Ankle sprains are a fairly common and well-known injury within society. Yourself, or someone you know has probably suffered an ankle sprain at some point in their life. For sports people it could very well be a right of passage and a great story about that one time you played the rest of the game even though you sprained your ankle. Another joint that can be sprained, and which sounds like would have a less heroic story, is your big toe. A sprain to your big toe is commonly referred to as turf toe. The name originates from the increasing occurrence rates of this injury in NFL players when their playing fields were converted to artificial turf. Turf toe affects more than just NFL players though.
There are 2 joints that make up the big toe. The main joint is the metatarsophalangeal (MTP) joint. Surrounding the MTP joint are certain structures that provide stability for the joint. These structures are collectively known as the plantar complex. Turf toe refers to any injury of the MTP joint or plantar complex.
Grading of Injury
- Grade 1 – stretching of the plantar complex. Pain on palpation and mild swelling are observed.
- Grade 2 – partial tearing of the plantar complex. Pain is more widespread, bruising may present, swelling more severe, and toe range of motion is decreased
- Grade 3 – complete tear of the plantar complex. Pain, swelling, and bruising are all severe. Big toe movement is difficult.
Turf toe occurs when the big toe is forced into hyperextension. This commonly happens when the front of the foot is fixed to the ground, the heel is raised, and there is a forceful push off through the big toe.
Risk factors include artificial surfaces, as they provide a harder less shock-absorbent surface, and shoes that are more flexible, as they reduce foot stability. Athletes that have a high incidence of turf toe include American football players, dancers, gymnasts, and basketball players.
A detailed history regarding how and where the injury occurred is an important step in the diagnosis of turf toe. The physical examination should involve observation and palpation around the area to check for tenderness, swelling, and bruising. Range of motion and strength testing of the toe and foot should be completed as able. Further investigations such as x-ray or MRI may be beneficial in looking for fractures or soft tissue involvement.
- Grade 1 – First line of treatment should be rest, ice, compression, and elevation (RICE protocol) to help manage pain and swelling. Taping of the toe or wearing stiff shoes will help protect the toe by providing more stability and reduce irritation. Your physiotherapist can advise you on this.
- Grade 2 – To allow for healing of the partially torn fibres of the plantar complex the MTP joint needs to be immobilised. A CAM boot may be prescribed to achieve this and will make weightbearing activities more comfortable. This is worn for approximately 1 week but can be longer if there are high amounts of pain. Taping can then replace the CAM boot once there is adequate healing.
- Grade 3 – Follows the same principles as management for Grade 1 or 2 injuries. However, the period of immobilisation in a CAM boot is much longer to ensure healing of the plantar complex.
The role of physiotherapy is to restore flexibility and progressively strengthen the toe and foot. This is particularly important after a period of immobilisation to help restore foot stability. Physiotherapy treatment can include soft tissue therapy, exercise prescription, and joint mobilisation to prevent excessive stiffness. Your physiotherapist will also be able to implement a plan with you for a graded return to activity or sport as able.
Surgery is often considered if conservative management fails but this is not common. The type of surgery recommended will be determined by your specific injury and which tissues are affected. After surgery there will be a period of immobilisation. Following this physiotherapy will assist in restoring flexibility and strength to the toe and foot. This will allow for a graded return to activity.
If managed appropriately and early, turf toe injuries generally heal well and have a positive outcome. Majority of individuals return to their desired sport or activity. In a few cases persistent stiff and pain can remain, but this is not common.