football Edit

Turf toe is far more serious than it sounds

As the madness of March continues to unfold, Michigan basketball fans have been collectively reflecting on 2014-15 with disappointment and questions of 'what if?' Season-ending injuries to key players - junior wing Caris LeVert and sophomore point guard Derrick Walton - in late January helped keep the Wolverines out of postseason play for the first time in five years.
Dr. Preeti Malani is a Professor of Medicine at the University of Michigan hospital and an avid Michigan football fan. She will produce pieces for us over the next few months as injuries pop up and we desire to offer a greater explanation to the subscriber that our staff can offer.
Days after LeVert suffered a left foot fracture, "turf toe" sidelined Walton, who also spent the remainder of the season looking on from the bench.
Turf toe refers to an injury to the foot at the base of the great toe, an area known as the first metatarsalphangeal (MTP) joint. The term turf toe implies an acute injury, stemming from a traumatic event that causes hyperextension of the great toe. As a result, the structures surrounding the great toe (ligaments, tendons, or even bone) are irritated, torn, and otherwise damaged.
Although most commonly associated with sports played on artificial surfaces, turf toe can be triggered by a wide range of athletic pursuits, including basketball, gymnastics, volleyball, as well as football, soccer, and lacrosse.
Despite the rather innocuous sounding name, turf toe can be severe. Dr. James Holmes, Assistant Professor of Orthopedic Surgery at the University of Michigan, explains that turf toe pertains to a broad spectrum of injuries, from minor irritation to complete dislocation of the MTP joint.
Holmes notes that the turf toe moniker frequently creates confusion among athletes, coaches, and fans. "One athlete may return from turf toe in two weeks, while another may be out for six weeks. While it's a natural comparison, they are comparing apples to oranges," says Holmes.
A diagnosis of turf toe is usually made based on an athlete's history and physical exam. Depending on the setting, patients may also undergo imaging with x-rays or magnetic response imaging (MRI), although Holmes notes that when an MRI reveals a disruption of the joint, the exam almost always suggests this clinically.
The treatment of turf toe centers on non-surgical interventions and symptom management. Holmes explains that swelling and pain tend to be particularly bothersome with this injury. Like other soft-tissue injuries, most episodes of turf toe are initially treated with rest, ice, compression, and elevation.
An orthopedic boot with or without crutches can allow injured tissues to heal without placing additional stress on the joint. "We judge the response clinically. If it's a low-grade injury, a few days of rest should begin to improve symptoms," Holmes remarks.
In contrast, injuries that don't show improvement in those first few days, often take many weeks to heal.
"This injury is different in every sport and every position," says Holmes, who illustrates with an example from football. "An offensive lineman [with turf toe] probably can be accommodated easier than a wide receiver or a cornerback."
Seasonal timing also has an impact on the treatment approach, with more opportunities to rest adequately in the offseason.
As players transition from an orthopedic boot back to walking, there is often swelling in the affected foot for several weeks. "Standard shoes can be very uncomfortable, especially turf shoes, which have a small toe box," says Holmes.
In order to smooth this transition, a special orthotic can be inserted into the shoe to provide extra support for the injured MTP. These thin, commercially-available inserts are most commonly made of carbon fiber. Some are designed to only go under the big toe. Still, these inserts are an imperfect solution. Holmes explains that you always give up something on the other side. "What you gain in pain relief, you may lose in traction."
According to Holmes, there are no specific anatomic factors that predispose an individual athlete to turf toe. As a result, there are also not effective ways to prevent these injuries. "Unfortunately, you can't just put plywood into shoes to prevent hyperdorsoflexsion," he says.
A prior turf-toe injury may leave an athlete with a stiff joint and residual stiffness can increase the risk of repeat injury. This underscores the essential need for athletes to regain full motion in the MTP joint after suffering from turf toe, so the tissues return can to normal.
For successful treatment of turf toe, there is no substitute for time and rest. Yet rest is often a difficult proposition as the lines between seasons has blurred, both among elite athletes and younger children. "In younger and younger kids, there is no longer in-season and offseason," Holmes laments. "The need to rest is harder to sell to coaches, parents, and athletes.
"With turf toe, like other sports injuries, we need more advocacy for general rest."