Turf toe is a hyperextension injury to the metatarsophalangeal joint of the hallux, or the ball of the foot on the great toe. It is unfortunately a fairly common injury in football, but it can occur in other sports, such as basketball and soccer, as well. It is called turf toe because early studies on the injury showed that it was very common in NFL players, especially those playing on artificial turf.

Mechanism of injury

An athlete commonly suffers the injury when he absorbs an axial load to the back of his ankle when the ankle is plantarflexed (pointing toward the ground) with the toes dorsiflexed or extended (pointing toward the head). An example of this mechanism is a running back or an offensive lineman pushing off when another player falls onto the back of his ankle. The force to the back of the ankle with the great toe extended injures the capsule and ligaments underneath the metatarsophalangeal joint. The severity of the injury ranges from a sprain of this soft tissue to a partial or complete rupture of the capsule, ligaments, and other tissue supporting this joint.

Tests for turf toe

A physician examining a player who suffers an acute injury to this joint on the great toe will note swelling and tenderness on the bottom of the joint. The player will usually complain of pain pushing off in either a straightforward direction or cutting side to side. The physician likely will order x-rays to assess the injury. While this is a soft tissue injury, the x-rays can show the sesamoid bones (smaller bones under this joint) being pulled closer towards the heel, which can indicate a more severe injury. An MRI can also be useful in fully assessing the severity of the injury.

Turf toe
An athlete who has suffered a turf toe injury typically hurts on the bottom of the first metatarsophalangeal joint (white arrow), especially when trying to push off.

Treatment of turf toe injury

Initially treatment involves taking pressure off the joint, avoiding offending activities (including sports), and ice. Sports medicine physicians or foot and ankle specialists will usually place the athlete in a walking boot or even a cast. As pain and swelling improve, physical therapy can be useful to help restore range of motion to the joint and later functional ability of the foot and ankle with activities. Taping or putting a rigid insert into the athlete’s shoe can help to limit the amount of bending at this joint when he goes back to the sport as well. For severe cases of turf toe, where the capsule and ligaments on the bottom of this joint have been disrupted, especially in high-level athletes, surgical repair is occasionally attempted.

Return to sports

One of the difficulties of this injury is that the mechanism involved in causing the injury in the first place is often what the athlete needs to be able to do in the sport. For instance, a running back, wide receiver, or offensive lineman needs to be able to push off to excel at his position on the field. This requires putting force on the foot and ankle with the ankle plantarflexed and the great toe dorsiflexed. Limiting motion at this joint with tape or an insert might decrease the ability or strength with this activity, and pain with this motion can decrease the effectiveness of the player on the field as well. Therefore, this injury can take many weeks or even an entire season to heal. Many famous athletes have reportedly never gotten back to sports after suffering a severe case of turf toe.

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