Turf Toe

Overview: With research showing 4-6 players per college football team annually and 45% of NFL players over the life of their career (including 83% of injuries occurring on turf)(3,4,5), it’s clear that turf toe is a serious concern for high level football players.

Anatomy of Turf Toe: Similar to a jammed finger in the hand, turf toe is actually a joint sprain. The capsular ligaments on the plantar surface of the 1st Metatarsalphalangeal (MTP) joint, as well as the plantar plate (see above) give stability and structure to the 1st MTP joint, the hinge joint of the big toe. Medial and lateral collateral ligaments give the joint further stability to check varus and valgus forces.

Mechanism of Injury: As shown above, an injury to the plantar plate (bottom side of foot) may occur with excessive extension of the 1st toe, as well as an axial (downward) force through the toe. Turf toe can happen is isolation or in combination of these forces, as shown above(1,2,6,8). You can also appreciate in the picture how a flexible shoe would contribute to a higher incidence of injuries.

Severity of injury: Since the 1st MTP must withstand 40-60% of body weight during walking, and 2-3x body weight forces during running and cutting(7), it’s important to protect the injured tissue in the acute phase. Turf toe injuries are classified into 3 grades (with rough return to play timelines in parenthesis):

Grade I: stretching of the plantar structures with tenderness (return to play as tolerated by symptoms)
Grade II: Partial tearing of the structures with tenderness, swelling, and likely bruising (2+ weeks)
Grade III: full tear with frank dislocation of the 1st MTP joint as all plantar capsular restraint is severed. May also occur with associated injuries such as sesamoid fractures and bone bruises (10-16 weeks)(1,2).

Diagnosis: The clinician should suspect a potential injury with any complaints of swelling and/or pain in the region of the 1st MTP, especially when the athletes described an injury similar to the aforementioned mechanism of injury. Furthermore, a clinical exam positive for tenderness, bruising, and positive special tests such as a dorsal-plantar lachman (+ with pain and/or laxity) indicates pathology. The medial and lateral collateral ligaments can be tested with a valgus/varus stress test(1).

Left: Sesamoid bones are retracted back , Normal presentation on the Right(8)

X-Rays can also assist in diagnosing injury, as retraction of the sesamoid bones (as shown above) indicate plantar plate rupture(1,8). MRI, albeit expensive, will also accurately diagnose a turf toe injury.

Treatment: Due to the stress through the injured region with walking, it’s important to take it easy following a turf toe injury. Rest, Ice, Compression, and Elevation (RICE) will help expedite healing and reduce swelling. A walking boot may be used, and in my experience a carbon fiber plate can be helpful to reduce the stress to the injured ligaments. The toe may also be taped into a position which will not allow for excessive 1st MTP extension. as shown below.  With all these interventions the patient would be weight bearing as tolerated(1,8).

After initial RICE, physical therapy treatments consist of maximizing pain-free range of motion (ROM) and strength to the ankle and 1st MTP. Low impact exercise such as the stationary bike, stairmaster, and elliptical can be used early on to maintain cardiovascular endurance. As the patient progresses jogging, running, and cutting can be incorporated in addition to plyomerics and ballistic activities. Anderson and McCormick indicate that 50-60 degrees of pain-free 1st MTP passive extension should be obtained before a return to running(1).

In the case of severe injury, surgical intervention may be required. Good results have been shown post-operatively(6).

Conclusion: Despite occurring in a small anatomical region, turf toe is a severe injury due to the unique stresses on the region during ambulation and running. Proper diagnosis and management is critical to an efficient and safe return to play.

References:
1. Anderson RB, McCormick JJ. Turf Toe: Anatomy, Diagnosis, and Treatment. Sports Health. 2010;2: 487-494
2. Anderson RB, Shawen SB. Great-toe disorders. In: Porter DA, Schon LC, eds. Baxter’s The Foot and Ankle in Sport. 2nd ed. Philadelphia, PA: Elsevier Health Sciences; 2007:411-433
3. Bowers KD Jr, Martin RB. Turf-toe: a shoe-surface related football injury. Med Sci Sports. 1976;8(2):81-83.
4. Clanton TO, Butler JE, Eggert A. Injuries to the metatarsophalangeal joints in athletes. Foot Ankle. 1986;7(3):162-176.
5. Coker TP, Arnold JA, Weber DL. Traumatic lesions of the metatarsophalangeal joint of the great toe in athletes. J Ark Med Soc. 1978;74(8):309-317.
6. McCormick JJ, Anderson RB. Rehabilitation following turf toe injury and plantar plate repair. Clin Sports Med. 2010;29:313-323.
7. Rodeo SA, O’Brien S, Warren RF, et al. Turf-toe: an analysis of metatarsophalangeal joint sprains in professional football players. Am J Sports Med. 1990;18(3):280-285.
8. Roser, S E. Foot and Ankle Injuries in the Athlete. St Lukes Sports Medicine Conference. March 17, 2012.

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