Turf Toe Injuries
Activities such as football, basketball, soccer, field hockey and lacrosse show the high incidence of injury to the great toe joint on artificial surfaces. Other non-sporting causes include change in shoe gear, limited range of motion of the great toe joint, and sometimes flat foot conditions.
Mechanism of Injury
There are two mechanisms of injury for turf toe. The most common cause is hyperextension of the great toe joint. The great toe joint is hyper-extended as the heel is raised off the ground. An external force is placed on the great toe and the soft tissue structures that support the great toe on the top are torn or ruptured.
Physical Signs and Symptoms
Symptoms of acute injury include pain, tenderness and swelling of the great toe joint. Often there is a sudden acute onset of pain during push-off phase of running. Usually, the pain is not enough to keep the athlete from physical activities or finishing a game. This causes further injury to the great toe and will dramatically increase the healing time.
Injuries to the great toe that cause turf toe are graded into three categories.
A Grade I turf toe injury is considered to be mild and the supporting soft tissue structure that encompass the great toe are only sprained or stretched. This is the most common type of injury. There is minimal swelling with mild local tenderness and usually no black and blue bruising evident.
Grade II turf toe injuries are considered moderate in severity. They present with more diffuse tenderness, swelling, restricted range of motion and usually are mildly black and blue in appearance. There is usually a partial tear of the supporting ligaments but no articular cartilage damage.
Grade III injuries are considered severe in nature because of the considerable swelling, pain on palpation, restriction of range of motion, inability to bear any weight on the injured foot and diffuse black-and-blue appearance of the great toe. There is generally tears to the joint capsule, ruptured, ligaments and possibly compression damage to the articular cartilage of the great toe.
Treatment is usually centered on an individual basis and the severity of the injury sustained. The following are general principle guidelines for turf toe injuries. The mnemonic “RICE” can be employed. The “R” stands for rest and is the hallmark component to allow for successful healing to occur. However, this is the greatest area of noncompliance because the athlete assumes the injury to be trivial and not severe enough to miss a game or practice. The “I” represents ice, which is usually performed for the first 48-72 hours after the initial injury. Cryotherapy consists of placing the injured toe in a bucket of ice water for 15-20 minute intervals. “C” signifies compression, which is done by taping the great toe in a compression dressing or strapping. The “E: stands for equipment modification or change. For example, the use of a stiffer athletic shoe to resist motion of the great toe or the insertion of an orthotic to increase the support of the great toe. Additionally, strapping of the great toe to limit motion may allow a highly competitive athlete to return to activities quicker. Non-steroidal anti-inflammatory drugs (NSAID) may be utilized for relief of minor pain as well as to decrease the inflammation of the injury.
Grade I injuries do well with strapping and usually only require a few days of rest. Grade II injuries should adhere to the “RICE” principles above and usually require one to two weeks of missed practices and games. Grade III injuries are more severe injuries and the healing process may take four to six weeks of recovery time from physical activities. Sometimes, Grade III turf toe injuries do not heal appropriately with conservative care and result in chronic pain and instability. Surgical reconstruction of the joint capsule, ligaments and articular cartilage may be necessary to restore proper alignment and function in these extreme cases.