Advice on Foot Care

Darren McFadden of the Oakland Raiders was limited to 20 yards on 7 carries in Sunday’s game. This under performance was most likely due to his recent turf toe injury. Turf toe is the hyperextension of the big toe joint, called the first metatarsal phalangeal joint (MPJ). The name was derived from the higher incidence of the injury on artificial turf. The combination of flexible shoes and cleats can cause the shoe to grab the turf, resulting in hyperextension of the 1st MPJ. This causes a tear or rupture of the capsule and ligaments on the bottom of the big toe joint. A more common mechanism, especially in football, is when a player falls back on the calf of his own leg, or another player’s leg, while the ankle is dorsiflexed and the big toe joint is extended, as seen in the picture above.

It’s hard to imagine why an injury to such a small joint can sideline professional athletes. But, after looking at the mechanics of the foot, it will make more sense. Almost all of the body weight is carried through the big toe joint when walking. When pushing off (called propulsion) a tremendous amount of force is placed on the great toe. Compare the big toe joint to the knee joint. The big toe joint is much smaller than the knee joint, yet it carries more weight and force through it. Tearing of the ligaments or the joint capsule of the big toe joint creates, not only pain and inflammation, but an instability at the joint. This makes it difficult for the joint to function effectively.

Grade 1: stretch injury or slight tearing of the capsule and/or ligaments at the bottom of the big toe joint. Symptoms include tenderness at the bottom of the big toe joint, minimal swelling, no bruising and only a small loss of motion. There may be minimal pain with weight bearing and continuing to play a sport with shoe modification and taping is possible. The loss of playing time is only 1-2 days.

Grade 2: a partial tear of the capsule and ligaments at the bottom of the big toe joint. Symptoms include pain at the bottom of the big toe joint, moderate swelling and bruising and limited motion at the joint. The symptoms worsen over the 1^st 24 hours and the athlete will typically be limping by the next day. Initial rest, ice, compression and elevation (RICE) are important the first few days after the injury. Rigid shoes, rest and taping when the athlete returns to play, are common treatments. The loss of playing time in a grade 2 injury is 3-14 days.

Grade 3: a complete tear of the capsule and ligaments at the bottom of the big toe joint in association with an impaction injury at the top of the big toe joint. Symptoms include severe pain, bruising and swelling with little to no motion at the big toe joint. The athlete is unable to place weight on the big toe joint. Initial treatment involves RICE for 2-3 days and crutches without weight on the big toe joint for 1-2 weeks. Loss of playing time for an athlete with a grade 3 injury ranges from 2 -6 weeks.

Treatment for all grades of injury should begin with a course of rest, ice, compression and elevation. After the initial inflammatory phase, generally 2-3 days, taping can be initiated for grade 1 and mild grade 2 injuries with a possible return to play. Stiff soled shoes will limit the extension of the great toe, which will assist with healing and help prevent re-injury. In some cases, graphite or steel insoles may be used to more aggressively limit the motion at the big toe joint. Steroids are generally not recommended as they can cause more damage to the joint and surrounding structures. Players rarely need surgical treatment for this injury.  

Trackback URI | Comments RSS