Turf Toe

What is Turf Toe?

Turf toe is also sometimes known as "Metatarsalgia" and "Metatarsophalangeal Joint Sprain". The Metatarsophalangeal Joint is the joint that connects the base of the big toe to the rest of the foot. The injury can range from simple sprains to dislocations of the joint.

Turf toe is a painful injury that can sideline a football player and happens when you bend your big toe too far. When this happens, tendons and ligaments in the big toe joint start to tear and this can be quite debilitating for a short while. Typically, the injury heals in a fairly short period with adequate rest and ice; however there are occasions where turf toe does not heal and as such surgery is required.

What & Where is the Metatarsophalangeal Joint?

The big toe consists of two joints. The largest of the two is the metatarsophalangeal joint (MTP), where the first long bone of the foot (metatarsal) descends from the foot arch to meet the first bone of the toe. In turf toe, the MTP joint is injured. The MTP joint is the large joint closest to the base of the big toe.

MTP = Metatarsophalangeal Joint

What Significant Structures Surround the MTP Joint?

The MTP is a very important joint that handles large forces when the heel is raised off the ground. The following structures assist in helping prevent dislocation of the MTP joint:

• Plantar plate. This thick, fibrous tissue under the MTP joint prevents the big toe from bending too far upward (dorsiflexion).
• Collateral ligaments. Located on each side of the big toe, collateral ligaments connect the phalanx bone to the metatarsal and prevent the toe from going too far side to side. It is the collateral ligaments that are commonly strained in a traditional turf toe injury (notwithstanding that the tendons and plantar plate can also sustain injury).
• Flexor hallucis brevis. This tendon runs under the first metatarsal bone and attaches to the proximal phalanx. It provides strength and stability to the big toe during push-off motions.
• Sesamoids. These two small bones are enveloped in the flexor hallucis tendon and help it to move more easily. In addition, the sesamoids provide stability to the MTP joint by helping to bear weight placed on the forefoot.

What Are Symptoms of Turf Toe?

Turf Toe can also happen over time due to repetitive upward stresses on the big toe; a good example would be a ballet dancer since they spend a lot of times jumping and running on their toes. In such cases, symptoms will be hardly noticeable to start with but worsen over time. Regardless of how you got it, common symptoms of turf toe are as follows:

Pain & Tenderness in the Big Toe

The pain can be at a constant level or in some cases you may not feel much pain unless you press on the toe or attempt to put your weight on it.

Swelling & Bruising in the Big Toe

If you have recently experienced turf toe, the base portion of the big toe will likely be swollen. You might also see bruising in the area that can encompass the swollen toe and extend upward toward the top of the foot.

Loss of Range of Motion in the Big Toe

If you are suffering from a severe case of turf toe, you may not be able to move the big toe or bend it up or down. You may also feel like the foot is weak and have trouble walking without a limp.

Loose or Stiff Feeling in the Big Toe Joint (the metatarsophalangeal joint)

There may be a feeling of tightness in the joint at the base of the big toe, OR there may be a feeling of looseness and/or instability. It is possible that the joint may have popped out of place, which is a good reason indeed to go get a doctor to look over it.

Who Is At Risk of Getting Turf Toe?

People That Play Sports on Artificial Surfaces (fake grass or "astroturf" for example)

Most instances of turf toe occur when playing sports - more particularly, when playing sports on artificial surfaces like fake grass. When the foot grips the field surface and the body weight is largely on the toe, an artificial surface is less likely than natural grass to let the shoe slip backward to relieve pressure on the big toe. In some instances this bends the big toe joint (the metatarsophalangeal joint) upwards to the point where the ligaments beneath the toe get pulled too far and start to tear.

People That Wear Very Light, Flexible Footwear

The sole of a shoe will take some pressure off of the bottom ligaments of the big toe, as shoe soles are at least somewhat rigid - helping keep the toe area from pushing up too far. Modern shoes are at times, designed to be very light and offer much less rigidity in the sole. For people that wear light shoes with little sole support, there is less rigidity from toe to heel on the base of the foot; as such, they are at increased risk of bending the big toe too far upward. These people are more likely to get turf toe when compared to a person that is wearing shoes with a more rigid sole.[1]

How Long Does It Take To Heal From Turf Toe?

