Background & Etiology (Cause)

There are over 30 joints in the foot. The joints in the foot include the subtalar, talonavicular, calcaneocuboid, the metatarsocunieform joints, and the metatarsophalangeal joints. The precise movement of these joints as they work together is what enables us to run, walk, and jump. Tendons are connective tissues that attach muscle to bone. They are strong, fibrous structures that transfer the forces generated by the muscle to the bone, producing movement at the joint. When a tendon becomes irritated or inflamed it becomes painful, especially with movement. Inflammation of the tendon is called tendonitis.

Turf Toe

Inflammation of the tendons in the metatarsalphalangeal joint of the big toe causes a condition called turf toe. These tendons include the flexor hallucis longus and the extensor hallucis longus. Turf toe occurs when these tendons become inflamed causing redness, pain and swelling in the big toe joint. This condition typically occurs due to acute traumatic incidents where the toe is stretched too far backward in the direction of the shin. This injury is common among those participating in rugby, soccer, beach volleyball, and football. Playing on rigid surfaces such as artificial turf can make one more susceptible to this injury. With this injury, activities involving quick acceleration, running, and cutting need to be curtailed.

Tendonitis is most often caused by an overuse repetitive strain injury (RSI). Other high risk activities or conditions that can lead to the development of turf toe include:

• Participating in athletic activities that strain the foot, like soccer, football or running.

• Sudden changes in athletic training schedules, increasing workload and stress on tendons.

• The use of artificial turf.

• Repetitive strain injuries (RSI) at work occur in people who have jobs that require performing activities of a repetitive or forceful nature, like running, cutting or sudden acceleration.

• Foot pain or tenderness directly over the injured tendon that can radiate through out the foot, heel and ankle

• Difficulty walking, running or performing sporting activities

• Pain or burning sensation during activities

• Difficulty performing activities of daily living

• Weakness may occur as the inflammation gets worse

• Feeling of tightness or loss of motion due to discomfort

• Swelling of the tendon

• Loss of motion of the foot

If an individual suspects they have turf toe, the initial treatment should consist of avoiding the positions and activities that produce the pain. A course of conservative treatment is usually recommended that would include rest and immobilization, possible splinting, ice, physical therapy and non-steroidal medications to reduce inflammation.

If symptoms persist, treatment by your physician may be necessary. This may include steroidal medication or injections, use of taping, orthotics or foot supports in conjunction with therapy. In severe cases surgical intervention may be needed to correct any mechanical causes of the tendon irritation.

Physical Therapists are professionals, educated and trained to administer interventions. As stated in The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and goal of the patient or client. Common interventions in the treatment of Turf Toe include:

• Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, deep friction massage, manual stretching and joint mobilization by a physical therapist to regain mobility and range of motion of the foot and tendon.

• Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen the foot and effected muscle.

• Neuromuscular Reeducation (NMR) to restore stability, retrain the lower extremity, and improve movement technique and mechanics (for example, running, jumping, kicking, or stepping) in daily use of the involved lower extremity.

• Modalities that can include the use of ultrasound, electrical stimulation, ice, cold laser and others to decrease pain and inflammation at the foot and tendon.

• Home program that includes strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.

Procedures that your physician may recommend and perform in addition to physical therapy may include:

• REST and ICE

• The use of NSAIDS (Non Steroidal Anti-Inflammatory Drugs)

• Steroidal injections to reduce inflammation

• Pain medication to reduce the discomfort and allow the patient to perform the recommended exercises

• Orthotics, arch supports and taping

• Surgery to correct underlying pathology or the cause of the tendon irritation. This may include debridement of the involved tendon.

• Splinting to rest or immobilize the ankle and effected tendons.

Prognosis

Most people recover full function following a course of conservative care that includes physical therapy, medication and/or injections. It is important that once the pain and inflammation is reduced, and motion and strength are restored, the patient gradually returns to full activities. Instruction in daily activities or sport performance is helpful for reducing a reoccurrence of turf toe.

Prevention

It is easier to prevent turf toe than to treat it. Below are some tips to reduce the risk of tendon irritation.

• Warm up lightly before activity to improve circulation and lubricate the muscle and tendon. Warm up should be performed to the area that will be used.

• Stretch the tendons and muscles you will be using after your warm up, prior to the activity and after it. Do not bounce when stretching. Instead, hold the stretch for 15-20 seconds.

• Strengthen the muscles and tendons that you need to use for your activity. A regular strengthening program three times a week will keep muscles prepared for the job you are asking them to perform.

• Do not work through pain. Listen to your body. Avoid the “no pain, no gain” philosophy.

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