Author: Chloe Wilson - BSc(Hons) Physiotherapy
Turf Toe is a painful condition where there is damage to the structures around the big toe caused by hyper-extension (when the toe bends back too far). The medical term is a metatarsophalangeal joint sprain.
It results in pain, swelling and stiffness around the big toe. It makes walking extremely uncomfortable and if left untreated, it can cause long-term problems.
Turf Toe most commonly affects athletes playing on rigid surfaces such as artificial turf e.g. American football, soccer and basketball players, but also affects other athletes including gymnasts, ballerinas and wrestlers.
Here we will look at the causes and symptoms of turf toe, how it is diagnosed, the best treatment options, the prognosis and recovery process and how to prevent it coming back or even developing in the first place.
Turf toe is essentially a sprain of the soft tissues surrounding the big toe. The joint between the big toe and the foot is known as the metatarsophalangeal joint, MTP for short.
Surrounding this joint are a number of soft tissues including ligaments, a joint capsule and the plantar plate, which are known collectively as the plantar complex.
If these structures are over-stretched, the fibres in the plantar complex can tear. The condition can be graded depending on how much damage there is to the plantar complex:
Grade 1: Mild over-stretching
Grade 2: Partial Tear
Grade 3: Complete tear/rupture
Turf toe develops when the big toe is bent too far back into hyperextension, most commonly when front of the foot is fixed to the ground, the heel is lifted and a force pushes through the toe.
If the big toe gets bent back too far, the ligaments and/or the joint capsule underneath the big toe get over stretched and can tear. This often happens when pushing off to sprint, if you are tackled from behind, or fall forwards, and the foot stays flat on the ground. Pain develops immediately and tends to get worse over the next 24-48 hours.
Turf toe can also develop gradually from repetitive, forced jamming through the big toe such as with quick pivoting, accelerating and jumping. When this is the case, the symptoms develop slowly and increase over time.
The symptoms vary depending on the severity of the injury:
Grade 1: Mild, localised pain with minimal swelling around the big toe
Grade 2: Moderate pain, swelling and bruising at the big toe and surrounding area
Grade 3: Severe pain, swelling and bruising around the joint and difficulty moving the big toe and walking
Pain can usually be felt immediately at the time of injury but may get worse over time as the swelling increases.
Playing on artificial surfaces rather than grass increases the chance of developing turf toe as the ground is harder and less flexible, putting more pressure through the toe.
A study in the American Journal of Sports Medicine looking at professional football players suffering from turf toe showed that eight three percent of them played on artificial surfaces.
Flexible foot wear can also increase the risk of developing the condition. Shoes that are flexible provide less support and allow the toe to hyperextend.
Your doctor can usually diagnose the condition from what you tell him about how the injury occurred, the sports you play and your footwear. He will examine your feet and may order an x-ray to check for signs of any damage to the bone, from either a fracture or arthritis.
The aim of treatment is to reduce pain and inflammation, and protect the joint from further damage. Turf toe treatment will depend on the severity of the injury. As a guide:
Grade 1 injuries: usually settle within a few days and are best treated with a combination of PRICE and strapping
Grade 2 injuries: may require the use of a walking boot to immobilise the joint for around one week, and then strapping. They usually take a couple of weeks to settle
Grade 3 injuries: may require several weeks of immobilisation with either a walking boot or a cast that holds the toe in slight flexion, followed by strapping and physical therapy to regain full range of movement
The acronym PRICE stands for Protect, Rest, Ice, Compression & elevation and is the best first-line treatment:
1) Protect: To protect the joint from further damage you should stop playing sport immediately
The joint will need time to recover so you will need to rest from
sports for a few weeks. You should avoid activities where you push
through your toe such as running, and you may need to use crutches
initially so you aren’t putting any weight through your foot at all when
walking. In severe cases, you may be given a cast or special walking
boot that stops the toe from moving altogether
4) Compression: You can help reduce further swelling by wearing a compression bandage like tubigrip
5) Elevation: keeping the foot raised higher than the level of your heart will help to reduce swelling
Other things that can help include:
1) Strapping: it can help to strap/tape the big toe to the second toe to limit movement and reduce stress on the big toe
2) Anti-inflammatory medication: your doctor may advise a non-steroidal anti-inflammatory (NSAID) such as ibuprofen to help relieve the inflammation
3) Physical Therapy: Mobilisations and exercises to stretch and strengthen the big toe will help prevent any long-term stiffness developing. This is particularly important with grade 3 injuries
4) Surgery: in severe cases, surgery may be required e.g. if there is ongoing pain and instability or a bone spur has formed which limits toe movement
The best way to prevent a metatarsophalangeal joint sprain is to wear stiff-soled shoes (e.g. containing a metal plate) that prevent the toe from bending too much.
You can also get special cushioned inserts that can help. Many athletes also tape their toes to keep them from bending back too far.
Playing on grass rather than artificial surfaces also helps reduce the risk as it is softer and absorbs shock better.
It usually takes three to four weeks to fully recover from turf toe, during which time complete rest from sport is required. It is really important to rest properly and not to return to sport too soon. If you keep aggravating the joint, the ligaments/capsule will not heal properly and recovery will take much longer.
Athletes who do not rest properly or address the cause of their injury are likely to develop long term problems such as arthritis and stiffness in their toe.
There are a number of other causes of toe pain. If turf toe isn't sounding quite like your problem, visit the toe pain section. Alternatively, if you want help working out what is causing your pain, visit the foot pain diagnosis section.