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Turf toe
Other Resources UpToDate PubMed

Turf toe

Contributors: Brianna Caraet MD, Benedict F. DiGiovanni MD, FAOA, FAAOS
Other Resources UpToDate PubMed


Causes / typical injury mechanism: Turf toe occurs after hyperextension, often with varus, of the plantar plate and sesamoid complex at the first metatarsophalangeal (MTP) joint. It is a common condition predominantly seen after athletic injury.

The first MTP joint is a hinge and sliding joint. The joint's dynamic stabilizers are the medial and lateral sesamoids that lie within the flexor hallucis brevis (FHB), the adductor hallucis tendon, and the abductor hallucis tendon. This MTP joint is also stabilized by the intermetatarsal, medial, and lateral collateral ligaments and the plantar plate, which is composed of the joint capsule.

The mechanism of injury involves hyperextension of the first MTP joint with axial force applied to an equinus foot, resulting in a capsular-ligamentous-sesamoid complex tear of the proximal phalanx. Studies have shown that when dorsiflexion of the MTP joint exceeds 78 degrees, there is a 50% risk of sustaining turf toe.

Classic history and presentation: Sequela of this injury may occur including pain, limited range of motion, decreased push-off strength, hallux valgus, and hallux rigidus.

Prevalence: Turf toe is commonly seen in football players. In these high-level athletes, prevalence is reported to be 45%. Turf toe is also seen in soccer players, basketball players, gymnasts, and dancers.

Risk factors:
  • Playing on artificial "fill" turf with grass fibers and sand or rubber fill. This increases the risk of turf toe by 85%. Risk is decreased when using "no fill" artificial turf and natural grass.
  • Increased footwear flexibility that allows excessive dorsiflexion.
  • There is an increased risk during game play compared to practice, likely due to the increased intensity of playing.
Grade / classification system: Anderson classification of turf toe –
  • Grade I: Sprain, completely intact plantar plate and capsule.
  • Grade II: Partial tear of the plantar plate and capsule.
  • Grade III: Complete tear of the plantar plate and capsule, possible fracture and sesamoid migration.


S93.523A – Sprain of metatarsophalangeal joint of unspecified great toe, initial encounter

238486004 – Turf toe

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Differential Diagnosis & Pitfalls

  • FHB strain – less severe injury, suggested by tenderness proximal to sesamoids
  • Sesamoiditis
  • Isolated sesamoid fracture
  • Arthritis
    • Sesamoid bones
    • First metatarsal head
    • First proximal phalanx
    • Hyaline cartilage
  • Nerve impingement of the medial branch of the plantar digital nerve
  • Sand toe (extensor hallucis longus)

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Last Reviewed:08/30/2020
Last Updated:02/03/2021
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Turf toe
Copyright © 2023 VisualDx®. All rights reserved.