Turf Toe - What is it?

In 2000, Deion Sanders, one of the greatest multi sport athletes of all time was forced to retire from the NFL due to injury. This injury was not a knee or ankle injury, or even a back, head, or neck injury that have ended so many great careers. This injury was to his left great toe. He suffered through the 1999 season and opted for surgical intervention to repair the damage but was unable to overcome the complications and was forced to retire from an injury commonly known as "turf toe".

It may be a surprise to some, but according to injury reports turf toe injuries rank third after knee and ankle injuries among the most common injuries causing loss of practice and game time among NCAA athletes. Although knee and ankle injuries can be as much as five times more prevalent than turf toe, turf toe can account for a larger proportion of missed practices and games.

What is a turf toe? Turf toe is an umbrella term for injuries affecting the joint that connects the great toe to the forefoot. This joint is known as the Metatarsophalangeal (MTP) joint. For our purposes, turf toe will be defined as a sprain or rupture of the ligament and capsule that stabilizes the MTP joint. This ligament is generally sprained during weight bearing activity when the great toe is hyperextended (bent backward toward the knee) beyond its limitation. This mechanism of injury is relevant to sports because pushing off to run, cut, jump, and land on the foot all involve this hyperextension motion of the great toe. The purpose of this paper is to inform the reader of the history of turf toe, the mechanism of injury, signs and symptoms, diagnosis and treatment of turf toe.

Prior to the development of Astroturf and other artificial playing surfaces in the late 1960's, injuries to the MTP joint were relatively scarce. As more and more venues began to use artificial turf in the late 1960's and early 1970's, these injuries became more common. Medical professionals began to draw a correlation between MTP injuries and the use of artificial turf.

The original artificial surfaces consisted of a synthetic nylon surface with a thin underpad that served to cushion the impact between the synthetic surface and the concrete underneath. Over time, these underpads began to get compacted and venues were left with a virtual nylon-on-concrete surface. This surface had little shock absorption and as a result contributed to injuries such as severe bruises, stress fractures, and turf toe injuries.

As turf surfaces wore down, the athletes began to complain of poor traction with traditional cleated shoes and instead chose a soft soled tennis shoe type shoe. These soft soled shoes helped increase traction and speed, but the soft sole could not help decrease the great toe hyperextension like the traditional cleats had been able to do. These soft soled shoes left the MTP joint vulnerable to injury. The two predisposing factors for a turf toe injury are hard surfaces (natural and artificial) and soft soled shoes that do not protect the foot.

Turf toe injuries are most often seen in football, soccer, basketball, rugby, and wrestling, but they can occur in all sports where running, cutting, and jumping occur. These injuries were once felt to be benign, but subsequent research shows that significant disability can occur when the periarticular structures of the MTP are injured. As many as 50% of athletes with turf toe injuries may experience symptoms for up to five years following the injury.

The most common mechanism of injury is hyperextending the big toe while bearing the weight of the body. This occurs most often with football offensive linemen pushing off to block, athletes stopping and pushing off to cut, wrestlers sprawling to counter an opponent's shot, and landing on the foot with the big toe hyperextended. Most rigid cleated shoes can prevent toe hyperextension, but soft soled shoes used on hard natural fields and artificial surfaces do not provide the same injury prevention.

Once an athlete hyperextends the toe, they will complain of sharp pain, decreased toe range of motion, and toe stiffness. They may report hearing or feeling a "pop". The athlete may be tender over the medial aspect or plantar aspect of the toe where the great toe meets the forefoot (MTP joint). If the athlete is tender over the joint and has increased pain with toe extension, and x-ray should be obtained to rule out a fracture. The athlete should apply ice and not bear weight until a fracture is ruled out. If no fracture is present, an MRI may be obtained to gauge the extent of soft tissue and ligamentous/capsular injury.

Turf toe injuries range in severity from grades 1-3. A grade 1 sprain is characterized by localized tenderness, mild swelling, and mild pain with range of motion. A grade 2 sprain is characterized by widespread pain and tenderness, moderate swelling and possible bruising, and moderate pain with range of motion. A grade 3 sprain is usually a complete rupture and is characterized by severe tenderness and instability, moderate to severe swelling and bruising, and severe pain with range of motion.

Once a diagnosis is made, the athlete is usually placed in a rigid soled shoe or walking boot to prevent toe hyperextension and facilitate healing. Depending on the severity of injury, the athlete may be placed on crutches. Conservative treatment of the turf toe will consist of ice, anti-inflammatory medication, and possibly physical therapy. Acute physical therapy may consist of ice, heat, ultrasound, high volt galvanic stimulation, interferential stimulation, gentle range of motion activities, and progression to strengthening and functional/sport activities. The less severe the injury, the less time is required for healing. The most severe cases may take up to six to eight weeks before an athlete can return to play. In cases where severe pain, decreased range of motion, or MTP joint instability persist, surgery may be indicated to repair the torn ligament and capsule.

Once the athlete is cleared to return to athletic activity, there are several preventative measures that can be taken. The first one is taping the toe to prevent hyperextension. This method can be uncomfortable for the athlete and may not provide the desired support of the MTP joint. Secondly, the athlete may be referred to an Orthotist to be fitted with an orthotic with a posting under the head of the first metatarsal to allow the athlete more pain free dorsiflexion (toe hyperextension). The orthotic has shown to be effective and is more comfortable for the athlete. Perhaps the two most effective ways to prevent re-injury are for the athlete to place a steel spring insert or a rigid graphite or carbon fiber shoe insert into more rigid athletic shoes. The combination of a rigid insert and more rigid soled shoes provides the most MTP support and is the most reliable and comfortable way to prevent re-injury of a turf toe.

Once the athlete returns to competition, there are several complications that are possible. The most common is persistent pain with running and cutting. Lack of strength, with push off and joint stiffness (hallux rigitus) are also very common complications. More severe but more rare complications can be traumatic bunion formation, arthrofibrosis, loose bodies in the MTP joint, and cock up deformity. These complications may eventually require surgery to alleviate the condition.

Although turf toes can become serious and debilitating injuries, they generally have a good prognosis. With conservative and surgically treated cases most athletes can return to their preinjury level of function. If proper management of the injury and patient compliance is achieved, there is a very high likelihood of return to play without complications. To prove this point, Deion Sanders, who was forced into retirement in part from complications from a turf toe in 2000 is currently playing for the Baltimore Ravens in the NFL.

Things to Remember Regarding Turf Toe

1. Turf toe can occur on hard natural surfaces just as easily as on artificial surfaces.

2. Proper footwear is the key to preventing turf toe.

3. Proper diagnosis and management of the initial injury can lead to a smoother treatment and better outcome with fewer complications.

4. If you have any further questions, please consult your physician.

Article submitted by Rodney Ford, MS, ATC 



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