Turf Toe

Turf toe refers to a sprain of the main joint in the big toe. This injury occurs when the toe is forcefully pushed into hyperextension, such as when accelerating into a sprint and the toe becomes stuck flat on the ground. While it is commonly associated with American football, turf toe can also occur in various other sports and physical activities.

Anatomy of the Big Toe and Turf Toe Injury

The big toe consists of two primary joints, with the largest being the metatarsophalangeal (MTP) joint. This joint forms where the first long bone of the foot (metatarsal) meets the first bone of the toe (phalanx). In the case of turf toe, the MTP joint is the site of injury. Surrounding the MTP joint are key structures that help stabilize it and prevent dislocation. Collectively, these structures are known as the plantar complex.

• Plantar Plate: A thick, fibrous tissue beneath the MTP joint, the plantar plate prevents excessive upward bending (dorsiflexion) of the big toe.
• Collateral Ligaments: These ligaments, located on either side of the big toe, connect the phalanx bone to the metatarsal and limit excessive side-to-side movement of the toe.
• Flexor Hallucis Brevis: A tendon running beneath the first metatarsal, this structure provides support and stability to the big toe during push-off motions.
• Sesamoids: Two small bones within the flexor hallucis tendon, the sesamoids help the tendon move smoothly and add stability to the MTP joint by assisting in bearing weight on the forefoot.

Description'

Turf toe refers to damage to any soft tissue structure within the plantar complex, such as the plantar plate or collateral ligaments. The severity of these injuries can vary, ranging from a simple stretching of the soft tissue to partial tears, and in more severe cases, complete dislocation of the metatarsophalangeal (MTP) joint. To determine the best course of treatment for turf toe, doctors typically grade the injury on a scale of 1 to 3, from mild to severe:

• Grade 1: The plantar complex is stretched, causing localized tenderness and mild swelling.
• Grade 2: Partial tearing of the plantar complex leads to more widespread tenderness, moderate swelling, and bruising. Toe movement becomes painful and limited.
• Grade 3: Complete rupture of the plantar complex results in intense tenderness, significant swelling, and bruising. Moving the big toe becomes extremely difficult and painful.

Causes'

Turf toe can occur during any sport or activity where the forefoot is fixed to the ground, the heel is lifted, and a force pushes the big toe into hyperextension. The prevalence of turf toe injuries increased among American football players after artificial turf became more common in stadiums, which is how the injury got its name. Artificial turf surfaces are generally harder and less shock-absorbing than natural grass. They offer less give when pressure is applied. Additionally, the athletic footwear designed for use on artificial surfaces is softer and more flexible, providing better agility but significantly reducing forefoot stability.

First Aid Treatment for Turf Toe

The RICE protocol is highly effective for managing most sports-related injuries in the early stages. RICE stands for:

• Rest: Avoid activities that caused the injury. Refrain from walking or putting weight on your foot.
• Ice: Apply cold packs for 20 minutes at a time, several times a day. Always place a cloth between the ice and your skin to prevent frostbite.
• Compression: Use an elastic compression bandage to reduce swelling and prevent further damage.
• Elevation: While resting, elevate your foot so it is higher than your heart to minimize swelling.

In addition to the RICE method, over-the-counter anti-inflammatory medications such as ibuprofen or naproxen can help alleviate pain and inflammation. If your injury is severe, or if symptoms persist, it's essential to seek medical attention. Before visiting the doctor, try to recall the exact circumstances of your injury, as this will help in diagnosing the issue and determining the best treatment plan.

Imaging Tests for Turf Toe Diagnosis

To confirm the diagnosis and assess the extent of your injury, your doctor may recommend additional imaging tests, including:

• X-rays: X-rays are useful for capturing detailed images of dense structures like bones. Although the plantar complex is composed of soft tissues, X-rays can help identify other potential issues, such as small bony pull-off fractures at the points where the plantar complex attaches to the bones. They may also reveal fractures or abnormal movement in the two small sesamoid bones beneath the big toe joint.
• Magnetic Resonance Imaging (MRI): MRI scans are more effective than X-rays at visualizing soft tissue structures and cartilage damage. They are particularly valuable for diagnosing Grade 2 and Grade 3 injuries, as well as when X-rays indicate abnormalities that require further evaluation.

The X-ray on the right shows normal bone positions

Treatment for Turf Toe Injury

Nonsurgical Treatment

Most turf toe injuries are managed without surgery, with the treatment plan based on the severity of the injury.

• Grade 1: The RICE protocol is the first line of treatment, including rest, ice, compression, and elevation. Taping the big toe to the adjacent smaller toes can help limit motion. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to reduce pain and swelling. In most cases, the pain is mild enough that athletes can continue participating in sports while wearing stiff-soled shoes. Using orthotics, such as a thin graphite shoe insert with a rigid forefoot component, can also help by reducing stress on the plantar plate and providing added stability. Stretching and strengthening exercises may be recommended to help alleviate joint stiffness.
• Grade 2: For Grade 2 injuries, your doctor may suggest wearing a walking boot to immobilize the MTP joint for up to a week. Afterward, the injury will be managed with taping and Grade 1 treatments. Typically, an athlete with a Grade 2 injury will need 3 to 14 days of rest before returning to their sport.
• Grade 3: These more severe injuries require extended immobilization, typically for several weeks. The athlete may need to wear a walking boot or be placed in a cast to keep the big toe in a slightly downward position. As healing progresses, treatment may transition from Grade 3 to Grade 2 and eventually to Grade 1 care. Physical therapy is often beneficial and should begin once symptoms allow. Specific exercises can help to stretch and strengthen the big toe, with early joint movement crucial for preventing stiffness.

Surgical Treatment

Surgery is usually not required for turf toe. However, if symptoms persist or significantly impact athletic performance, surgical intervention may be considered. Surgery is most often recommended for severe Grade 3 injuries, such as:

• Complete tear of the plantar complex
• Fracture of the sesamoid bones
• Vertical instability (abnormal up-and-down motion) of the MTP joint
• Loose bone chips within the joint
• Cartilage damage in the joint
• Development of a bunion or worsening of an existing one

The specific surgical procedure depends on the nature of the injury, with the goal being to repair damaged soft tissues and restore proper MTP joint motion for normal functionality.

Long-Term Outcomes

When treated early, turf toe injuries generally heal well. However, mild to moderate persistent symptoms, such as pain and joint stiffness, are common. Potential long-term complications can include:

• Loss of push-off strength
• Joint stiffness
• Development of a bunion
• Cocking up of the big toe (hallux rigidus)