Physical Therapy Guide to Turf Toe

January 28, 2021 Travis Tanasse

Turf toe injury is an injury to the main joint of the big toe. The formal medical name for the condition is metatarsophalangeal (MTP) joint sprain. This injury occurs when the big toe is forced into extreme positions of hyperextension (where the toe moves back toward the top of the foot past its normal range of motion). It occurs primarily in athletic environments, particularly in football, such as when an athlete pushes off to sprint or is tackled with the front of the foot fixed and jammed into the ground, causing the toe to get stuck or caught in a hyperextended position. In most circumstances, a turf toe injury does not require surgery and can be treated effectively by a physical therapist.

What is Turf Toe?

There are 2 joints in the big toe. These joints allow the toe to move in an upward motion and bend in a downward motion. The big toe plays a significant role in our ability to walk and run; when the foot touches the ground and prepares to take another step, the big toe is the last joint through which the foot pushes off to move the body forward. The primary joint that this motion occurs through is the metatarsophalangeal joint, where the metatarsal, the first long, straight bone of the foot, attaches to the phalange, the first shorter bone of the toe.

If the big toe is forced into an extremely unnatural position, the MTP joint and surrounding structures may be injured. These structures may include ligaments, muscle tendons, or the small bones that sit under the big toe, called the sesamoid bones. All of these structures play a role in maintaining the integrity and function of the MTP joint; they are often grouped together and termed the plantar complex. Sometimes, 1 of the soft-tissue structures is simply stretched when the toe is bent back toward the top of the foot. However, a turf toe injury may involve a subluxation (where 1 bone of the joint slips out of place, but comes back to its normal position) or a dislocation (where the 2 bones of the joint are completely separated).

How Does It Feel?

The most common symptoms associated with a turf toe injury are:

Localized pain at the MTP joint
Feeling a "pop" at or around the MTP joint at the time of the injury
Swelling
Bruising
Tenderness to touch
Cramping in the arch of the foot
In more severe injuries, a disfiguring of the MTP joint (as in a dislocation)

How Is It Diagnosed?

Turf toe injuries are typically classified into grades 1 to 3 to describe the severity of the injury and to guide treatment:

Grade 1: stretching of the plantar complex
Grade 2: partial tearing of the plantar complex
Grade 3: complete tearing of the plantar complex

Diagnosis of turf toe injury starts with an interview to learn the mechanism of injury and your symptoms. Your physical therapist will perform a gentle clinical examination to assess the toe's movement and muscle function as well as to note any swelling or tenderness in the area. Your physical therapist may ask you if you are able to walk on your foot and, if so, will analyze your gait pattern. If your therapist suspects a fracture of 1 of the bones or a tearing of the muscle-tendon unit, your physical therapist may refer you to an orthopedic physician who specializes in foot and ankle injuries for diagnostic imaging (i.e., x-ray, MRI).

How Can a Physical Therapist Help?

Immediately following a turf toe injury, the RICE protocol is recommended: Rest, Ice, Compression, and Elevation. The goal of the RICE protocol is to decrease pain and swelling and protect the joint from further injury until it can be more thoroughly assessed. Most turf toe injuries do not require surgery and are treated with physical therapy. The treatment depends on the severity of the injury.

Grade 1. To treat a Grade 1 injury, your physical therapist may use narrow athletic tape to immobilize your big toe with your second toe to restrict painful motion. Your physical therapist may also place a firm insert in your shoe to limit motion and promote healing. In many cases, an athlete may be able to return to sport soon after a Grade 1 injury.
Grade 2. Treating Grade 2 injuries may require immobilizing the foot in a brace or walking boot, and allowing several weeks of rest.
Grade 3. Treatment of Grade 3 injuries is dependent on the severity of the damage to the structures of the foot. Surgery may be required if there is a fracture of a bone, damage to the cartilage (the tissue that lines the bones of the joints), a complete tearing of the tendon, or excessive movement of the joint that causes repetitive instability (subluxation or dislocation).

In each case, your physical therapist will work with you to design an individualized treatment program specific to the exact nature of your condition and your goals. Treatment may include:

Range of Motion Exercises. It is important to regain a full range of motion of your big toe. Your motion may be limited after a turf toe injury, particularly one that requires immobilization in a brace or boot. Your physical therapist will teach you gentle stretching exercises to help regain motion.

