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Turf Toe
Turf toe is a condition in which the big toe bends
upwards to an abnormal degree, causing pain at the
bottom of the big toe, damage to the ligaments that
connect the foot to the big toe, and damage to the joint
capsule. A ligament is a tough band of tissue that
attaches to joint bones. Ligaments normally prevent the
joint from moving too much. A joint is a place where two
bones contact each other. A joint capsule is a saclike
structure of tissue that surrounds the ends of bones in
certain types of joints and which contains a clear fluid
that makes the joint move easier.
The foot postion where turf toe
injuries usually occur.
 
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Turf toe is a form of a condition known as hallux limitus. Hallux limitus is defined as pain in
the big toe and decreasing range of motion of the joint of the big toe. Range of motion
means the degree in which a person can move a body part. Turf toe got its name
because it often occurs to people who play games, such as football, on hard surfaces
such as artificial turf (fake grass).

WHAT CAUSES TURF TOE?

In turf toe, the shoe grips hard onto the surface and sticks to it. This is especially true for
shoes with many cleats on them because the cleats help the shoe grip the ground surface
more. The shoe sticks to the ground as the person tries to stop quickly when in motion.
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The gripping of the shoe onto the surface causes the body weight to
move forwards and the big toe to hit the inside of the shoe. Thus,
the big toe gets jammed. As it does this, the big toe, its ligaments,
and its joint capsule bend abnormally in an upward direction. This
overextension of the big toe is the most frequent cause of turf toe.
See the previous section of this entry for an explanation of
ligaments and joint capsules. What you see above is what
commonly happens in turf toe injuries. Usually, the front of the foot
is flat on the ground and slightly flexed upwards, with the heel raised
off the ground. With the heel in this position, an outside force, which
is usually another player, forces the joint of the first toe upwards
even more.
When the big toe bends upwards too much it causes damage to the ligaments and joint capsule (as
described in the previous section), which can become stretched or torn. In turf toe, the surfaces of the
bones at the joint can become damaged as well. A joint is a place where two bones contact each other.
Tiny breaks can also occur in the big toe bone, which is discussed in more detail below.

Another cause of turf toe is when a person is standing on the front part of the feet and is pushed forward
by someone else. This can cause the toe to be extended outwards too much, leading to the same type of
damage described above. Pushing off of the front toe repeatedly while running or jumping can also cause
turf toe.

WHAT ARE THE SIGNS AND SYMPTOMS OF TURF TOE?

The signs and symptoms of turf toe include pain, restricted movement, tenderness, and swelling at the
joint (the place where two bones contact each other) of the big toe and the metatarsal bone in the foot.
There are five metatarsal bones in the foot. They are located in the center of the foot, behind the toes.
One metatarsal bone attaches to each toe. The pain in the big toe may cause the person to limp while
walking. The outside of the toe may appear red and bruised.

In mild conditions of turf toe, there will little damage to the area of bone beneath the cartilage (a type of
tissue) in the big toe. However, there will signs and symptoms of swelling inside the joint. In more severe
cases of turf toe, the signs and symptoms will be worse because there will be damage to the area of bone
beneath the cartilage, the surface of the joint, or both. These types of injuries are usually visible on x-
rays.

If turf toe is caused by repetitive actions that cause injury (such as continuously jamming the toe), the
signs and symptoms will usually begin slowly. This usually happens in younger athletes as they try to
increase their activity. The problems may not be noticeable until after the first or second athletic season,
but once the pain begins it will occur more often and be more severe, depending on the activity the person
is doing.

If turf toe is caused by a direct injury to bone beneath the cartilage or the articular cartilage, the signs and
symptoms may begin suddenly and get worse over a 24-hour period or may get worse slowly as the
season progresses. Articular cartilage is a type of tissue that covers some types of bone joints.

ARE THERE DIFFERENT TYPES OF TURF TOE?

Yes. There are three different types (or grades) of turf toe, ranging from the least severe to the most
severe. The severity depends on the type of damage to the ligaments and joint capsule. See our first
section of this entry for an explanation of ligaments and joint capsules. The types of turf toe are as
follows:

GRADE I: In this type, the ligaments and joint capsule are stretched.

GRADE II: In this type, the ligaments and joint capsule are partially torn.

GRADE III: In this type, the ligaments and joint capsule are completely torn.

As you might imagine, the more severe the injury, the longer it will take to recover.

WHO GETS TURF TOE?

Turf toe usually occurs in people who play games on fake surfaces such as fake grass. Football players
get this condition the most, especially offensive players. Of football players, running backs, wide
receivers, and linesmen are most likely to get turf toe. Baseball players, soccer players, and people who
do martial arts often get turf toe as well.

WHAT PUTS PEOPLE AT RISK FOR TURF TOE?

Playing on artificial surfaces puts people at risk for turf toe. People are more at risk for turf toe that wear
soft, flexible shoes and who have increased range of motion in the ankles. Range of motion means the
degree in which a person can move a body part. Playing positions in sports in which the ankle flexes
backwards (towards the front part of the legs) puts one at risk for turf toe. Wearing a wider and longer
shoe puts one at risk for turf toe because the big toe has more room to move around and get injured.

HOW IS TURF TOE DIAGNOSED?

Turf toe is not a difficult diagnosis to make. The first step is for the doctor to obtain an accurate patient
history. This will help determine how the injury happened. The patient usually states that a snapping sound
was heard at the time of injury. It needs to be determined that the big toe was extended too much in an
upwards direction, accompanied by pain and swelling. Depending on the severity of the injury, the big toe
may have bruises on it and decreased range of motion when examined. Range of motion means the
degree in which a person can move a body part. An x-ray of the foot is taken to make sure there are no
breaks.

