Turf Toe Management

Turf Toe Caused By Hyperextension

Turf toe is an injury with a short name but a long history of pain in the NFL.  With large men rapidly changing directions on varying surfaces, the forces originating at the ground level are extremely high.  Simply stated, every football player move that you see on your plasma screen during Sunday’s game start at the foot and big toe.

Turf toe is the medical term related to a sprain of that 1st metatarsophalangeal (MTP) joint or, as it is commonly referred to as, the “big toe”. The name turf toe originated in the mid-1970’s when certified athletic trainers and physicians reported an increase in 1st MTP joint injuries with a large number of games being played on artificial turf.  The combination of harder playing surfaces, increased shoe traction and lighter less rigid shoes proved to be the main contributing factors to injuries related to the big toe.

Big toe pain originates at the 1st metatarsophalangeal (MTP) joint and usually includes surrounding soft tissue.  The most common mechanism of injury is joint compression with hyperextension of the 1st MTP joint.  In reality, turf toe can occur with any combination of compression with excessive extension, flexion, rotation, adduction (moving away from the 2nd toe) or abduction (moving towards from the 2nd toe) of the 1st MTP joint.

An example of this injury in football is when a player lands on the back of another player’s ankle while athlete’s big toe is planted in the ground and extended.  With the extra weight applying pressure into the arch and the player’s inability to unload the front of the foot, the 1st MTP joint is forcefully hyperextended and the joint surfaces are compressed.  It’s easy to see how this mechanism of injury can create considerable damage to the joint itself and all the structures on the plantar (undersurface) of the distal arch and big toe.

With the example noted above, the muscles that flex or bend the 1st MTP joint can be stretched or torn.  The capsule that surrounds the joint is vulnerable along with the ligaments and plantar plate complex, which is the stabilizing structure on the underside of the big toe.

Lastly, the two small sesamoid bones that rest under the 1st MTP joint, or “ball of the foot”, are potential sources of pain with turf toe and any injury that affect this area of the distal arch.  With direct trauma or hyperextension of the big toe, the sesamoids can become inflamed or fracture.

Signs & Symptoms of Big Toe Pain

  • A sudden or slow onset of pain anywhere encompassing the base of the big toe.
  • With an abnormal motion of the 1st MTP joint, a “pop” or a “shifting” sensation is noted.
  • Point tenderness and swelling at the base of the big toe.
  • Passive and active movements of the toe upward (extension) are painful and the amount of motion is significantly limited when compared to the other foot.
  • When moving the big toe into the direction of the injury, the symptoms increase and the strength in that position is significantly reduced.
  • Pressure while weight bearing, twisting and pushing off the front of the foot will increase symptoms in the big toe.

Treating Turf Toe Pain

  • Icing, elevate and rest the foot is the best start to controlling the swelling and pain.
  • Icing techniques include a 15 minute ice bag (good), a 10 minute ice massage (better) or the Granddaddy of them all, the 12 minute ice bucket (the best).
  • Walking boots are valuable tools in the NFL and a wonderful ways to protect the toes, forefoot and ankles while allowing an athlete to walk.
  • When you’re able to comfortably wear a shoe, utilizing a steel shoe insert or rigid orthotic in all of your shoes will stabilize the forefoot and minimize extension at the big toe.
  • Avoid barefoot walking or any activities in flimsy and unsupported shoes.
  • Massage of the arch, gentle painfree range of motion (ROM) of the toes, stretching of the ankles and calves will enable better blood flow to the injured tissue while maximizing the drainage from the areas with excess swelling.
  • When the warmth in the joint has subsided and at least 75% of your painfree motion had returned, picking up marbles/rocks/peanuts with your toes will increase the strength and mobility of your toes.
  • Towel curls, to be started with the same criteria as the marbles, will effectively strengthen your arches and intrinsic muscles of your forefoot.

Asking the Right Questions Like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Do I have turf toe and exactly what structures did I damage with my injury?
  2. Do I need an x-ray, MRI or CT Scan to determine the extent of my injury?
  3. Will orthotics help me and if so, where do you suggest that I purchase them at a reasonable price?
  4. Did my shoe wear contribute to my injury and if so, what changes do you suggest?
  5. Are my non-athletic shoes contributing to my problem?
  6. Do you think that I need surgery on this injury now or in the future?

Elite Sports Medicine Tips from Mike Ryan

  • Swelling Control – Your toes are located at the end of very long network of blood vessels, which are assisted by both contracting blood vessels and gravity.  Help control your swelling by minimizing your standing time, maximizing your elevation time, aggressive icing, wearing stiff shoes and being consistent with your physical therapy.
  • Gout? – I have pro football players fight me on this every year.  Sometimes Gout really is the source of the pain if the mechanism “just doesn’t fit”.  If your unsure, check with your doctor because Gout is more common than you think.  “If the Gout shoe fits, wear it.”
  • Joint Surface Status – Degenerative joint disease (DJD) in the big toe is common with high level “stop and go” athletes as are…(are you ready for this?)….women who commonly wear crowded, pointed-toed high heeled shoes. If your toe angles are changing and your toe ROM is decreasing, your joint surface is probably less then ideal.
  • Don’t Forget About Your Calves – Ankle ROM is an important factor related to toe pain.  Keeping your calves loose and limber will help.  Massage and stretching of the calves will immediately increase ankle ROM and decrease the need for excessive 1st MTP extension.  Flexible calves and loose ankle can reduce your turf toe pain by 25%!
  • Little Piggy’s #2, 3, 4 & 5 – Don’t forget about the little guys in the neighborhood.  Your other toes need to be stretched and cared for as well.  I see many bad looking toes and toenails in my business and I can tell you that your foot will function allot better with all five Little Piggy’s doing their part.
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