This is very much dependent on the severity of the injury. For grade 1 sprains, full recovery should be achieved in a matter of weeks, whereas a grade 3 sprain could take 6 months or more. Note that surgery may also be required for the most severe cases (ie. surgery will typically be recommended for tendon ruptures, major ligament tears, bone fractures) .[3]

What Causes Turf Toe?

If the pain persists or becomes severe as time goes on, surgery may be necessary to repair torn ligaments and stabilize your big toe joint.

Turf Toe Injury Severity

Much like a sprain or strain, there are 3 grades of severity of turf toe:

• Grade 1. The plantar complex has been stretched, causing pinpoint tenderness and slight swelling.[2]
• Grade 2. A partial tearing of the plantar complex causes more widespread tenderness, moderate swelling, and bruising. Movement of the toe is limited and painful.[2]
• Grade 3. The plantar complex is completely torn, causing severe tenderness, severe swelling, and bruising. It is difficult and painful to move the big toe.[2]

Can I Expect to Fully Recover From a Turf Toe Injury?

"In over 85% of sportspersons a return to full sporting activity can be expected. Some intermittent symptoms may persist however including minor toe stiffness and swelling."[3]

Scar Tissue & Fibrotic Adhesions

All connective tissue is living tissue; tissue requires a blood supply and is continually in a state of regeneration. Any and all connective tissue has the potential for injury and inflammation. Injuries can be small such as in the case of a strain, or injuries can be large tears or even avulsions (complete tearing). Once an injury is experienced, the area will experience both inflammation and the growth of scar tissue (otherwise known as adhesions).

The occurrence of scar tissue is a regular part of life. Scar tissue forms as part of the progression after injury occurs. Scar tissue essentially 'fills in the gaps' after a cut, tear or wound presents itself in the body. Scar tissue is composed of the protein, collagen; it is widely known in the medical community that scar tissue is weaker and less flexible than original tissue.

• Normal/original connective tissue is made up of collagen, but this collagen is aligned in a specific direction with each strand in alignment. This results in the connective tissue having a strong tensile strength while also having excellent flexibility and extensibility.
• Scar tissue is made up of a 'criss cross/ random' formation of collagen and attaches to everything in the area. You can likely imagine the result of a patch of scar tissue; the effect is similar to pouring extremely sticky glue in your hair. It interrupts everything and is disruptive to the function of the connective tissue. The caveat is that the scar tissue does its job - it binds tears together. You definitely want the tear to heal, but it is important to ensure the scar tissue goes away despite the fact that it does not go away easily.
• After scar tissue forms, although the wound or cut is now closed (and less prone to infection), the area of tissue itself is inferior in functionality to what it replaced.

Continuous re-injury and build-up of scar tissue makes it more likely that you will wind up with chronic pain, reduced Range of Motion or even arthritis (permanent damage).

Heal Quickly to Minimize Scar Tissue Growth & Reduce Re-Injury Risk

For tissue injuries, it is important to heal quickly and completely; this will help minimize the build up of scar tissue. If you don't, your tissue injury may be the start of a long term chronic injury resulting in a loss of Range of Motion and joint atrophy.

The human body will use scar tissue as a temporary solution and will try to build the scar tissue as fast as possible to heal tears in soft tissue (muscles, tendons). Scar tissue can form fast to bring together the edges of a tear, but working fast doesn't mean that the job's done right. When scar tissue forms it doesn't come together as neatly as regular (healthy) tendon/ligament tissue would. Scar tissue fibers will lay down over top of your tear in a cluttered, messy and jumbled up way.

This is how scar tissue works - it is messy and inelastic. The scar tissue that forms in your soft tissue will be unorganized and won't line up properly with the healthy tissue surrounding the tear. This scar tissue will attach to everything in and around the tear including the surrounding healthy tissue as well. This results in a long-term fusing together of everything the scar tissue touches, reducing your ability to move and making the injury even more painful!