Rarely, a magnetic resonance imaging (MRI) scan or a bone scan may be performed to make sure there
are not other causes for the foot pain. MRI scans produce extremely detailed pictures of the inside of the
body by using very powerful magnets and computer technology. A bone scan is a scanning technique
used to produce pictures specifically of bones.

HOW IS TURF TOE TREATED?

Doctors recommend treating turf toe in the following manner. First, the toe should immediately be iced
after it has been injured. Next, a bandage or tape should be placed around the toe that compresses
(squeezes together) the area. This helps rest the joint and reduce swelling. Heat is sometimes applied to
the toe as well to provide pain relief. Another technique used is called a contrast bath, in which a person
places the foot in hot water and then in cold water, repeating this process for a certain period of time.
Contrast baths are used in the early stages of injury.

As much rest as possible is recommended, which usually involves elevating the foot while resting.
Crutches may also be used to take pressure and weight off of the big toe. After 2 to 4 days, the person
may be able to walk without the crutches. A brace is also recommended to protect the big toe by
restricting its movement and preventing it from being injured again. If a person does not want to wear a
brace, a shoe or boot should be worn that has a firm sole (bottom), which will not allow the big toe to bend.
Sometimes, a Morton's extension is used to accomplish this, which is a type of pad fitted under the joint of
the big toe.

A sports injury professional should be sought for advice. He/she can take an x-ray of the toe bone to
make sure it is not broken, tape the toe to prevent movement, and recommend a rehabilitation program. A
sports injury professional can also apply ultrasound treatment, which involves using high-frequency sound
waves to soft tissues. This technique can reduce swelling and speed up healing.
Electrotherapy, in which electricity is used to treat the tissues, is another option that a sports injury
professional can use to reduce pain and swelling. One such technique is called iontophoreisis, in which
ions (electrically charged atoms) of certain salts are introduced into the tissues by electric current. An
atom is the smallest part of a substance that can exist alone or in combination with something else.

A sports injury professional can give medications at times to decrease pain and swelling. The drugs that
are given to do this are known as NSAID's (Non Steroidal Anti-inflammatory Drugs). Corticosteroids, a
different type of medication, are usually not recommended because they have been known to weaken the
tendons (groups of fibers that attach muscles to a bone) and ligaments (see first section), and make the
patient more likely to get an infection. Corticosteroids are a group of drugs that act similarly to a natural
chemical in the body known as corticosteroid hormone. Corticosteroid hormones control the body's use of
nutrients and the amount of water and salts in the urine.

Surgery is rarely used to repair damage to the ligaments or joint capsule of the big toe joint. See our first
section of this entry for an explanation of ligaments and joint capsules. Surgery can also be done to
shorten the size of the first of two bones that make up the big toe. Surgery is reserved for severe cases
that do not respond to other treatments to repair the damaged areas. Sometimes surgery is used to
remove any bone spurs that may have formed near the big toe. A bone spur is a knobby, abnormal bone
growth.

HOW LONG DOES IT TAKE TO RECOVER FROM TURF TOE?

Depending on how bad the condition is, it can take three to four weeks to recover from turf toe. As a
general rule, the more severe the injury, the longer it will take to recover. It is important to note, however,
that it is not uncommon for the signs and symptoms of turf toe to go away during the time of the year that
the person is not playing sports, only to come back when the person starts to exercise again.

WHAT CAN BE DONE TO PREVENT TURF TOE?

Playing on natural grass helps prevent getting turf toe. Some of the recommendations in the treatment
section, such as using a brace, tape, and different types of shoes, can be used for prevention of turf toe.

WHAT IF TURF TOE IS NOT TREATED?

If turf toe is not treated, it is possible for the injury to develop into decreased range of motion due to
arthritis around the joint of the big toe. Range of motion means the degree in which a person can move a
body part. Arthritis is an inflammatory condition of the joints, which is a place where two bones contact
one another.

Many tiny breaks in the bone beneath the cartilage (a type of tissue) of the big toe can occur if this bone
continues to be squeezed together from turf toe injuries. Normally, the area of bone between the end of
the big toe and the main part of the big toe is soft and spongy. However, when turf toe becomes more
severe, this area of bone can become hard and more easily broken, a process known as eburnation.
When this happens, the articular cartilage loses its support and is more easily damaged. Articular
cartilage is a type of tissue that covers some types of bone joints.

Many conditions can develop that can cause slow, but worsening destruction of the joint. These
conditions include bone spurs (knobby, abnormal bone growths), lipping (the formation of a liplike structure
at the end of a bone), osteophytes (bony outgrowths), eburnation (described above), and arthritis
(described above).

WHEN DID DOCTORS BEGIN TO RECOGNIZE TURF TOE?

Doctors began to recognize turf to in the late 1960's because this is when turf was used to replace grass.
There is some evidence that turf becomes harder and less able to absorb shock over time. However, one
study did not find any change in reported turf toe injuries when old and new turf surfaces were compared.

WHAT ELSE IS TURF TOE KNOWN AS?

Turf toe is also known as turf toe syndrome and metatarsalphalangeal joint sprain.

WHAT IS THE ORIGIN OF THE TERM, TURF TOE?

Turf toe condition got its name because it often occurs to people who play games, such as football, on
hard surfaces such as artificial turf (fake grass).