Turf Toe Injury (Metatarsophalangeal Joint Sprain)

What is Turf Toe?

Turf toe occurs when the big toe is forcefully bent upwards (called hyperextension), causing sprain in the ligaments of the metatarsophalangeal joint (MTP) or the main joint of the big toe.

MTP joints connect the first bones of the toes (called phalanges) and the long bones of the foot (called metatarsals).

MTP sprain of the big toe became rampant when artificial turf was used as a substitute for real grass in football fields because it is cheaper to maintain.

Artificial turf is stiffer than grass because there is no soil beneath it. Since it does not absorb moisture like soil in the grass, it gets slippery when it rains or snow.

Because artificial turf does not have much “give,” it makes it easier for athletes to slip and get injured when their foot slams the turf.

Although turf toe is common in football players, it can also occur to ballet dancers, basketball players, and wrestlers because they constantly use their feet on hard surfaces.

Turf toe injuries can be classified into three types:

• Mild or Grade I: The structures are stretched, resulting in localized pain and mild swelling.
• Moderate or Grade II: The structures are partially torn, resulting in bruising, moderate swelling, and limited and painful movement of the big toe.
• Severe or Grade III: The structures are completely torn, causing severe pain, extensive swelling, and bruising. There may be associated fractures and extreme limitation of movement.

Signs and Symptoms of Turf Toe

Individuals who have a turf toe injury may experience the following:

• Pain at the base of the big toe (at the MTP joint)
• Tenderness when touched
• Joint stiffness
• Swelling and bruising
• Limited movement of the big toe

When the injury is due to sudden and forceful movement, the pain can be felt instantly, which can worsen within 24 hours; a “popping” sound can also be noticed when the toe is bent at the time of injury.

If the injury is due to repeated stress over time, the pain can be felt gradually, worsening over time.

Cause of Turf Toe

An individual may obtain a turf toe injury when the forefoot is fixed on the ground, the heel is up, and the big toe is being pushed by a strong force causing it to hyperextend.

One example is when pushing with the foot to go on a sprint, and the toe remains flat on a firm surface instead of lifting to push off.

In turf toe injuries, several soft tissue structures in the MTP joint area, collectively called the plantar complex, can be injured. These structures are as followed:

• Sesamoid bones: these are two pea-shaped bones located at the base of the MTP joint that acts as a shock absorber and function like a pulley for the tendons.
• Flexor hallucis brevis tendon: the tendon located under the first metatarsal bone that provides strength and keeps the big toe stable during push-off when walking or running.
• Collateral ligaments: two bands of ligaments that prevent excessive side-to-side motions of the toe.
• Plantar plate: a thick and fibrous structure that prevents the big toe from bending upwards excessively.

Risk Factors

The factors that risk an individual from developing turf toe are as follows:

• The type of sports: Football athletes are particularly prone to having an MTP joint sprain. Basketball, soccer, hockey, and gymnastics can also predispose an individual to turf toe. Activities that cause forceful hyperextension and place a lot of pressure on the big toe, such as constant running and jumping, could result in this type of injury.
• The type of surface: Almost all turf toe injuries in football have occurred in artificial turfs. Surfaces that are hard and firm that provide little shock absorption could lead to turf toe.
• Soft-soled shoes: Flexible and light shoes that do not provide adequate support on the forefoot, which allows the big toe to bend too much.

Diagnosis

A trained medical physician will conduct a thorough physical examination and history taking to diagnose turf toe.

The doctor will ask about any previous injury to the affected foot, how the injury occurred, the individual’s occupation and participation in sports activities, and the usual type of shoes worn.

Physical Examination

• The doctor will look at the individual’s big toe and the foot as a whole and will compare it with the uninjured foot in terms of bruising, swelling, tenderness, and pain.
• The range of motion will also be checked, and the big toe may be moved upward, downward, and side-to-side to assess the integrity of the structures in the plantar complex.
• The gait pattern and how the injury affects walking will also be checked.

Imaging Tests

An X-ray may be ordered to determine if any of the sesamoid bones were fractured or if there is a fracture in the bones of the foot.

Aside from this, a magnetic resonance imaging (MRI) scan may be done to provide the doctor with a clear picture of the injured structures in the foot.

Treatment and Home Remedies

Mild or grade I turf toe can be managed at home through [R.I.C.E protocol] rest, ice, compression, elevation, and pain medication such as non-steroidal anti-inflammatory drugs (NSAIDs).

The individual may be asked to tape or strap the big toe to the second toe to immobilize it and avoid or lessen weight-bearing. For moderate or grade II injury, a cast or a special boot may be used instead to keep the big toe from moving for faster healing.

Grades I and II injuries usually need 2 to 3 weeks of immobilization for the pain to recede. For grade II, physical therapy intervention focusing on strengthening the muscles, improving flexibility and range of motion, and general body conditioning is recommended to prevent re-injury.

Severe or grade III turf toe injuries that affect athletic performance may require surgery. The type of surgery will depend on the severity, and which structure of the plantar complex was injured. Doctors usually prescribe surgery to those who present with the following:

• Severe tear of the plantar complex as a whole
• Sesamoid bone fracture
• Instability of MTP joint
• Cartilage damage
• Presence of new or worsening of a bunion

Turf toe injuries left untreated may lead to long-term foot problems such as weakness of toe muscles, difficulty in push-off, stiffness of the MTP joint, and bunion.

Prevention

Aside from the goal of returning to function after a turf toe injury, treatment intervention should also focus on preventing reinjury and avoiding injury to other parts of the foot.

One way to prevent turf toe is to wear shoes that can provide adequate support and appropriate for the sports or activity that will be participated in. Shoe inserts specially designed and recommended for the athlete by a doctor or a physical therapist may also be used.

An individual or athlete may also work with a physical therapist or a specialist in sports medicine to correct gait problems and provide training on proper body mechanics and correct posture when engaging in sports to lessen the chances for injury.

Sources

FootPhysians.com (American College of Foot and Ankle Surgeons): “Sesamoid Injuries in the Foot and Turf Toe.”

Intellihealth.com: “Foot Sprain.”

FamilyDoctor.org: “Foot Problems.”

American Academy of Podiatric Sports Medicine: “What Is ‘Turf Toe’ and How Should It Be treated?”