Working as an orthopedic physical therapist, I have seen many foot injures. Turf toe is no exception. We have many athletes and active people that are treated at our clinic, and turf toe is more common in this population. Turf toe is really just a sprain of the structures under the big toe. Depending on the severity of the sprain, it can be a lengthy rehab. However, most recover well, and in a relatively, short time frame. Read on to learn more about turf toe and turf toe treatment. Let’s start with anatomy!
Tell me about the big toe
The hallux is the medical term for the big toe. The big toe is made up of two joints. The first one is called the metatarsophalangeal joint (MTP). This is the larger of the two joints and is where the first metatarsal (long bone of the foot) meets the first phalanx (toe bone). The second joint of the big toe is the proximal interphalangeal joint (PIP). This joint is smaller and it is where the two bones (phalanges) of the big toe meet.
The primary motions of the MTP joint of the big toe are flexion and extension. Flexion is when the toe curls down and extension is when the toe bends back. Normal range of motion of MTP flexion is 50 degrees and 90 degrees for extension. The big toe has some side to side motion but it is very small.
The big toe is very important in daily life. While walking the big toe bears twice the load of the other toes and plays a key role in forward propulsion of the body. The big toe also is a vital component in balance.
What is a joint capsule?
All joints are surrounded by a joint capsule. A joint capsule is a fluid-filled fibrous structure that forms a seal around the joints of the body. The capsule provides stability, nutrition, lubrication, and assists with proprioception. Proprioception is being aware of the position of the joint. For example, knowing if your big toe is flexed or extended without having to look at it.
The MTP of the big toe has a joint capsule that has extra support at the bottom of the joint. This is called the plantar plate. The plantar plate is composed of ligaments, muscle tendons, and small bones called sesamoids. These structures play a major role in the stability of the MTP joint.
What is turf toe?
Turf toe is a forceful hyperextension of the big toe. It causes the plantar plate to stretch or tear. It is called turf toe because the injury occurs more frequently when playing on artificial turf. The player’s shoe is more likely to stick to the artificial turf when the player tries to stop quickly. The player’s body weight would move forward while the foot stayed planted. The toe would be forcefully positioned into hyperextension. However, one does not need to be playing on artificial turf to sustain a turf toe injury. It refers to any hyperextension injury of the MTP of the big toe.
Grades of turf toe
Not all turf toe injuries are the same. There are different grades to indicate the severity of the injury.
- Grade 1
- Mild swelling
- Stretching of the plantar plate
- Slight bruising might be present
- Can walk with little to no pain
- 1-2 week recovery time
- Grade 2
- Moderate swelling
- Partial tear of the plantar plate
- Big toe mobility restricted because of pain
- Pain with walking
- 4-6 week recovery time
- Grade 3
- Significant swelling and bruising
- Complete tear of plantar plate
- Weakness in big toe flexion
- Difficulty walking because of pain
- Instability of the MTP
- Could lead to subluxation (partial dislocation) or dislocation of the joint
- 6-12 month recovery time
Symptoms of turf toe
There are several symptoms associated with turf toe. These include:
- Pain at the MTP joint of the big toe
- Swelling and bruising around the MTP
- Might feel a “pop” at the MTP joint during the injury
- Pain with walking, standing, or running
- Unable or very difficult to stand on toes
- Tenderness at the MTP joint
- Cramping in arch of foot
Who gets turf toe?
Turf toe can happen during many sports, but it most often occurs on artificial turf. Therefore, it is more prevalent in football and soccer. It is often a sudden, acute injury. However, it can be a chronic condition that is caused by frequent running and jumping in overly flexible shoes.
Who should I see?
- Physical therapy – Physical therapy can help decrease the pain and swelling with techniques including manual therapy, taping, and dry needling. PT can evaluate and address abnormal joint mobility, muscle weakness, and flexibility. Your PT will also assess your gait, shoe wear, training schedule, and technique to help return to sport and prevent the problem from happening again.
- Orthopedic physician – An orthopedist that specializes in the foot and ankle will be necessary especially if the injury is a grade 2 or 3. Most grade 3 injuries do not need surgery but would need to be in CAM boot or walking cast for 4-6 weeks. Surgery is an option if the toe does not respond to conservative treatment.
What can I do at home?
- Relative rest – Resting the area to decrease further pain and damage from occurring is one of the best ways to decrease pain and inflammation at the toe. Basically, stay away from the activities that are causing pain and putting stress on the MTP joint. Swimming and biking would be good alternative activities that do not put much stress through the ankle and foot.
- Ice – Ice can help decrease the pain and swelling at the toe. Ice the painful area for 15 to 20 minutes at a time. I would recommend using an ice pack several times per day if the pain is constant or preventing you from participating in an activity. Ice immediately after activity.
- Stretching – Stretching the calf muscles can help improve the motion at the ankle. This includes stretching the gastrocnemius and the soleus. See the video below.
- Strengthening the foot and ankle – It is important to strengthen the muscles of the foot and ankle in order to be able to safely return to all activities. These exercises are to be started once the swelling and pain has subsided. For grade 3 injuries, make sure you are under the guidance of a physical therapist to help determine when to start strengthening exercises. Using resistance bands can increase strength and difficulty of the exercises. See the videos below.
- Balance – Working on balance is important in strengthening the foot and ankle but also improving proprioception. Improving proprioception will help improve the overall stability of the ankle. See the video below.
- Taping – Taping can help decrease the movement of the big toe. This can really help right after the injury. Taping is also helpful when you are returning to your sport or activity. It can give the toe a little extra protection and support. You can buy pre-cut strips of turf toe tape or you can use kinesiology tape and tape it yourself. See the video below for instructions on how to tape turf toe.
- Carbon fiber insoles – These insoles are very rigid. They can off-load the big toe and decrease the amount it needs to move while walking. Using carbon fiber insoles can help decrease the pain when walking while allowing the toe heal.
- Shoe wear – Changing shoe wear to stiff-soled shoes while the toe is healing will help limit the motion of the MTP. This will help the healing process and improve your ability to walk with less pain. A rocker bottom or stiff soled shoe can help decrease the amount of extension needed from the big toe. Your PT can also evaluate your foot and help determine appropriate shoe wear.
In review
- The big toe is made up of two joints.
- The first one is called the metatarsophalangeal joint (MTP).
- The primary motions of the MTP joint of the big toe are flexion and extension.
- The MTP of the big toe has a joint capsule that has extra support at the bottom of the joint.
- This is called the plantar plate.
- Turf toe is a forceful hyperextension of the big toe.
- It causes the plantar plate to stretch or tear.
- There are different grades to indicate the severity of the injury.
- Symptoms include pain and swelling at the MTP joint of the big toe.
- Physical therapy can help with recovery and return to sport.
- An orthopedist would be needed for higher grade injuries.
- There are things that you can do.
- Relative rest
- Ice
- Stretching
- Strengthening the foot
- Balance
- Taping
- Carbon fiber insoles
- Shoe wear
As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.
Additional resources
https://www.physio-pedia.com/Turf_toe
https://www.choosept.com/guide/physical-therapy-guide-turf-toe