Muscle Strengthening. It is common to lose strength in the muscles of your leg, particularly around your foot and ankle after a turf toe injury due to the limited weight-bearing and activity that is required to allow the injury to heal. Your physical therapist will determine which muscles are weak and teach you specific exercises to treat them, such as strengthening with resistance bands, balance activities, and functional activities, like stair climbing.

Manual Therapy. Many physical therapists use manual (hands-on) therapy to gently move and manipulate muscles and joints to improve their motion and strength. These techniques can target areas that are difficult to treat on your own. Manual therapy can be especially effective for joints that become stiff following immobilization; with turf toe injury, your physical therapist will use different techniques to mobilize your big toe as well as the other joints of your foot and ankle that may have become stiff during your recovery.

Patient Education. Your physical therapist will educate you on the dos and don’ts following turf toe injury to ensure that your recovery is a smooth one. Your physical therapist will work with you to develop an individualized rehabilitation program, including expected timelines and goals to give you a roadmap for your return to full activity.

Can This Injury or Condition Be Prevented?

There are certain external factors that may increase the risk of turf toe injury, such as competing on artificial turf surfaces and wearing shoes with highly flexible soles. Care can be made to ensure that your footwear is supportive and appropriate for the surface on which the sport is being played. Additionally, performing preventative flexibility and strengthening activities for the foot and ankle may improve your body's ability to withstand the stresses placed on the body during athletic activities.

Real Life Experiences

Chris is the starting running back on his high-school football team, the Jets. His team had a great summer of training and is ready to compete for the state championship after a heartbreaking playoff loss last year. Several teams are looking strong; the Jets are prepping for a challenging journey to the playoffs.

In the third game of the season, the Jets are facing the Knights for their first road contest of the year. Over the summer the Knights renovated their stadium, including the installation of artificial turf. Chris is excited to play under the lights in this new venue.

On a play in the third quarter, Chris finds a narrow hole and just before breaking loose for the end zone, is tackled from behind and goes down. His coach tells him later that it looked like his foot got stuck in the artificial turf. When Chris tries to get up and walk it off, he can't; he is pulled off the field for the next play. He complains of sharp pain under his big toe and notices some swelling. His coach keeps him out of the rest of the game. Chris applies ice to his foot and elevates his leg when he gets home that night. When his foot pain fails to improve over the weekend, his father takes him to see his physical therapist.

Chris's physical therapist asks him about the injury. He says his toe got pushed back when he was tackled and he felt a small pop with stabbing pain as he fell forward. She performs an examination, assessing his range of motion and strength, and gently pressing around his foot to find where it hurts. She suspects a turf toe injury. Because Chris is unable to bear his full weight on his foot and has limited motion, she refers him to the orthopedic physician next door for an x-ray to examine the bones of his foot.

Fortunately, the x-ray results show there is no fracture; his physical therapist and the physician agree Chris has a grade 2 MTP sprain—a turf toe injury. Chris is fitted for a walking boot; his physical therapist tells him he will not be able to play football for 4 to 6 weeks.

Chris attends physical therapy twice a week. Together, he and his physical therapist develop a plan to get him back on the field by the end of the season. They first work on gentle movement and strengthening exercises, and Chris performs low-impact cardio activities, like aqua jogging and stationary biking.

As he continues to heal, his physical therapist teaches him more advanced exercises, like squatting and lunging. Chris works hard on his exercise program in and out of the clinic, and is able to return to practice after 5 weeks, using a firm shoe insert to protect his toe.

With the help of his physical therapist and coach, Chris is able to return to game-day action in the district playoffs. He leads the team with carries, and helps the Jets win the district championship in a comeback effort on their home field!

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and clinical experience to treat a variety of conditions or injuries. You may want to consider:

A physical therapist who is experienced in treating people with orthopedic or musculoskeletal injuries.
A physical therapist who is a board-certified specialist or who has completed a residency in orthopedic or sports physical therapy, as they will have advanced knowledge, experience, and skills that apply to an athletic population.

You can find physical therapists that have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

Get recommendations from family and friends or from other health care providers.
When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with turf toe injury.
During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and report activities that make your symptoms worse.

Pro Dynamic Physical Therapy Inc.