range of motion exercises are commenced once swelling and pain have diminished.

[This piece is reprinted with permission from Bartold, S.J., 2014, The Foot and Leg in Sport, Amazon Publishing,  pages 255-257]

Simon Bartold
Director of Bartold Clinical