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Injury/Pain

How to Come Back from Turf Toe

Overview

Turf toe is a simple reference to what can be a complicated injury. There are tendons, ligaments, joint surfaces, nerves, and bones in the affected area. When the big toe is sprained, which is what usually happens in turf toe, any combination of those structures can be damaged.

How Turf Toe Happens

The most common cause of turf toe is hyperextension (bending backward) of the joint, but an injury to the joint surface may be caused by placing an unusually heavy load on the ball of the foot and by bending the toe excessively forward.

A scenario in which turf toe could happen is a football player who falls forward while the big toe is planted flat against the ground or artificial turf. Another example: A wide receiver runs downfield to catch a pass. He cuts sharply to his right and reaches up to make a reception, but his cleats are locked into a seam of artificial turf or into a divot on natural turf. His big toe is forcefully driven into the ground and is extended beyond its normal range of motion. The capsule and ligaments under the big toe are torn as it is stretched upward. The same thing can happen to beach volleyball players. Then it’s called—what else?—sand toe.

Some experts say that any association with synthetic surfaces is coincidental and that toes can be sprained on grass, wood, or artificial turf. However, there is some evidence that the combination of artificial surfaces and very flexible shoes can produce higher rates of turf toe. Flexible, lightweight shoes may not provide enough protection for the big toe joint.

Turf Toe by the Numbers

3rd
Rank of turf toe as a cause of loss of playing time among college athletes (behind knee and ankle injuries).

50
Percentage of athletes who will have symptoms of turf toe five years after the injury.

85
Percentage of cases among football players in which turf toe was caused by hyperextension, or bending the big toe backward (American Journal of Sports Medicine).

Who’s At Risk for Turf Toe?

This injury is more likely to be associated with the activity rather than with the surface, and football players (especially linemen) head the high risk group. A study conducted among football players at the University of Arkansas reported six cases during one academic year. At Rice University, there was an average of four-and-a-half cases per year among all athletes over a 14-year period. Turf toe can happen in any sport, but basketball, soccer, volleyball, and rugby include more of the movements that might result in the injury. Athletes who have sustained a turf toe injury are more susceptible to similar injuries in the future.

Symptoms

  • Grade 1: Mild sprain, localized pain, little swelling or bruising
  • Grade 2: Possible popping sound when the injury occurs; tenderness, moderate swelling, bruising, and loss of motion; partial tear of the capsule and ligaments; no injury to the joint surface
  • Grade 3: Significant swelling, bruising, and loss of motion; complete tear of the capsule and ligaments; possible dislocation

Initial Treatment

  • Rest (immobilization)
  • Ice applications for 15-20 minutes, several times a day
  • Elevation (to reduce swelling) 2-3 hours a day and at night, if possible
  • Anti-inflammatory drugs (aspirin, acetaminophen, ibuprofen, naproxen) to control pain and inflammation

Comeback Strategy

“All too frequently, return to athletics is rushed, the injury is not completely healed, and the athlete suffers with a chronic condition as a result,” says Dr. Ramin Modabber, MD, Santa Monica Orthopaedic and Sports Medicine Group. “Return to sports that involve running on hard surfaces should be assessed very carefully. In first-time or minor injuries, 3-4 weeks may be adequate rest. However, in severe or chronic conditions, activity modification may be required for 2-3 times as long. In extreme cases where bone spurs are present and range of motion of the joint are limited, surgical management may be considered as well.”

Dr. Modabber says that Grade 1 big toe sprains (turf toe) are manageable and may not prevent a quick return to action in two or three days, if not sooner. Grade 2 sprains may prevent playing time from one day to two weeks, and Grade 3 sprains could keep a person out of action 3-6 weeks; longer if surgery is required.

  • When you begin exercising again, limit the movement of your big toe—wrap it with tape or an elastic wrap to restrict bending (hyperextending)
  • Wear shoes with stiff insoles that do not force the toe to bend with every step
  • Start an exercise program to enhance strength and improve flexibility

Prehab

Incorporate these prehab exercises into your comeback workouts:

  1. Short Foot [sit in a chair with your foot flat on the ground; lift the arch of your foot up, without curling your toes or rolling your foot to the outside; hold this arch for five seconds and release; repeat until fatigued]
  2. Tennis Ball Massage [place a tennis ball on the floor while you are sitting down; place your foot on the ball and roll back and forth; [you may feel some tender spots; stay on these tender spots as tolerated; perform for 3-5 minutes, 1-2 times per day.
  3. Toe Spreading; sit in a chair with your foot flat on the floor; actively spread your toes apart and then release; repeat 10-15 times, 1-2 times per day.

How to Avoid This Injury

  • You may not be able to completely protect yourself against turf toe, but the goal is not to jam the big toe into a hard surface.
  • Wear shoes that fit properly and have soles rigid enough to protect the joint at the base of the big toe.
  • When possible, avoid playing or practicing on poorly maintained playing fields.

Movement Prep

Incorporate these movement prep exercises into your warm-up routine:

  1. Inverted Hamstring Stretch 
  2. Toe Walks

Jim Brown, Ph.D. has written 14 books on health, medicine, and sports. His articles have appeared in the Washington Post, New York Post, Sports Illustrated for Women and Better Homes & Gardens. He also writes for the Duke School of Medicine, UCLA School of Medicine, Cleveland Clinic and Steadman-Hawkins Research Foundation.


Tags: Football, Volleyball, Injury, Lacrosse, Foot, Foot Pain, Soccer, Baseball

References

  1. Sue Falsone PT, MS, SCS, ATC, CSCS, director of performance physical therapy, Athletes’ Performance and Core Performance
  2. Ramin Modabber, MD, Santa Monica Orthopaedic and Sports Medicine Group
  3. American Academy of Orthopaedic Surgeons
  4. American College of Foot and Ankle Surgeons
  5. American Journal of Sports Medicine
  6. Scientific American

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