Turf Toe - So What Actually Is It?

You may read in the paper about your favorite AFL player being sidelined with Turf Toe and wonder, what is all the fuss about a big toe? Why does this player expect to be out for up to 10 weeks?

Turf Toe is a relatively common injury, particularly in football, which seemed to increase in prevalence in American footballers during the late 60's, when artificial turf became more common, hence the name.

In essence, it is an injury, or sprain, to the big toe joint and may include damage to the joint capsule (soft tissues around the joint), ligaments, cartilage and bone of the big toe joint ( 1st Metatarsophalangeal joint , or MTPJ).

The injury most commonly occurs when the 1st MTPJ is forced to bend upwards (dorsi flex) beyond it's normal range. Usually the ankle is flexed downward, the great toe bent up and another player may fall onto the back of the leg, forcing the big toe to jam further into dorsiflexion. The joint capsule can tear off the metatarsal head and compression can occur to the joint cartilage and the bone underneath.

Turf toe can vary in severity from minor grade 1 which may not require any time out of the season, to Grade 3 which may require weeks or months to recover. Many of those players who sustain a Grade 3 Turf Toe go onto long term 1 MTPJ joint pain, restricted movement, joint degeneration, osteoarthritis, and bunion (Hallux Abducto Valgus) deformity.

The joint can also be injured by force in the opposite direction, hyperflexion. If a player's ankle is pointing downwards and they are tackled from behind and fall forward, the 1 MTPJ may be forced into hyperflexion, and thus the structures on the top, rather than bottom of the joint will be injured.

How do you know if it is Turf Toe? Evaluation of how the injury occurred will usually lead to suspicion of this injury. Previous injury or pain in the 1 MTPJ may predispose to future injury. Pain, swelling and bruising around the 1 MTPJ are likely indicators, the extent of which often matches the extent of the injury. Ultrasound scan may assist to screen for soft tissue injury of the ligaments and capsule. X-rays should be taken to assess the boney structures for any fracture or displacement of bone. There are 2 small bones the size of a large pea under the 1 MTPJ, these can be injured as part of this injury. Ultimately, CT, or better still MRI will provide a more detailed evaluation of the extent of the injury, which may be critical in knowing when it is safe to return to activity.

The treatment follows the same as for all sprains including rest, ice, compression, elevation. For the first 48-72 hours. Anti inflammatory medication may be prescribed to reduce the pain and swelling. Taping may provide some restriction of motion to support the joint while healing. Stiffer soled shoes or a carbon fiber plate to prevent flexion at the forefoot of the shoe is required. A CAM boot will provide stiffness, a rocker sole to allow easier forward motion without stressing the joint, it will also enable the use of compression bandaging. As the great toe joint is required for push off in propulsion forward with running and at take off in jumping, a range of 50-60 degrees of dorsiflexion is considered necessary before returning to football.

If conservative care fails and there is persistent pain with push off, pivoting, running and jumping, then surgical intervention may be necessary to repair large tears of the capsule or ligaments, disruption of the sesamoids, or traumatic bunion formation. Surgery is rarely indicated however, repairing painful or unstable structures early may reduce the chance of earlier joint degeneration. Most footballers can return to activity 12 weeks after surgery if this is required. A rigid orthotic with stiff extension under the forefoot is usually necessary in order to support the joint and protect from further injury. Those who need to undergo complex reconstructive surgery of the 1 MTPJ may take 6-12 months before they are completely back to their pre injury functional level.

So, if your favorite AFL player is out for 10 weeks due to Turf Toe, expect they have had a more complex, possibly Grade 3 injury which may be quite disabling to even walk on.