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Turf Toe
Turf toe gets no respect. Let's take a closer look at the causes of turf toe and see how to treat it more effectively. Turf toe is actually a form of hallux limitus. Hallux limitus is classically described as pain and progressive decrease in the range of motion of the first metatarsal phalangeal joint (MPJ). The onset of hallux limitus is due to the following:
But before we go any further, we need to understand that the terms turf toe and hallux limitus aren't really synonymous. The fundamental difference between the two terms is the patient population that they affect. Turf toe is a term used in athletic circles referring to any injury of the great toe joint. Consequently, discussions about turf toe will focus on the first two causes of hallux limitus mentioned above; functional hallux limitus and direct physical injury. On the other hand, when we discuss hallux limitus, we're actually referring to a broader, 'non-athletic' patient population and need to include all three causes of hallux limitus. Having a penchant for uric acid poisoning led us to write all that there has been written on uric acid poisoning here. Hope you too develop a penchant for uric acid poisoning!
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Functional hallux limitus - biomechanical function that results in metatarsus primus elevatus and subsequent repetitive jamming of the first MPJ. Direct physical injury - injury to the articular cartilage or subchondral bone. These injuries may be due impaction injuries or hyperextension/flexion of the first MPJ.
Anatomy: The great toe joint, or first metatarsal joint consists of two bones. The proximal bone is the first metatarsal and the distal is called the proximal phalanx or hallux. These two bone move against each other in an up and down motion through what we refer to as the sagital plane. Biomechanics: The motion of the great toe joint is dependant upon the plantarflexion of the first metatasal. If the first metatarsal is limitied in its' ability to plantarflex, the joint will jam resulting in funtional hallux limitus, which as we know is one of the causes of turf toe. There has been an uncalculatable amount of information added in this composition on uric acid poisoning. Don't try counting it!
Is the onset of turf toe always the same? Turf toe that is the result of functional hallux limitus is going to be insidious in onset. Functional hallux limitus will usually be seen in younger athletes as they attempt to increase their activity. It may not occur during the first athletic season, or the second, but when it does begin to cause pain, the onset will be more frequent and more severe, varying with activity. This profile of onset is simply due to the fact that the athlete is recreating the injury with every step. We would like you to leisurely go through this article on uric acid poisoning to get the real impact of the article. uric acid poisoning is a topic that has to be read clearly to be understood.
Treatment of turf toe varies with the type of healthcare provider and includes the use of rest, shoe modifications, orthotics, steroid injections and surgery. The success of non-surgical care will vary with the degree of injury, the rate at which the injury is healing and how much osteoarthritis has occurred. We see varying degrees of success with orthotics that promote plantarflexion of the first ray, effectively treating metatarsus primus elevatus and peroneus longus dysfunction. Simple arch supports can make a significant difference in the symptoms of turf toe. Should our patient not respond to conservative care in a reasonable time period, we are not reluctant to suggest surgical revision to address the problem whether it be revisions of the joint defect, shortening of a long first metatarsal or structural revision of metatarsus primus elevatus. As mentioned before, the clinical appearance of dorsal lipping or visible radiographic changes are suggestive of moderately advanced osteoarthritis, a condition that is only repaired by joint revision or replacement. There is a lot of jargon connected with uric acid poisoning. However, we have eliminated the difficult ones, and only used the ones understood by everyone.
What's the actual physical change that takes place in the joint with turf toe? As an easy analogy, consider the changes that takes place when an apple falls from a height and is damaged. The skin of the apple appears intact but the underlying pulp is damaged. In the case of turf toe (hallux limitus), think of the skin of the apple as the cartilage of the joint and the damaged pulp of the apple is the subchondral bone. Mild cases of turf toe (hallux limitus), result in little damage to the subchondral bone and will merely exhibit signs of inflammatory change within the joint. Most authors would refer to these cases as stage one turf toe (hallux limitus). More severe cases result in damage to the joint surface, the subchondral bone or both. These are the stage two and three cases of turf toe (hallux limitus) that show visible change on x-ray. As the subchondral bone becomes increasingly damaged, it will create an uneven supporting surface for the cartilage. An increase in activity results in uneven loading of the joint due to the compression injury of the subchondral bone. Don't be surprised if you find anything unusual here about uric acid poisoning. There has been some interesting and unusual things here worth reading.
