What is Turf Toe?
It was in 1976 when “turf toe” was used by Bowen and Martin to describe a common sports injury that refers to “sprain of the plantar capsuloligamentous complex of the metatarsophalangeal joint of the great toe [1, 2].”
Famous American football players like Deion Sanders and Tom Brady are among the many who have already experienced this injury.
Picture 1: Turf toe refers to sprain of the plantar capsule ligamentous complex of the metatarsophalangeal joint of the great toe.
Image Source: kenoshaorthopedics.com
Causative Factors of Turf Toe
Almost all victims of turf toe injury are athletes who engage in contact sports, specifically football (most common), wrestling, lacrosse, and rugby.
The reason why this injury is called “turf toe” is because the culprit is pointed to artificial turf plus the use of flexible shoes.
Picture 2: Flexible shoes causes turf toe.
Image Source: orthoinfo.aaos.org
According to a study, more cases of turf toe injury happen in modern artificial turfs than in natural grass fields. It was also reported that 45% of National Football League (NFL) players have already suffered from turf toe injury and most of them happened in artificial turfs.
Turf toe injuries may also be caused by dancing, running, basketball, horseback riding, and even in vehicular accidents. Other contributory factors include the person’s age, weight, position, great toe motion, flat metatarsal head, ankle dorsiflexion, and previous injury to the area.
There are medical conditions that can cause turf toe. These are gout, arthritis, sesamoiditis, bunion, hammer toe, fracture, blister, and neuroma [1, 3, 4].
Mechanisms of Turf Toe
The mechanism of turf toe injury lies on the amount of force placed on the first metatarsophalangeal joint and the degree of movement at the time of force.
Turf toe primarily occurs due to exaggerated hyperextension of the great toe. Furthermore, the body weight of the player or another player (i.e., in football or rugby) puts axial load or vertical force on the already injured toe, worsening it.
The plantar capsule serves as a restriction for hyperextension of the metatarsophalangeal joint. In turf toe, the plantar soft tissues are torn because of excessive hyperextension. Flexible shoes are not hard enough to restrain the extension of the great toe [1, 5].
Picture 3: Hyperdorsiflexion of the Great Toe
Image Source: texasfootdoctor.org
Picture 4: Axial load worsens turf toe injury.
Image Source: angelopodiatry.com
Classifications of Turf Toe: Manifestations and Treatment (Recovery)
Signs and symptoms of turf toe include pain, swelling, warmth, discoloration, and restricted mobility and functionality of the big toe which are seen immediately after the injury .
Clanton classified turf toe based the severity of the injured great toe and its supporting structures. How to treat turf toe depends on the actual case of the patient and how fast it heals depends on how he complies with the treatment.
Picture 5: Capsuloligamentous Complex of the First Metatarsophalangeal Joint
Image Source: uwbadgers.com
Grade I turf toe injuries are the mildest, with limited swelling. These result from stretching of the capsuloligamentous complex of the first metatarsophalangeal joint. Range of motion of the great toe is generally unaffected because the plantar capsule is not torn.
Treatment is symptomatic which basically involves RICE (rest, ice, compression, elevation). The person is allowed to get back in the game as soon as the turf toe is healed. Taping immobilizes the first metatarsophalangeal joint, preventing further injury.
The examiner can test the patient’s tolerance by extending the great toe at 90°. Continuous movement is tolerated if passive extension is painless.
Picture 6: Turf Toe Taping Technique
Use nonstretch zinc oxide tape.
Place the tape around the big toe.
Tape another around the middle part of the foot.
Apply another set of overlapping tapes connecting the ones placed over the big toe and the middle part of the affected foot.
Secure the tapes by taping the big toe and middle part of the foot once again.
Grade II turf toe injuries has increased pain because there is already partial tearing of the capsuloligamentous structures. Along with this, there is moderate swelling and limitation of movement. Patient becomes limp on affected side so there may be a need for turf toe braces, walking boots, or crutches.
Pain medications and physical therapy will be helpful. Two weeks of recovery time is recommended for patients belonging to this category. As the patient returns to play, orthotic with Morton’s extension or a turf toe plate is used shoe inserts to provide rigidity and to resist torque as it allows for comfortable play. This prevents re-injury.
Picture 7: Turf Toe Brace Splinting
Image Source: amazon.com
Picture 8: Boot for immobilization of turf toe
Image Source: fieldgulls.com
Picture 9: Custom Orthotic Morton’s Extension
Image Source: columbusfoot.com
Picture 10: Turf Toe Plates used as Shoe Inserts
Image Source: myfootshop.com
Grade III turf toe injuries are the worst because there is complete tear of the capsuloligamentous structures. As a result, there is increased pain, ecchymosis, and limitation of movement (i.e., weakness upon bending the great toe and unstable metatarsophalangeal joint). At this point, the patient cannot bear weight. If turf toe is accompanied by dislocation, there may be a need for closed reduction.
This is followed by the use of immobilization devices (braces, boots, casts, and crutches), cold compress, and pain medications for 4-6 weeks. Another 4-6 weeks will be allotted for physical therapy and rehabilitation. The recovery time can take up to 10-16 weeks. He must be able to dorsiflex the great toe without pain in order for him to get back in the game.
Steroids should not be used during rehabilitation because it interferes with healing of the soft tissues and it conceals the pain which is an indicator if the patient is ready to play again. If all of these do not render improvement, surgical repair of the involved anatomical structures may be necessary [1-10].
Complications of Turf Toe
Persistent pain and joint stiffness of the big toe is the most common sequelae of turf toe injuries if left untreated.
Turf toe injuries lead to avulsion (tearing) of the plantar plate. This may result to subluxation (partial dislocation) of the sesamoid bones. Complete dislocation of the first metatarsophalangeal joint rarely happens. If the injury is severe and surgery is not performed, this may result to degenerative joint diseases such as arthritis.
Long-term complications of turf toe injuries include hallux rigidus, hallux valgus, hallux varus, arthrofibrosis, cock-up deformity, loose joint bodies, and loss of strength for push-off. Half of the patients suffer for more than 5 years. Eventually these athletes will have an early retirement due to functional disability [1, 3, 8].
- Philbin TM, Sports Injuries of the Foot: Evolving Diagnosis and Treatment, Springer Science & Business Media, 21 Mar 2014
- Saxena A, International Advances in Foot and Ankle Surgery, Springer Science & Business Media, 28 Sep 2011
- Thordarson DB, Foot and Ankle, Lippincott Williams & Wilkins, 2004
- Micheo W, Musculoskeletal, Sports, and Occupational Medicine, Demos Medical Publishing, 2010