Turf toe: what it is, symptoms, grades, treatment and recovery time

BOFAS, the British Orthopaedic Foot and Ankle Society, describes turf toe as a spectrum of injuries to the capsuloligamentous structures of the first metatarsophalangeal (MTP) joint, the big toe joint, typically sustained on artificial turf or hard ground. It was described in 1976 and can be easily missed.

The structures involved are the plantar capsule, plantar muscles and the sesamoid complex. Two small sesamoid bones lie within a tendon under the head of the first metatarsal. BOFAS says that in normal walking the joint complex withstands 40 to 60% of body weight, which can rise to eight times body weight during running and jumping, and that a turf toe injury represents injury to some or all of this complex.

BOFAS says it is common in American football players, up to 45% of whom are affected, and has a low incidence in the UK.

BOFAS lists swelling, plantar bruising (bruising under the foot), pain with weight bearing, especially during push-off, and point tenderness over the plantar structures, capsule and ligaments. It warns that symptoms and signs may be subtle and that a high index of suspicion must be maintained.

Tenderness proximal to the sesamoids suggests a low-grade injury, whereas tenderness distal to the sesamoids suggests a more serious and often unstable injury. A clinician tests range of motion, varus and valgus stress and a dorsoplantar drawer test.

BOFAS says the evidence is based only on a few retrospective case series, but most suggest non-operative management is sufficient for grade I and II injuries and the majority of grade III injuries. It says to establish whether the injury is stable or unstable before planning management.

Initial measures are rest, elevation, ice packs and pain management, with a walking boot, short leg cast or a toe spica with the toe in slight flexion. For grade I, tape the big toe in a slightly plantarflexed position, wear a stiff-soled shoe or individualised orthotics with a Morton's extension, and commence gentle range of motion at 3 to 5 days with a return to low-impact activities.

Grade II is treated with supportive measures as for grade I, with early gentle passive motion, low-impact activities with toe protection and a gradual return to running, jumping and pivoting. BOFAS says athletes are likely to lose about 2 weeks of playing after acute pain and swelling resolve. For grade III, athletes may need up to 8 weeks of immobilisation, and it is recommended that the joint has 50 to 60 degrees of painless dorsiflexion before returning to running or high impact activities.

NHS advice for toe pain in general is to rest and raise your foot, use an ice pack wrapped in a towel for up to 20 minutes every 2 to 3 hours, wear wide comfortable shoes with a low heel and soft sole, and use paracetamol or ibuprofen gel. Do not buddy strap a big toe.

BOFAS gives times by grade rather than a single figure. For grade II, athletes are likely to lose about 2 weeks of playing after resolution of acute pain and swelling. For grade III, up to 8 weeks of immobilisation and up to 6 months for complete symptom resolution. After surgery BOFAS describes a protocol of 4 weeks non-weightbearing in a toe spica splint, protected weight bearing at 4 weeks, full weight bearing in a stiff-soled shoe at 8 weeks and a gentle return to impact activities at 12 weeks.

BOFAS cites one retrospective review of 56 turf toe injuries in which 95% were able to return to sport, although 50% reported ongoing pain and stiffness. Another series of American collegiate football players reported a mean loss of 10 days of sport and under 2% requiring surgery.

BOFAS says surgery may be indicated for some grade III injuries, listing large capsular avulsions with instability of the joint, separation of a bipartite sesamoid, sesamoid fracture or retraction, traumatic hallux valgus, vertical instability, a loose body in the joint and chondral (cartilage) injury. The aim is to restore normal anatomy and stability of the joint, usually by repairing the plantar structures with sutures.

In one series of 9 people who had plantar plate repair, 7 (78%) were able to return to full level of activity with minimal pain, and 2 were not able to return to full athletic activity.

BOFAS says a detailed history is crucial, along with examination. Weight-bearing X-rays and sesamoid views may be normal but can show a small fleck of bone suggesting capsular avulsion, or proximal migration of the sesamoids suggesting rupture of the plantar plate. Comparing with the other foot is helpful.

MRI is commonly performed to assess the extent of the injury and soft tissue disruption, and can show bone marrow oedema or a loose body, and helps tell a bipartite sesamoid from a fracture.

The NHS says to contact NHS 111 if you have badly hurt your big toe, you are in severe pain, you feel faint, dizzy or sick from the pain, you have any tingling or loss of sensation in your foot, your toe is pointing at an odd angle, you heard a snap, grinding or popping noise at the time of injury, you have difficulty moving your toes or cannot walk, or you have toe pain and feel hot, cold or shivery.

See a GP if you think you might have broken a toe, pain is stopping you doing normal activities, is getting worse or keeps coming back, has not improved after 2 weeks of treatment at home, or you have diabetes and foot pain. The NHS says you might be able to refer yourself directly to a podiatrist.

Most people are assessed through a GP, urgent treatment centre, podiatrist or sports injury service. A foot and ankle orthopaedic team arranges MRI and surgery for unstable or complete injuries. Many professional athletes are seen privately for quicker imaging; the grading and treatment approach described by BOFAS is the same.