Examining the Irish: Turf Toe

Introduction

The term "turf toe" was coined in 1976 to describe a hyperdorsiflexion of the first metatarsophalangeal joint.  Essentially, the big toe is bent back on itself causing damage to the connective tissue surrounding the bones.  An in-depth inventory of these connective tissues is beyond the scope of this article, so it is sufficient to say that they include a fibrous joint capsule, small ligaments, and the tendons of the muscles that move the big toe.  When a turf toe injury occurs, the patient's risk for fracture or dislocation of the bones in the joint increases significantly.

Anatomy

Since this injury occurs in the foot, I've used some of the images from a previous article on LisFranc sprains to give the reader some idea of scale, location, and relationship between these two injuries.  In the picture below, I have labeled the bones involved in a turf toe injury in purple.  The injury occurs when the toe is bent backward at the joint between the 1^st metatarsal and the proximal phalange.  This joint is the metatarsophalangeal joint.  Normally it allows for a gliding, up-and-down movement by the big toe, and is essential for stability and push-off during walking or running.  I've labeled the distal phalange as well for completeness sake, but it is neither involved in a turf toe injury, nor does it move much in relation to the proximal phalange in a healthy individual.  In a turf toe injury, the big toe is bent backward (red arrow) and as a result tears the connective tissues that surround the joint.

Blausen.com staff

Mechanism of Injury

A question that people have asked me before is "does turf toe actually have to do with artificial turf or is that just an urban legend?"  The answer to that question is a bit complicated.  First of all, older artificial turf had a lot more in common with the carpet in your living room than it did to natural grass.  Because of its construction, it was easily compacted after heavy use and its nylon threads had a tendency to grab the cleats worn by players of that time.

The usual scenario in a turf toe injury is a player is tackled, and has he goes to the ground the spikes nearest his toe get "hung-up" in the turf.  This situation is bad news because in a fall, our feet and toes naturally want to extend out behind us with the laces of our shoes making contact with the ground and our toes pointed.  Since the turf prevents the toe from straightening out, all the weight of the body (and of the tackler) fall on that metatarsophalangeal joint and result in hyperdorsiflexion and injury.  To illustrate this process, check out a zoomed in image of the cover photo for this story:

Notice how Jaylon Smith's toe is dorsiflexed as he pushes off.  Under normal circumstances, he would be able to complete the motion, drive through, and his toe would end up pointed back behind him.  However, if this were a case of turf toe, his foot would not release from the artificial surface.  As he falls forward, his body weight would move downward with the big toe planted just as it is in the picture.  The end result would be  hyperdorsiflexion of the big toe and injury.

We can see in the image below the relationship between a turf toe injury and a LisFranc injury.  Notice that the turf toe injury occurs at the base of the big toe (purple circle) and is the result of improper force applied to this joint.  In contrast, the LisFranc injury (green line, red arrows, and blue lines) occurs in the mid-foot region and is the result of excessive force to the instep.

James Heilman, MD

As I suggested above, artificial turf is not solely responsible for turf toe injuries.  When artificial turf was becoming popular in the 1970s, players found that the cleats that provided good stability on natural grass were ungainly on turf.  These shoes designed for natural grass had metal reinforcement in the sole for greater stability and support.  This reinforcement prevented too much dorsiflexion of the toes and in effect protected players from getting turf toe.  As artificial turf became more prevalent, players began switching to more flexible cleats that had more in common with modern sneakers than old-fashioned cleats.  The combination of increased flexibility in the footwear with the tendency of turf to grab onto the spikes has lead to an increased incidence of turf toe injuries.

Grading and treatment

Turf toe injuries are graded on a scale from 1 to 3.  A grade 1 injury involves over-stretching and minor tearing of the connective tissue.  A grade 3 injury involves complete tearing of the connective tissue and is associated with fracture and dislocation of the involved bones.  All of these tend to be rather painful and limit an athlete's ability to adequately push of the toes when running or to stabilize when changing direction.

Grades 1 and 2 are treated via immobilization by taping the damaged big toe to the second toe.  An athlete with a grade 1 injury usually can return to play immediately, meaning it can be treated on the sidelines.  Grade 2 injuries usually require a player to miss approximately 2 weeks of activity.  Grade 3 injuries are usually treated by immobilization in a walking boot, but surgical intervention is indicated if the risk of secondary injury is significant.  A player suffering a grade 3 turf toe injury can be out of action for as many as 6 weeks.

Summary

• Turf toe injuries occur when the toe bends back on itself.
• Athletes that suffer turf toe injuries are at risk for fracture and dislocation of the bones of the big toe.
• Turf toe injuries are painful and prevent players from being able to generate power when running or maintain stability when making quick lateral movements.
• Both artificial turf and the evolution of modern cleats have contributed to the increased incidence of turf toe in modern football.