Description
Turf toe, without any complications, is a sprain of the ligaments and/or the joint capsule on the underside of the foot at the joint of the big toe. In some severe cases, there may also be injury to the tendons, sesamoid bones or even the occurrence of a fracture or dislocation (1,4,5)
Mechanism of injury
In dancing, turf toe is caused by the repeated hyperextension movement of the big toe during demi-pointe as well as during jumping and landing. The injury commonly occurs when the forefoot is fixed to the ground whilst the big toe is hyperextended (4). With a load through the heel, this combination may lead to tearing of the plantar plate (a tough structure made of cartilage which attaches the big toe to the metatarsal head) (5).
Turf toe classification (4)
| Grade of classification | Description |
| 1 | Mild swelling and joint tenderness with no sign of structural damage on imaging. |
| 2 | As above with bruising and minimal reduction in big toe joint range of movement. |
| 3 | As above with a significant reduction in big toe joint range of movement and an altered gait (walking) pattern due to pain. Tissue damage will also be apparent on an MRI scan. |
Signs and symptoms of turf toe (1)
- Pain located at the underside of big toe.
- Bruising
- Tender to touch at the underside of the big toe.
- Inability to push off with big toe.
- Pain with extension of the big toe
How is turf toe diagnosed? (1)
Turf toe can be diagnosed clinically based on the presentation. X-rays taken from different weight-bearing views can also exclude a fracture. In severe cases where there is concern regarding the integrity of the affected structures, an MRI will be useful with the diagnosis and its severity.
Grade 1 and in some instances, grade 2 injuries can be managed conservatively. Surgical intervention is advised for grade 3 injuries and for grade 2 injuries where conservative management has failed. As a result of the minute size of the affected joint, quite often an injury here, is not given enough attention. However, the big toe plays a critical role in the ability to run, jump, change direction and push off your foot and is thus an essential structure.
Rehabilitation for turf toe should follow a loading continuum which is dictated by the severity of the injury and the associated structural damage.
1 Joint protection
During the early stages after the injury, it may be necessary for the foot to be placed in a moon boot and for the dancer to use crutches. This will assist in restricting movement and reduce load/weight through the joint.
2 Sub-maximal strengthening
These exercises look to strengthen the intrinsic foot muscles and consist of the piano toe series. No pain should be felt during these exercises.
3 Range of motion
Once symptoms have subsided, it is important to ensure that the joint range of movement going to extension is maintained. This can be done actively and/ or passively. This is essential as this joint movement is important for dancers. These exercises can also be prescribed in different loading positions, depending on the phase of rehabilitation and stage of healing.
4 Strengthening
This again is done in accordance with the loading continuum. Calf muscle strength is an important factor to address. Calf raises should be commenced in a seated position and progressed to double leg and single leg standing positions.
5 Balance training
It is important to retrain single leg balance as the injury will most likely affect this. Balance should be retrained in the static and dynamic forms.
6 Agility training
The big toe plays an important role in changing direction and being able to ‘push off’ whilst doing so. Thus, certain agility drills need to be carried out.
When can I return to dancing/sports?
At Floyd Lebatie Physiotherapy we are committed to evidence-based outcomes to determine return-to-play readiness. These criteria will look at the joint range of movement, muscle strength and endurance, the ability to successfully complete balance, walk run cycles and agility training.
References
Aran, F., Ponnarasu, S., & Scott, A. (2022). Turf Toe. Statpearls.
2. Fraser, T., & Doty, J. (2019). Turf toe: review of the literature and surgical technique. Annals of Joint, 4(28), 1-6.
3. Hainsworth, M. (2018). The management of turf toe - A systematic review. Baltic journal of spport and health sciences, 25-37.
4.McCormick, J. J., & Anderson, R. B. (2010). Turf Toe: Anatomy, Diagnosis and Treatment. Sports Health, 2(6), 487-493.
5.Najefi, A.-A., Jeyaseelan, L., & Welck, M. (2018). Turf toe: A clinical update. Sport and Arthroscopy, 3, 501-506.
