Turf Toe: Causes, Symptoms and Treatments

Turf toe is a sprain-type problem that occurs at the level of the big toe. It's not usually serious, but it's very annoying for athletes.
Turf Toe: Causes, Symptoms and Treatments

Last update: 31 July, 2021

“Turf toe” is a term that refers to a sprain (strain) of the big toe joint. The correct medical term is hyperextension of the first metatarsophalangeal (MTF) joint, as excessive upward bending of the hallux joint complex is what usually causes it.

This physiotherapeutic problem is very common in soccer players. Sources we will explore later estimate 5.4 turf toe events per sports season in some teams, which translates to 0.062 patients per 1000 active athletes. Specialists estimate that those affected lose an average of 10.1 usable days of sport during recovery.

If we turn our attention to professional soccer players, we’ll find that 45% of them have suffered from turf toe during their sporting career. If you want to know more about this problem and how to deal with it effectively, you’re in the right place.

The anatomy of the foot and turf toe

Before we jump right into the injury that concerns us here, we must explore the physiology of the parts involved. The human foot and ankle are true works of art of biomechanics, having a total of 33 joints, 26 bones and over 100 ligaments, tendons and muscle tissues.

In this case, we turn our attention to the first metatarsophalangeal joint. This is integrated into the functional and anatomical unit of the first radius of the foot, which constitutes 75% of the plantar arch. This structure is key, as its range of motion in the plane conditions the functionality of the entire foot.

The first metatarsal (that of the big toe) and the proximal phalanx form the metatarsophalangeal joint which is damaged in turf toe. This joint performs the impulsion in the final phase of gait, so it isn’t surprising that the problem is evident in athletes who suffer from it.

What are the symptoms of turf toe?

Orthoinfo.org shows us the typical symptoms of turf toe. As we’ve said, it’s a lesion in the plantar complex, so the most common signs are pain when walking, intolerance to palpation of the affected area and localized swelling.

Anyway, we should note that there are several degrees of the injury, which condition the severity. These are the following:

  • I: this is a sprain in the plantar complex of the foot. It produces localized sensitivity and a slight inflammation.
  • II: there’s a partial tear in the plantar complex. This causes more general tenderness and pain, moderate swelling and bruising. Movement of the foot is painful and limited.
  • III: a complete tear in the plantar complex. The injury is very painful, swollen and there’s considerable bruising. At this point, movement of the big toe is almost impossible.

Turf toe can develop sharply or gradually, depending on the type of trauma. If the damage occurs gradually, the patient will worsen over time, until the condition makes physical activity impossible.

Men playing soccer
Sports played on grass courts are at greater risk of developing the injury.

Main causes of turf toe

As indicated by the EFORT Open Reviews portal, physical activities are the main cause of turf toe. In American soccer players, 45% of interviewed players reported having suffered from the problem during their professional career. The incidence is estimated at 0.062 cases per 1000 athletes exposed to the risk.

Eighty-five percent of these injuries occur on artificial turf. This is much harder than normal turf, so the resistance provided by the turf probably plays an important role in the injury.

Athletes playing other sports also suffer the effects of this medical condition. For example, it’s estimated that 0.4% of rugby players suffer turf toe each season. This entity accounts for 11% of all foot injuries in this demanding physical activity.

Mechanism of injury

Most injuries are caused by repeated contact with the playing surface or by a direct blow against another player. The events carry an axial load on the overextended first metatarsophalangeal joint.

The force and the atypical position of the structure result in ligamentous injuries of varying severity.

Beyond tendon damage, it can also affect the sesamoid bones. These bony structures are injured or even rupture, although there are usually previous injuries or problems that cause this damage.

Risk factors

As we’ve mentioned, playing a demanding sport on artificial turf is a clear predisposing factor. In any case, beyond the terrain, any blow against another player (or solid element) can cause the aforementioned strain.

Below is a list of the sports considered the riskiest as far as this injury is concerned. As indicated by the Western New York Urology Associates website, these are the following:

  • American soccer or traditional soccer
  • Rugby
  • Basketball
  • Track and field athletics: running, jumping, hurdles
  • Dancing

Diagnostic tests

Doctors may suspect a sprain of the big toe joint with a physical examination. However, we need an X-ray of the plantar bone structure, as indicated by the Stat Pearls portal. Bilateral radiographs of the foot are also important to assess for sesamoid damage.

Magnetic resonance imaging is very useful in quantifying damage to the sole of the foot. Clinical evidence will depend on the extent of the injury and the patient’s condition.

Treatment of turf toe

Regardless of the degree of injury, the first step is always to apply the RICE criteria: rest, ice, compression, elevation. This methodology is based on the following principles:

  • Keep the foot free of stress and use it as little as possible: The average recovery time in athletes is about 10 days, always in the case of a grade I injury. Grade II injuries take 4 to 6 weeks to recover, while grade III injuries don’t begin the process until a month and a half later.
  • Ice: It’s always advisable to place ice compresses for 20 minutes, 3 or 4 times a day, on the affected area.
  • Compression: To avoid inflammation and pain, we must use an elastic compression bandage.
  • Elevation: If the patient is able, it’s best to rest with your leg above the level of the heart.

Even grade III injuries usually respond to conservative treatment, although recovery time is very slow. If the patient doesn’t improve, they may need a surgical procedure: an incision in the sole of the foot.

Bandaged foot
A compressive bandage over the entire foot, in addition to immobilization with rest, is the approach of choice for the injury.

Recovery of the turf toe

As mentioned above, recovery time varies from 10 days to several months, depending on the degree of damage to the sole.

In addition, in the most severe cases, the patient may never recover the initial osteoarticular structure. This results in an arthritic limb or stiffness in the big toe.

Turf toe isn’t serious

It’s essential to inform athletes about the possible risks of practicing demanding exercises, especially if the activity is performed on a solid surface or, in other cases, if there’s a high chance of collision.

We can prevent this type of injury, in part by performing exercises at the plantar level that help the structures involved to gain resistance. Footwear should also be appropriate and as soft as possible, in order to protect the sole of the foot from injury.

In any case, we mustn’t forget that these are normal and expected events. Fortunately, they’re hardly ever a serious problem. With a few days of rest, ice and physiotherapeutic care, there’s improvement after a couple of weeks.

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