TURF TOE

1. TURF TOE Michael LaBella

2. OBJECTIVES • After viewing this presentation, you will be able to: • Define what turf toe is • Determine the anatomy and physiology of the forefoot • Identify the mechanisms of injury for turf toe • Describe the three different grades of turf toe • Cite three symptoms of turf toe • Explain the types of treatment needed for the three different grades of turf toe • Discuss the necessary guidelines for returning to play after experiencing turf toe

3. What is Turf Toe? • Turf toe is a sprain injury to the 1st metatarsophalangeal joint. The incidence of the injury has increased over the years because of many factors. (Childs, 2006).

4. Anatomy of the Forefoot • Anatomical structures of the forefoot work together to provide a smooth glide for walking and athletics. These structures include: • Foot Bones • Blood Vessels • Fascia • Ligaments • Nerves • Tendons • The 1st metatarsophalangeal (MTP) joint also known as the great toe, or hallux is very important to the structure of the forefoot. The MTP is composed of the following: • Bones • Ligaments • Muscular Attachments (Childs, 2006)

5. Anatomy of the Forefoot Continued… • Bones of the MTP include: • Sesamoid Bones that are encapsulated within the flexor hallucis brevis tendon • Large Bones that process weight bearing, walking, athletics, and balance • Ligaments: • Two Collateral Ligaments (sides of the joint) support the 1st MTP • Two Plantar Ligaments • Muscles: • Abductor Hallucis and Adductor Hallucis • Other soft tissues helping the MTP include: • Extensor and flexor hallucis longus, tibialis anterior, peroneus longus, and the retinaculum (Childs, 2006)

6. Anatomy of the Forefoot Images (Childs, 2006)

7. Anatomy of the Forefoot Image (Childs, 2006)

8. Anatomy of the Forefoot Image (Childs, 2006)

9. Physiology of the Forefoot • Hallux: • Allows the joint to transmit weight bearing loads and position changes from maximum plantar flexion to moderate dorsiflexion • Capsuloligamentous soft structures around the 1st MTP joint: • Provide stability to the joint in relation to varus and valgus stabilizing forces • Sesamoid Bones: • Provide a fulcrum point to assist with kinetic energy of the muscles that traverse the joint • Dorsal Capsular Structures: • Are composed of muscle-forming tendons proximally and subsequently extending medially and laterally to the base of the 1st MTP joint • Dorisflexion: • Causes stretching of the synovial attachment and capsule about the 1st MTP joint (Childs, 2006)

10. Physiology of the Forefoot Image (Childs, 2006)

11. Mechanisms of Turf Toe • The mechanism of injury of Turf Toe is a sprain injury to the joint capsule and surrounding structures of the metatarsophalangeal (MTP) joint of the great toe. Injury occurs most commonly as the joint is forced into hyperextension, causing strain or avulsion of the plantar plate. The medial collateral ligaments may also be partially avulsed from a valgus stress. A less common mechanism is hyperflexion of the MTP joint. Either of these injuries may occur traumatically or from chronic overuse (Glasco & Hunter, 1998).

12. Causes of Turf Toe • Artificial Turf and Playing Surfaces • Athlete’s experience • Position of an athlete • Weight of an athlete • Foot pronation • Increased toe flexibility and decreased number of cleats in the shoe • Prior 1st MTP joint injury (Childs, 2006)

13. Recognizing Symptoms of Turf Toe • Symptoms and Signs of Turf Toe include: • Pain along the plantar aspect of the MTP joint • Tenderness to palpation • Decreased range of motion of the great toe (MTP joint) • Inability to bear weight on the injured foot • Inability to push off with the great toe • Running • Jumping (Allen, Flemming, & Sanders, 2004)

14. Evaluating Turf Toe • Questioning the injured athlete: • What part of your body hurts? • Where does your foot hurt? • Did you feel anything happen when your foot moved a certain way? • Test Methods for Coaches: • A coach could ask the athlete to remove their sock, so they could get a visual of the injury and look for swelling, and also compare the injured toe to the other. • A coach could feel the injured area for tenderness (palpation). • A coach could have the athlete attempt to move their toes in order to check for a decreased range of motion.

15. Treating Turf Toe • The first step in treating turf toe is to determine the severity level. Severity levels can be a 1st, 2nd, or 3rd degree sprain. Determining the severity of the turf toe injury is vital in in deciding what type of treatment the athlete may need. • Regardless of what severity level the turf toe is, a coach must motivate the athlete to Rest, use Ice, apply Compression, and Elevate his/her foot. (Edell, 2006)

16. Severity Levels of Turf Toe • First Degree: • This type of sprain usually results in very little time loss. The athlete must be able to run and change direction properly prior to return to competition. Application of ice and taping the toe may be enough treatment for return to competition on the day of the injury. Also, spring steel shoe inserts can be of great benefit to reduce the forces applied to the joint. • Second Degree: • This type of injury often leads to time loss. This is due to the greater amount of tissue damage suffered. This athlete may need crutches for walking, and should be seen by a physician to rule out a bony fracture. When the athlete can run and change direction with out pain and loss of mobility, he/she may return to participation with the toe taped and a steel shoe insert. • Third Degree: • These injuries are severe and may be a season ending injury. It must be determined if the joint surfaces have been damaged. If so, early return to participation may result in severe degenerative arthritis, and the loss of a career. Surgery may be required to repair the torn ligaments and tendons. (Edell, 2006)

