Turf toe refers to an injury that affects the ligaments around a person’s big toe. It is a common sports injury, particularly among football and soccer players who play on artificial turf.
Pushing forcefully off the big toe, as players do when they begin to run or jump, puts repeated stress on the joints around this area, which are known as the metatarsophalangeal (MTP) joints.
Dancers, gymnasts, and basketball players are also at risk of developing the condition. The repeated flexing of the big toe on hard surfaces during these activities can lead to the ligaments stretching or tearing.
According to a report in Clinics in Sports Medicine, most turf toe injuries are mild and do not require surgical treatment. In more severe cases, however, surgical management may be necessary.
Image credit: Stephen Kelly, 2018
The symptoms of turf toe include:
- pain that increases on extending the big toe or bearing weight upon it
- a “popping” feeling in the foot when the injury occurs
- swelling around the big toe
- instability and limited movement of the big toe
- stiffness around the big toe
These symptoms may be mild at first, but they can get worse if repetitive strain causes the injury to progress.
If the damage occurs as a result of a sudden movement, these symptoms may develop immediately and be severe.
Turf toe occurs when a person bends their big toe too far up toward the front of their foot. When the toe extends past its normal limits in this way, the ligaments can stretch or tear.
Some common causes of turf toe include:
- playing sports that involve frequent stopping and starting and changing direction
- wearing high heels
- walking in a way that puts excessive pressure on the big toe and the area surrounding it
- doing activities that involve putting weight on the big toe, especially when this is for extended periods
- wearing the wrong type of footwear when playing sports
According to UW Health, wearing footwear that grips the playing surface could put people at higher risk of developing this injury.
The big toe joint acts like a hinge, allowing a person to flex their toe and push up and off from it.
Behind the big toe joint, two round bones called the sesamoids sit within a tendon. The sesamoids absorb the weight of a person’s body as they stand on the ball of the foot. The bones also act as a pulley for the tendon, allowing for leverage when walking or running.
If the big toe does not push up off the ground but stays flat when someone begins to walk or run, the weight can cause it to strain as it bends backward beyond its normal range. The same damage occurs if the big toe bends back forcefully while the feet stay flat.
A sudden and forceful motion can cause turf toe to occur immediately. In some cases, however, it is the repetition of this movement over time that leads to the condition developing.
While turf toe injuries can be mild, a person should make an appointment with their doctor if they find it too painful to walk on the affected foot or if other physical activities, such as running and playing sports, become difficult.
It is also best to seek medical advice if turf toe develops over time and does not improve with rest or home treatment.
A person may require physical therapy or surgery if the injury is severe.
To diagnose turf toe, a doctor will need to know how the injury took place. If the symptoms have developed gradually, the doctor will ask for details on when they started and any activities that worsen them.
Other information that will aid a doctor with their diagnosis includes:
- the individual’s occupation
- the sports that they play
- their choice of footwear
- whether or not they have experienced any foot problems before
The doctor will carry out a physical examination of the foot. They may also suggest an X-ray or other imaging tests to rule out bone fractures, breaks, or other damage.
Treatment of turf toe will depend on how severe the injury is.
Doctors grade turf toe injuries from 1 to 3 according to the extent of the damage to the MTP joint, sesamoids, and surrounding tissues, ligaments, and tendons. This part of the foot is called the plantar complex.
- Grade 1: The plantar complex has stretched, leading to some tenderness and swelling.
- Grade 2: There is partial tearing of the plantar complex, resulting in tenderness, swelling, and bruising that is more widespread. The toe is painful, and its movement is restricted.
- Grade 3: The plantar complex has torn, leading to severe tenderness, swelling, and bruising. The toe is very painful and difficult to move.
Grade 1 treatment
Treatment of grade 1 turf toe usually involves protecting the toe and following the RICE method:
- Rest
- Ice
- Compression
- Elevation
Some doctors may recommend wearing stiff-soled shoes or using athletic tape to help keep the toe still and prevent the injury from worsening. After recovery, they may advise athletes to return to sports gradually, slowly increasing the duration of exercise over time.
Grade 2 treatment
Grade 2 turf toe may require wearing a special walking boot to help keep the plantar complex together while it heals. The person will usually wear a walking boot for up to a week before using the same treatment options as a grade 1 injury.
Grade 3 treatment
For grade 3 injuries, there must be no movement of the plantar complex for an extended period. A doctor may recommend wearing either a walking boot or a cast.
Surgical treatment of turf toe is rarely necessary. However, some grade 3 injuries may require it to repair the damaged tissues and restore the MTP joint motion. The type of surgery will depend on the nature of the injury.
People can take preventive measures to reduce the likelihood of a turf toe injury reoccurring. The steps they can take may depend on how the injury first developed.
Wearing shoes with better support can help stop the toe from bending excessively when a person pushes off from it.
People can also wear inserts in their shoes to help prevent the toe from bending too far backward.
A physical or sports therapist can work with an individual to correct any problems with the way they walk and run. This could help them develop different techniques for training or playing sports, which could help prevent frequent turf toe injuries.
Without recognition and treatment, turf toe injuries can affect a person’s ability to walk, run, and play sports. Early intervention leads to the successful treatment of most turf toe injuries. It is possible for athletes to recover from turf toe and return to the level of health and fitness they had before the injury.
If the injury is serious, surgical treatment may be necessary. Severe grade 3 turf toe can have a long-term impact.
A 2018 study evaluating the outcomes of surgery for grade 3 turf toe injuries in 15 competitive football players found that the players missed an average of 16.5 weeks of playing time. The authors concluded that positive clinical results were possible with surgical repair.
A person with a milder turf toe injury will not need surgery. Instead, pain management medication and physical therapy can help them recover full range of motion, flexibility, and strength in the toe.
Q:
Can you continue participating in sports with any form of turf toe? If so, are there any exercises that are best?
A:
A person can continue to participate in sports with a grade 1 injury to the big toe. The primary treatment for all forms of turf toe is rest, so using a shoe with a stiff sole will help relieve the tension on the metatarsophalangeal joint of the toe. With grade 2 and grade 3 injuries, participation in sports is not advisable because it could worsen the injury and make surgical intervention necessary.
Seeing a physical therapist is often helpful. A therapist can help maintain motion and allow the healing process to progress without damaging the joint further.
One exercise that might be beneficial is to stand with one foot in front of the other, turning in the toes on the front foot. Bend the front knee slightly and, while keeping the back foot flat on the floor, rock back and forth on the front foot from heel to ball.