Turf toe is a condition that describes injury to the plantar metatarsophalangeal-sesamoid complex of the great toe. The injury happens when the toe is forcibly bent up into hyperextension, such as when pushing off into a sprint and having the toe get stuck flat on the ground.
It is a relatively rare and debilitating condition, particularly seen in American footballers after the introduction of harder, artificial ‘turf’ surfaces. However, if unrecognized, it can lead to chronic problems including reduced push-off strength, persistent pain, progressive deformity and eventual joint degeneration.
Mechanism of injury
The majority of turf toe injuries occur as a result of contact with the playing surface or contact with another player. This essentially causes an axial load, on a hyperextended MTP joint, with fixed equinus at the ankle.
The load drives the hallux MTP joint into hyperextension, which leads to attenuation or disruption of the plantar capsular ligamentous complex supporting the joint. Sprains of the big toe joint became especially prevalent in American football players after artificial turf became more common on playing fields — hence, the term “turf toe.”
The plantar plate complex is designed to resist dorsiflexion of the first MTP joint, but these tissues can be torn, with the degree of damage dependent on the severity of injury and forces to the joint.
Depending on the position of the hallux at the time of injury, variations from the classic hyperextension injury can occur. If the force vector on the great toe at the time of impact has a medial component to it, greater injury occurs to the medial and plantar-medial ligamentous structures, as well as the tibial sesamoid complex.
As a result, there is a relative contracture of the lateral structures (lateral sesamoid complex and adductor hallucis), leading to a traumatic hallux valgus and bunion deformity.
Severity and Grades of Injury
These injuries can vary in severity — from stretching of the soft tissue to partial tearing, and even total dislocation of the MTP joint.
To help plan treatment for turf toe, your physical therapist grade the injuries from 1 to 3 — mild to severe.
Grade 1. The plantar complex has been stretched, causing pinpoint tenderness and slight swelling.
Grade 2. A partial tearing of the plantar complex causes more widespread tenderness, moderate swelling, and bruising. Movement of the toe is limited and painful.
Grade 3. The plantar complex is completely torn, causing severe tenderness, severe swelling, and bruising. It is difficult and painful to move the big toe.
Diagnosis
The diagnosis of your injury start with physical examination of your foot, your physical therapist will check for swelling, bruising, and the range of motion of your MTP joint. In addition, your story and the mechanism of your injury will help him to role out the differential diagnosis.
Other tests that helps confirm your diagnosis include:
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- X-rays. X-rays provide clear pictures of dense structures, like bone. Although the plantar Fascia complex is made up of different soft tissues, your therapist may ask for X-rays to make sure there are no other problems in your toe. These may include small bony pull-off fractures where the plantar complex attaches to the bones, and fractures or movement of the two small sesamoid bones.
- Magnetic resonance imaging (MRI) scans. MRI scans can create better images of soft tissue than X-rays and can show soft tissue and cartilage injuries. An MRI scan may be useful in Grade 2 and 3 injuries or when abnormalities are noted on the X-rays.
Acute Managment
The first aid method of treating musculoskeletal injuries has been taught through the pneumonic, R.I.C.E, (Rest, Ice, Compress, Elevate.) and P.R.I.CE (Protection,Rest,Ice,Compress,Elevate). However, we are going to show you the POLICE protocol. The POLICE Principle is a modern modified first aid method of treating musculoskeletal injuries. We are going to show you with a couple of steps how to protect your acute injury.
These steps are known as POLICE protocol as we could divide them into Protection, Optimal Loading, Rest, Ice, Compression, and Elevation. This procedure should be applied within the first 24 to 72 hours immediately after an injury.
Grade 1 injury usually allows return to activities and sport as soon as tolerated usually within (2 to 3 weeks). Nonsteroidal anti-inflammatory medications may relieve pain and swelling.
After the acute phase of injury, the great toe will benefit from taping in a slightly plantar-flexed position to limit motion and provide compression. Its recommended using the stiff-soled shoe with a turf toe plate insert or a custom orthotic with a Morton’s extension to limit hallux motion. If the injury is more medially based and there is concern of a traumatic hallux valgus, a toe separator between the hallux and second toes can provide further support.
- Grade 2. To keep the MTP joint immobilized, you may prescribe a walking boot to wear for up to a week, if needed. Afterwards, these injuries are managed with a taping regimen and the Grade 1 treatments and rehab exercises.In most cases, an athlete with a Grade 2 injury needs 3 to 14 days of rest before returning to play.
- Grade 3. These more severe injuries are most often treated with immobilization for several weeks. You may wear a walking boot or be put in a cast that keeps the big toe in a partially pointed down position. As the injury heals, treatment will gradually step down to Grade 2 and then to Grade 1.
- Physical therapy will be helpful and should begin as soon as symptoms allow. Specific exercises will help to stretch and strengthen the big toe. Early joint movement is essential for reducing or preventing joint stiffness.
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Chronic presentation
Turf toe injuries that are addressed early typically heal fairly well.
However, missed diagnoses can lead to unrestrained dorsiflexion of the injured toe. This can lead to longitudinal tears of the FHL tendon, hallux rigidus from repetitive joint impaction, progressive hallux valgus or varus deformity, or a cock-up toe with a hallux IP joint flexion contracture.
Our Approach
Dublin Sports Injury Clinic is a physical therapy clinic based in Pearse Street, Dublin 2. We have a holistic approach to our assessment and treatment. The initial assessment helps us to explore the cause of your injury and help you to get pain free shortly and stop any further injuries. We will design a customized training program for you to start with, and we will coach you and monitor your progress closely. We will prescribe relative rest or modified activities as required. Depending on the individual requirement, we apply manual therapy accompanied by stretching to restore tissue elasticity and reduce the strain in the muscle-tendon unit with joint motion.
Next step
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Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. You can contact us if you would like to book an appointment or get some advice from our therapist.