17. Rehabilitating Turf Toe • Rehabilitation for turf toe is fairly simple. Acutely, ice and restriction of motion of the joint is critical in the healing process. Also, crutches for walking may be necessary for a period of 1 - 2 weeks. • After the acute stage, it is necessary to return full strength and range of motion to the toe, foot, and ankle. During the acute phase lower body strength and endurance will decrease. Utilizing a stationary bicycle for aerobic conditioning is advised. Strength training in a non-weight bearing fashion for the affected limb is also appropriate. The strength of the foot and ankle should be addressed with Theraband and range of motion exercises. • For the 1st MTP itself, gentle range of motion exercises should be instituted as pain allows. These are necessary to prevent Hallux Rigidus (arthritis), a condition that arises when the joint is not moving properly. This can also result in degenerative arthritis of the MTP. Have the athlete bend the toe gently within the limits of pain. As the pain decreases, the amount of motion increases. • Lastly, toe taping and spring steel shoe inserts will assist in supporting the toe and allow the athlete to return to participation sooner. (Edell, 2006)

18. Turf Toe Taping • Objectives of Turf Toe Taping: • To support the first Metatarsophalangeal (MTP) Joint, • To allow moderate flexion and minimal extension • To limit end range of flexion, extension, and adduction (Edell, 2006)

19. Steps to Turf Toe Taping • First Steps: • Clean and prepare the area by shaving if excessive hair is present. Spray the area with skin toughener (Tuf-Skin®, STA®, etc.). • Place an anchor of 1” white tape around the distal toe. Place an anchor of 1 ½” tape around the mid-foot. • Place a longitudinal supporting strip of 1” tape from distal to proximal anchor on medial aspect of foot. (Edell, 2006)

20. Steps to Turf Toe Taping Continued… • Second Steps: • Begin a plantar X with a longitudinal strip diagonally from lateral aspect of distal anchor to medial aspect of proximal anchor on plantar aspect of first MTP joint. • Cross this with second strip from the medial aspect of the distal anchor crossing MTP joint at its midpoint on plantar aspect. (Edell, 2006)

21. Steps to Turf Toe Taping Continued… • Last Steps: • Begin dorsal X with a 1” strip from the medial aspect of the distal anchor to dorsal aspect of the proximal anchor. • Finish the dorsal X by crossing this strip from lateral aspect of distal anchor to medial aspect of proximal anchor, forming an X over the dorsal MTP joint. • Close up taping with light circumferential strips covering sites of original anchors with 1” tape for toe, and 1½” tape for mid-foot. Start proximally and move distally with anchors, overlapping each previous strip by ½. • Test tape for adequate restriction of toe motion and ensure that tape on mid-foot is not too tight. (Edell, 2006)

22. Returning to Play Guidelines • The goal of rehabilitation is to return you to your sport or activity as soon as is safely possible. If you return too soon, you may worsen your injury, which could lead to permanent damage. Everyone recovers at a different rate. Return to your sport or activity will be determined by how soon your toe recovers, not by how many days or weeks it has been since your injury has occurred. In general, the longer you have symptoms before you start treatment, the longer it will take to get better. http://www.ubsportsmed.buffalo.edu/education/turf.html

23. Specific Returning to Play Guidelines • An athlete may safely return to a sport or activity when, starting from the top of the list and progressing to the end, each of the following is true: • You have full range of motion in the injured toe compared to the uninjured toes • You have full strength of the injured toe compared to the uninjured toes • You can jog straight ahead without pain or limping • You can sprint straight ahead without pain or limping • You can do 45 degree cuts, first at half speed, then at full speed • You can do 20 yard "figure eights", first at half speed, then at full speed • You can do 90 degree cuts, first at half speed, then at full speed • You can do 10 yard "figure eights", first at half speed, then at full speed • You can jump on both feet without pain, and you can jump on the foot with the injured toe without pain http://www.ubsportsmed.buffalo.edu/education/turf.html

24. Preventing a Turf Toe Injury • Turf toe cannot be prevented for the most part. However, an athlete can reduce their chances of suffering from a turf toe injury. In order to reduce the risk of getting turf toe, an athlete should wear stiff-soled athletic shoes when playing sports. • Another way to prevent turf toe from occurring is to avoid jamming your big toe into a hard surface. • Athletes should know about the type of surface they are playing on. http://www.med.umich.edu/1libr/sma/sma_turftoe_sma.htm

25. References Glasco, K., & Hunter, S. (1998). Sports medicine: Turf toe management includes scrutiny of flexible footwear. Retrieved February 17, 2008, from http://www.biomech.com/db_area/archives/1998/9803sports.77-79.bio-.html Allen, L. R., Flemming, D., & Sanders, T. G. (2004). Turf Toe: Ligamentous Injury of the First Metatarsophalangeal Joint. Military Medicine, 169, 19-24. Rouzier, P. (2005). Turf Toe. Retrieved February 17, 2008, from http://www.med.umich.edu/1libr/sma/sma_turftoe_sma.htm Childs, S. G. (2006). The Pathogenesis and Biomechanics of Turf Toe. Orthopaedic Nursing, 25, 4, 276-280. Edell, D. (2006). Turf-Toe. Retrieved February 17, 2008, from http://www.athleticadvisor.com/Injuries/LE/Foot&Ankle/turf_-_toe.htm University Sports Medicine. (2008). What is turf toe? Retrieved February 17, 2008, from http://www.ubsportsmed.buffalo.edu/education/turf.html