Physical Therapy Guide to Turf Toe

August 22, 2021 Travis Tanasse

Turf toe is the common name for a sprain of the metatarsophalangeal, or MTP, joint. The MTP joint is located where the big toe meets the foot. This injury occurs when the big toe is forced back toward the top of the foot past its normal range of motion. It is more common in athletes, especially those who play football and similar sports. It can occur when an athlete pushes off to sprint or is tackled from behind. The front of the foot gets fixed and jammed into the ground, forcing the big toe to bend too far backward. In most cases, a turf toe injury does not require surgery. Physical therapy is effective for managing turf toe.

What Is Turf Toe?

There are two joints in the big toe. These joints allow the toe to flex downward and extend upward. The big toe plays a major role in the 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 the ground to move the body forward. The primary joint involved in this motion is the MTP joint. This joint is 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 a very unnatural position, the MTP joint can be injured, along with any surrounding structures such as:

Ligaments.
Muscle tendons.
Small bones that sit under the big toe, called the sesamoid bones.

All of these structures help to maintain the integrity and function of the MTP joint. When described together, they are called the plantar complex. Sometimes, one 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 result in one of the following:

Subluxation (where one bone of the joint slips out of place but comes back to its normal position).
Dislocation (where the two bones of the joint are completely separated).

How Does It Feel?

The most common symptoms of a turf toe injury are:

Localized pain at the first 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.
Pain with weight-bearing, especially if trying to rise up onto the toes.
A dislocation, in more severe injuries.

How Is It Diagnosed?

Health care providers classify turf toe injuries into one of three grades to describe the severity of the injury and 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.

Diagnosing a turf toe injury starts with an interview to learn about how your injury occurred and your symptoms. Your physical therapist also will perform a gentle physical examination to:

Assess the toe’s movement and muscle function
Note any swelling or tenderness in the area.
Analyze your gait pattern (how you walk, if you can).
Determine if you should see an orthopedic doctor for imaging (X-ray, MRI), splinting, or for casting your foot to restrict movement. A doctor may recommend surgery in severe cases.

How Can a Physical Therapist Help?

Immediately after a turf toe injury, the following approaches can help ease pain and prevent further injury. You can easily remember these using the acronym “PEACE”:

Protect: Limit movement and use pain as a guide to avoid causing discomfort.
Elevate: Put your feet up (above heart level if possible).
Avoid anti-inflammatories: Inflammation is the first stage of the body’s natural healing process. You don’t want to disrupt or delay your recovery.
Compress: Pressure on the toe/foot (such as when using a compression sock) may help limit swelling. Too much compression may restrict needed blood flow. Your physical therapist will choose the right amount of compression to treat your specific injury.
Educate: Your physical therapist will educate you about the injury and instruct you on an active approach to recovery and your options for treatment. They also can determine when it is safe for you to return to activity.

After a few days of “PEACE,” physical therapists recommend the following steps. (You can remember them using the acronym “LOVE”):

Loading: Your body needs a certain amount of stress to stimulate repair and recovery. Your physical therapist will work with you to determine how much weight (such as standing or walking) you can put on your toe, and decide when the time is right to do so.
Optimism: Stay positive, even though you’re injured.
Vascularization (improving blood flow): Cardiovascular (aerobic) exercise that does not put too much stress on your injured toe joint will help you:
- Reduce pain.
- Improve blood flow to the injured area.
- Stay motivated through your recovery.
Exercise: Use pain as your guide for a gradual return to normal activity. Your physical therapist will design a treatment plan with specific and targeted exercises for your condition.

Most turf toe injuries do not require surgery. They can be managed by working with your physical therapist. Your treatment plan will depend on the severity of your injury and your goals. In all cases, the main goal of treatment is to restore your ability to return to normal activity.

The following are typical treatment options, depending on the grade of your injury:

Grade 1. Taping or inserts may be used to restrict painful motion at first. In many cases, an athlete may return to sports within a few weeks. Often, your physical therapist will have you do strength and weight-bearing exercises almost immediately.
Grade 2. A brace or walking boot may be prescribed for several weeks to restrict movement and allow rest. Your physical therapist will then start you on a structured exercise program and a gradual return to activity.
Grade 3. Surgery may be needed for a grade 3 injury. Your health care team will determine whether you need surgery based on the severity of the damage and its impact on your function. Surgery is more likely if there is:
- Fracture of a bone.
- Damage to the cartilage (the tissue that lines the bones of the joints).
- Complete tearing of the tendon.
- Excessive movement of the joint that causes ongoing instability (subluxation or dislocation).

With any grade of injury, your physical therapist will work with you to design a treatment program specific to your condition and goals. Your treatment plan may include:

Range-of-motion exercises. It is important to regain the full range of motion of your big toe and foot. If your injury required use of a brace or boot to restrict movement during healing, your toe and foot joints may be stiff. Your physical therapist will teach you gentle stretching and movement exercises, including guided toe exercises, to help restore normal movement.

Muscle strengthening. It is common to lose strength in the muscles of your foot, ankle, and leg after a turf toe injury. This is due to the change in activity and any bracing or boot used to restrict movement during healing. Your physical therapist will determine which muscles are weak and teach you specific exercises to strengthen them. Exercises may include:

Balance activities.
Climbing stairs.
Using resistance bands.

Manual therapy. Many physical therapists use manual (hands-on) therapy to gently move and treat muscles and joints to improve their function. These techniques can target areas that are difficult to treat on your own. Manual therapy can be especially effective to restore movement in joints that become stiff after being immobilized. Your physical therapist may gently move the joints involving your injury for you. This might feel like your foot is being gently “wiggled.”

Patient education. Your physical therapist will educate you to help ensure that your recovery goes smoothly. They will identify any activities you should avoid or limit at certain stages in your recovery. They also can help you understand how long it may take until you can return to full activity.

Can This Injury or Condition Be Prevented?

Certain external factors may increase the risk of a turf toe injury. These factors can include:

Competing on artificial turf surfaces.
Wearing shoes with highly flexible soles.

It is important to ensure that your footwear properly supports your foot and is the right type for the surface on which you play your sport. Also, performing regular flexibility and strengthening activities for the foot and ankle may improve your body's ability to withstand athletic activities. Your physical therapist can teach you these exercises and how often to do them.

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 (muscle, bone, and joint) injuries.
A physical therapist who is a board-certified specialist or who has completed a residency in orthopedic and/or sports physical therapy. This physical therapist will have advanced knowledge, experience, and skills that apply to athletes and turf toe injuries.

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

Here are some general tips for when you are looking for a physical therapist (or any other health care provider):

Get recommendations from family, friends, or other health care providers.
When you contact a physical therapy clinic for an appointment, ask about the physical therapist’s 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 and better.

Pro Dynamic Physical Therapy Inc.