Physiotherapy for Turf Toe (Big toe pain)

Posted by Helen Potter on 15 November 2017 | Filed under Foot Pain, In Touch Physiotherapy, Tips

Modified from Physiopedia by Helen Potter 2017

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Turf toe is an injury of the first metatarsophalangeal(MTP) articulation, due to hyperextension of the big toe. This leads to damage to the plantar capsuloligamentous complex. It may cause tearing or complete disruption of ligaments .

Anatomy of Turf Toe

  • The slightly concave shape of the proximal phalanx of the first metatarsal articulates creates little joint stability.
  • The plantar capsule is thicker on the proximal phalanx (tip of toe) and finishes in a thinner part of the metatarsal head (base of toe).
  • It supports the undersurface of the metatarsal head and resists hyperextension of the metatarsophalangeal joint.
  • Additionally to the plantar capsule and the collateral ligaments, the MTP joint is dynamically stabilized by the flexor hallucis brevis (FHB), the adductor hallucis and the abductor hallucis tendons.

Epidemiology /Etiology of Turf Toe

  1. Injury is more frequent in by soccer played on artificial turf surfaces.
  2. It is caused by an overload on the hallux MTP joint in hyper-dorsiflexion position as happens when one player falls on another players’ heel. Too strong adhesion at the surface so that the shoe sticks.
  3. The bodyweight moves forwards when the player tries to stop quickly may cause an acute turf toe.
  4. A chronic condition is mostly caused by frequent running and jumping with extremely flexible shoes.
  5. The injury results very often not due only to hyperextension but also to a degree of valgus (sideways) stress.


Characteristics/Clinical Presentation of Turf Toe

The first symptom is pain in the big toe. Then localised swelling, ecchymosis (redness) and stiffness of the joint.
We divide the disease into three grades, each with his proper symptoms and treatments.

Grade I injury symptoms are: local swelling, plantar structures attenuation or stretching, minimal ecchymosis.
Grade II injury symptoms are moderate swelling, partial tear of plantar structures and restricted motion as result of pain.
Grade III injury symptoms are indicative swelling and ecchymosis, total disruption of the plantar structures, weakness of the hallux flexion, and high instability of the MTP joint.[2][3]


Examination for Turf Toe

As a Physio, I observe and assess the sensitivity on the hallux MTP joint then evaluate the stability and the flexion strength. The palpation focuses especially the collateral ligaments, dorsal capsule and the plantar sesamoid complex.

  • Pain on palpation of the proximal sesamoids indicates a strain of the flexor hallucis brevis musculotendinous junction. Turf toe injury is located distal to the sesamoids.
  • Varus and valgus stress (sideways stress)  test the collateral ligaments.
  • The dorsoplantar drawer test tells about the competence of the plantar plate
  • Active flexion and extension of the MTP and interphalangeal joints give indications about the extensor and flexor tendons and the plantar plate.
  • Comparing the active flexion strength with the contralateral side may reveal a disruption of the FHB or plantar plate.


Medical Management of Turf Toe

Injection therapy may be useful.

The indications for a surgical treatment are the following:

Large capsular avulsion with unstable MTP joint
Diastasis of bipartite sesamoid
Diastasis of sesamoid fracture
Retraction of sesamoid
Traumatic hallux valgus deformity
Vertical instability (positive Lachman test result)
Loose body in MTP joint
Chondral injury in MTP joint
Failed conservative treatment

Physiotherapy Management of Turf Toe

The three grades of the injury got a different physical therapy but the initial approach for all three consists in the RICER (rest, ice, compression, elevation, rehab).

Grade I

  • Once the acute phase is over, tape in a lightly plantar flexion protects the toe from a too big range of motion and supplies compression.
  •  Start early rehabilitation 3 to 5 days after the injury.
  • Gentle passive plantarflexion
  • Gradual strengthening.
  • Distraction
  • Dorsal and proximal sliding of the proximal phalanx of the first metatarsal to improve flexibility
  • Do an athletic activity like bicycling, pool therapy and elliptical training.
  • Wears stiff-soled shoes limiting the motion of the hallux.

Grade II

A second-grade turf toe needs at least 2 weeks to return to activity depending on the athletes’ sport.

  • Passive joint mobilisations
  • After pain and swelling, reduce start rehabilitation in a soft way with a toe protection
  • Control inflammation and assist the healing of the soft tissues with ultrasound
  • Active exercises: toe extension and flexion, toe crunches, curling a towel with toes, moving the toes in the sand and intrinsic exercises.
  • Progress to higher impact activities (jogging, running, cutting and jumping) when ready

Grade III

  • The nonsurgical management of a third-grade injury requires 8 weeks of recovery and immobilization in plantar flexion.
  • Before restarting sports activity, MTP joint should have  50° to 60° painless passive dorsiflexion.
  • Complete rehabilitation can take up to 6 months.[2]
  • The most important part of the treatment of turf toe is physiotherapy rehabilitation and prevention by using protections.

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