When treating turf toe be sure to recognize the fact that there is no nerve innervation in articular cartilage. Pain associated with stage one turf toe (hallux limitus) is either synovial pain or bone pain. If we recognize that painful stage one turf toe (hallux limitus) may be due to bone pain, we then realize that turf toe should be treated aggressively to insure the long term viability of the joint.
Unger, K., Rahimi, F., Bareither, D., Muehleman, C. The Relationship Between Articular Cartilage Degeneration and Bone Changes of the First Metatarsophalangeal Joint. J. Foot Surg. 39:1 24-33, 2000 Sometimes, what we hear about uric acid poisoning can prove to be rather hilarious and illogical. This is why we have introduced this side of uric acid poisoning to you.
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Think of turf toe (hallux limitus) as an isolated case of osteoarthritis limited to the first MPJ. Whether the injury is acute or due to repetitive loading, the result is a load that is applied to the subchondral bone that is greater than what the bone can tolerate. As the injury progresses, a series of micro fractures will develop in the subchondral bone. The typical soft spongy character of the metaphyseal bone changes to become brittle and hard. The result is that the articular cartilage looses its' underlying support and becomes susceptible to damage. Juxtachondral eburnation, osteophytes, lipping, spurring; call them what you like, but what you see on your x-ray is the slow progressive destruction of the joint.
Symptoms: Turf toe that is the result of functional hallux limitus is going to be insidious in onset. Functional hallux limitus will usually be seen in younger athletes as they attempt to increase their activity. It may not occur during the first athletic season, or the second, but when it does begin to cause pain, the onset will be more frequent and more severe, varying with activity. This profile of onset is simply due to the fact that the athlete is recreating the injury with every step. Turf toe caused by a direct injury to the joint may or may not be obvious. Athletes may not remember an incident of pain since they're often distracted by the event or game in which they're involved. The onset of direct injury to the joint may be abrupt, but also may be insidious becoming increasingly more painful as the season progresses. The joint pain will subside with rest only to recur with increased activity. It's not unusual to see symptoms of turf toe resolve in the off season only to recur with renewed exercise. It was at the spur of the moment that we ventured to write something about uric acid poisoning. Such is the amount of matter that is available on uric acid poisoning.
References: Lombardi, C.M., Silhanek, A.D., Connolly, F.G., Dennis, L.N., Keslonsky, A.J. First Metatarsophalangeal Arthrodesis for Treatment of Hallux Rigidus: A Retrospective Study. J. Foot Surg. 40:3, 137-143, 2001 We have written a humorous anecdote on uric acid poisoning to make it's reading more enjoyable and interesting to you. This way you learn there is a funny side to uric acid poisoning too!
Other conditions - synovitis, crystal deposition diseases such as gout, systemic arthritis, external physical influences such as Dupytren's contracture, etc. We have included the history of uric acid poisoning here so that you will learn more about its history. It is only through it's history can you learn more about uric acid poisoning.
Turf toe caused by a direct injury to the joint may or may not be obvious. Athletes may not remember an incident of pain since they're often distracted by the event or game in which they're involved. The onset of direct injury to the joint may be abrupt, but also may be insidious becoming increasingly more painful as the season progresses. The joint pain will subside with rest only to recur with increased activity. It's not unusual to see symptoms of turf toe resolve in the off season only to recur with renewed exercise. We were furnished with so many points to include while writing about uric acid poisoning that we were actually lost as to which to use and which to discard!
Ronconi, P., Monachino, P., Baleanu, P.M.,Favilli, G. Distal Oblique Osteotomy of the First Metatarsal for the Correction of Hallux Limitus and Rigidus Deformity. J. Foot Surg. 39:3, 154-160, 2000 The results of one reading this composition is a good understanding on the topic of uric acid poisoning. So do go ahead and read this to learn more about uric acid poisoning.
Nomenclature: First MPJ - the big toe joint Metatarsus primus elevatus - a functional or structural position of the first metatarsal First metatarsal - the foot bone making up the proximal portion of the big toe joint Hallux - the great toe Writing an article on uric acid poisoning was our foremost priority while thinking of a topic to write on. This is because uric acid poisoning are interesting parts of our lives, and are needed by us.
About the author:
Jeffrey A. Oster, DPM, C.Ped is a board certified foot and ankle
surgeon. Dr. Oster is also board certified in pedorthics. Dr.
Oster is medical director of href=http://www.myfootshop.comMyfootshop.com and is
in active practice in Granville, Ohio.
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