Turf toe is an injury to the underside of the big toe and joint at the base of the big toe. This joint, the first metatarsalphalangeal (MTP) joint, is commonly known as the "ball of the foot." Turf toe is specifically a sprain of the big toe joint. This injury may involve damage to ligaments, tendons, or bone separately or in combination.

This injury, often is a result of playing on artificial surfaces, was first documented in American football players in 1976. Turf toe was recognized as a common injury soon after the invention of AstroTurf in 1964. There are varying degrees of severity of the injury. While sometimes mild, which injured athletes can play through, turf toe is sometimes more serious and can be career-ending.

The amount of damage to the ligaments, tendons, bones, and surrounding tissues determines the severity of the injury. Though often referred to as a ligamentous injury or sprain of the MTP joint, the tendons may be strained and bones may be fractured. American football players such as Tom Brady and Deion Sanders and soccer great George Best are among the notable athletes to have suffered from this injury.

What is the anatomy of the big toe?

The first MTP joint is a hinge joint with sliding and rotational components. There is also a set of paired sesamoid bones underneath the base of the big toe. There are nine ligaments that span the joint, which is covered by a capsular ligamentous balloon-like structure that helps holds the synovial fluid that lubricates the joint. The primary movers or muscles that move the joint of the MTP are the flexor hallicis brevis. Flexor hallicus longus are the muscles that plantar flex or curl the big toe; contraction of the extensor hallicus longus and brevis lift the toe and important muscles in normal foot function.

The primary movements of the joint at the base of the big toe are flexion and extension. The toe is also capable of being moved closer to and away from the foot.

The Pain can start to come on gradually if you’ve hyperextended your toe over and over. You may also notice a popping sound when you first bend the toe too far and feel the pain.

Other symptoms include:

• Tenderness or sensitivity around the toe and nearby joint
• Swelling around the big toe and the joint
• not being able to move the toe around normally
• Stiffness in the toe joint

Turf toe is caused by bending the big toe too far back toward your foot. When this happens, the big toe area and the MTP joint, known as the plantar complex, can get injured. Areas that may be affected with turf toe include:

• Sesamoids: two small bones that help absorb weight on the front of your foot
• Flexor hallucis brevis: a tendon that helps the big toe when you put your weight on it when running or jumping
• Collateral ligaments: bands of tissue that connect your toe bones and keep the big toe from bending too much to either side of your foot
• Plantar plate: a structure that keeps your big toe from being bent too far up

Acute management of turf toe injuries includes rest, ice, compression, and elevation (RICE). Immobilization will allow the affected tissues to begin to heal without stressing the joint. Ice will help to manage the discomfort and reduce swelling, while compression will aid in stopping bleeding under the skin surface and prevent fluid accumulation in the joint and surrounding areas. Elevation will drain and prevent fluid from accumulating in the joint. Over-the-counter (OTC) medications can help to manage pain and inflammation from the injury. A physician may prescribe stronger medications for inflammation. Once the severity and cause of foot pain is determined, a course of corrective and rehabilitative actions can be started. Goals of treatment include pain management, increasing muscle strength and range of motion, maintaining cardiovascular conditioning, and re-establishing neuromuscular control. The following treatments and exercises are instituted at the appropriate phases of recovery.

• Qualified medical personnel may use electrical medical devices such as ultrasound, various forms of electrical stimulation, LED light therapy (laser), and/or manual therapies to reduce pain and increase circulation to the area to promote healing.
• Various stretching and strengthening exercises and techniques are gradually added.
  • Rehabilitation will likely include exercises to maintain and improve the range of motion (ROM) of the joint; strengthening exercises of the small muscles of the foot along with the calf, lower leg, and core muscles should be addressed; and cardiovascular conditioning often including stationary biking.
• Maintenance of fitness levels via modification of activity
  • Substitute for activities that aggravate the pain and soreness. Running causes the body to have repetitive impact with the ground. The use of bicycling, elliptical trainers, step machines, swimming, or ski machines minimize impact and allow the individual to maintain and improve his or her fitness without causing irritation to the injury.
• Biomechanical evaluation
  • The body will create various changes in the natural movement after an injury. A therapist can evaluate these biomechanical changes and help make the appropriate corrections. Prolonged, uncorrected biomechanical changes may lead to secondary mechanical changes that are painful and difficult to correct and may lead to a poor prognosis and possibly a slow or incomplete recovery from the symptoms.

Footwear often does not provide enough support for the person with turf toe. Corrective and OTC orthotics may also be of use. In-shoe supports (such as a steel insole), prophylactic athletic strapping or bracing, and a decreased range of motion may be needed. Occasionally, surgery may be necessary to repair or remove scar tissue or loose bodies that are in the joint.

What follow-up care is needed after foot pain is treated?

There may be follow-up tests, scans, or X-rays. A plan for a gradual return to play begins once the pain is reduced and muscle strength and flexibility are restored.

You can get this type of injury doing any activity that involves putting a lot of weight on your big toe. Professional athletes are most prone to turf toe because they’re constantly running, jumping, and generally putting weight on their feet for long periods.