Definition:
Turf toe, or metatarsalphalangeal joint sprain, is an injury to the ligament in the ball of the foot, under the big toe.
The first metatarsalphalangeal joint is found at the junction of the medial (nearest the arch) long bone in the foot, and the first bone of the big toe. As well as the ligaments and muscles associated with the joint, there are two sesamoid bones embedded in a tendon that serve to increase the amount of power in the muscles.
The joint functions as a hinge, allowing the big toe to move up and down. When a step is taken, weight is transferred from the heel to the ball of the foot and finally to the big toe as the foot pushes off from the ground. The base of the big toe lifts during the push off movement. If the big toe remains flat on the ground instead of lifting, the joint can be extended beyond its normal range of motion. If this happens, the ligament that runs under the big toe and connects the bones can be stretched or torn. In severe cases, the capsule around the joint may also be injured. Another situation that can result in damage to the joint is compression of the toe, which can happen if the toe slides forward and strikes the end of the toe box in the shoe, an injury known as 'jamming'.
Turf toe is so-called because athletes playing on artificial turf commonly suffer from this injury. Artificial turf is a harder surface than grass, and wearing 'turf shoes' that grip the surface excessively increases the risk of jamming the big toe.
Martial arts practitioners and dancers are also at risk of turf toe, as the movements involved require repeated extension of the big toe.
Injuries usually happen suddenly, but turf toe can develop gradually.
The condition causes instability of the joint, the risk of dislocation of the big toe, and potential extra wear and tear on the joint that may lead to the early development of arthritis.
Causes:
Hyperextension of the big toe, either suddenly or repeatedly
Blunt trauma to the end of the big toe - 'jamming'
Wearing footwear with soles that are too flexible
Playing on hard surfaces, or artificial turf
Symptoms:
The initial injury may not always be noticeable, due to being distracted by the particular activity in which the athlete is involved. Symptoms may only begin to appear some time after the event. The primary symptom is pain at the base of the big toe, in the ball of the foot. There may be localized swelling, and the toe joint may be stiff. Occasionally there may be redness visible at the site of injury. Pain may subside with rest, only to reappear with the resumption of activity. A 'pop', either audible or felt, may be experienced at the moment of injury.
Diagnosis:
The diagnosis of turf toe is usually quite simple. Your doctor will take a full medical history, noting in particular any previous injuries to your foot. He or she will ask you about the specific circumstances of the injury, and also about your occupation, lifestyle, level of activity, and the types of footwear that you use.
Following the medical history, a physical examination of your foot will take place. The location of the pain will be noted, as will any swelling or stiffness. The big toe may be lifted, which will cause pain if the ligament has been sprained. The range of motion of the joint will be assessed and the foot will be compared with the unaffected foot.
X-rays may be taken to rule out a possible bone fracture or arthritis, and in certain circumstances an MRI (magnetic resonance imaging) or CT (computer tomography) scan may be necessary.
As with most joint injuries, the severity of the damage is graded, with stage 1 being relatively mild, and stage 4 the most severe.
Treatment:
It is very important to take the time necessary in order to let the ligament heal properly. If you try to return to your previous level of activity too soon you run the risk of damaging your joint again.
Initial treatment consists of resting the damaged ligament. Your doctor may recommend immobilizing the joint by taping the big toe to the next toe. Taping the toe will also provide a measure of relief from pain. You may also need to use crutches to avoid placing weight on the toe when walking, or you might be instructed to wear a walking boot.
During the acute phase, applying ice to the painful area will help to relieve swelling and discomfort. Crush ice in a bag and wrap the bag in a towel before placing on the skin. Keep the area iced for as long as is comfortable, and repeat several times a day.
Elevating the foot above the level of your heart whenever possible will reduce swelling, and you may take over-the-counter pain medication as needed and as directed by your doctor.
It may take three to four weeks for the pain to subside, and physiotherapy might be helpful to regain full range of motion of the toe joint, especially if the joint has been immobilized for some time.
Orthotics:
A turf toe T-strap is an inexpensive, readily available strap that is placed over the big toe to restrict the movement of the joint.
Dancer's pads are also inexpensive and easily obtained. They are inserts that can be applied directly to the skin, just behind the ball of the foot, in order to deflect weight away from the first metatarsalphalangeal joint. They can also be placed in the shoe, under the inner sole.
Turf toe plates are orthotics designed to limit the range of motion of the big toe. They are made of composite carbon graphite, which results in a very thin but stiff shoe insert. These are more expensive than straps of pads, but are very effective for the treatment of turf toe.
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