How To Treat Turf Toe Injuries

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What You Should Know About Athletic Shoes And Turf Toe

Coker and Arnold also concluded that football shoes can contribute to turf toe due to fitting issues.3 At the time of their study, most football shoes were sized primarily by length. Athletes who needed wider shoes were in general forced to wear longer shoes that created the potential for excess shoe length in the toe box. This created more of a lever during dorsiflexion of the forefoot, leading to potential turf toe injury.

Nigg and Segesser studied an increase in friction between the fixed forefoot and the artificial turf in turf toe injuries.6 Bowers and Martin wrote another paper commenting on the relationship between the shoe and the surface relationship causes of turf toe.1

Unfortunately, I feel the evaluation test that Bowers and Martin used to determine shoe stiffness was flawed. In their study, the midfoot and posterior aspect of the football shoe was clamped down while researchers tested the flexibility of the forefoot. However, this is a flawed test because the flexibility of many shoes can and will continue into the midfoot portion of a shoe.

The American Academy of Podiatric Sports Medicine utilizes a shoe evaluation process that evaluates both the forefoot and midfoot stiffness of running and athletic shoes as two of the three most prominent components in athletic shoe function. From my perspective as well as the the academy’s perspective, it is important to have some flexibility of the forefoot in a shoe so the MPJs are allowed to pivot in late midstance and early propulsion. Loss of this important portion of the gait cycle can lead to significant negative compensations throughout the foot, ankle and lower extremities.

By Bruce E. Williams, DPM

A Pertinent Guide To Treatment Options

Rest, ice, compression and elevation (RICE) are best when it comes to initiating treatment for turf toe. Some authors caution against the use of taping to limit first MPJ range of motion during the first few days after injury as it could lead to restriction of arterial and venous circulation. After the acute stages of injury, taping can be a reasonable treatment for this type of injury.
   Other treatments include equipment modification, stiffer shoes or the use of steel or graphite plates with full width at the digits or with just a Morton’s extension. With a grade 1 injury, a shoe plate and/or taping will usually get an athlete back in the game. The average loss of playing time for grade 2 injuries is three to 14 days. Players with grade 3 injuries will usually miss two to six weeks of playing time. These grade 3 players will need crutches as well during the first few days or weeks after the injury has occurred.
   For most of these problems, if one diagnoses the injuries early and treats them correctly, athletes will have alleviation of turf toe in three to four weeks. Do not use corticosteroids as they can make the problem worse or mask acute symptoms, causing potential for further injury.
   A return to play is considered acceptable when one can achieve painless dorsiflexion of 50 to 60 degrees of the first MPJ.9 Early joint mobilization is key according to Clanton and Ford.8 Consider the Dananberg manipulation technique for increasing the first MPJ range of motion.12 Returning too soon to play will almost always prolong the convalescence of this injury.
   Operative treatment of turf toe is rarely indicated except when it comes to the removal of large capsular avulsions or for bipartite or sesamoid fractures. Occasional repair of a traumatic bunion may be necessary as well as loose body removal or fixation of retracted sesamoids. Physicians have used the abductor hallucis to reinforce the plantar plate when necessary.9

In Summary

One may consider turf toe to be a sprain or partial tear of the plantar ligaments or plate of the first MPJ. It is primarily a hyperextension injury of the first MPJ. However, some have documented it as a hyperflexion injury (sand toe) and, at times, one may see it as a varus or valgus injury as well.
   Turf toe is a significant injury given its ability to keep athletes out of practice and games. Turf toe injuries have grades of 1, 2 and 3. One can best evaluate them via X-ray initially and subsequently by CT or MRI, depending on whether you consider soft tissue or bony injury as a primary cause.
   Treatment for turf toe starts with RICE, taping, protection of the affected joint and partial or non-weightbearing as determined by the grading system. One can utilize steel or graphite insoles to limit first MPJ extension or motion once weightbearing and return to play commence. A stiff soled shoe can be effective as well.
   Beware of the prolonged use of forefoot-limiting shoes and insoles as this could lead to sagittal and frontal plane compensations of the ankle, knee and hip. Also feel free to access the American Academy of Podiatric Sports medicine Web site ( for athletic shoe recommendations.

Dr. Williams is a Fellow and President of the American Academy of Podiatric Sports Medicine. He is also a Fellow of the American College of Foot and Ankle Surgeons, and a Diplomate of the American Board of Podiatric Surgery. He is in private practice in Merrillville, Ind.


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