Turf Toe management in American Football players  

Turf Toe management in American Football,

Turf Toe management in American Football – What is turf toe?

Turf toe is the sprain of the plantar capsule-ligament of the first metatarsal phalangeal joint (see picture below).


This injury occurs through forced hyper-extension of the big toe. For example, the jamming of the toe into the end of the football boot.

Turf toe is commonly seen within the game of American Football when the American Football players cleat is in contact with the turf and another player lands on the back of the athlete putting increased pressure through the foot and lifting the heel.

Following the installation of Astro-turf, players of West Virginia University football team suffered from turf toe (an average of 5.4 cases per year), a condition not normally experienced among the group.

Similarly, the University of Arkansas football players developed the same symptoms with an average of 6.0 cases per year from 1972 to 1974. At this university, turf-toe accounted for 7 missed games, with ankle sprains trailing behind at 6 missed games.

Interestingly, a review of the effect of sports surfaces on injuries in American Football concluded that surfaces with artificial turf produces ‘non-severe’ injuries more frequently than surfaces with natural grass, particularly 3rd generation artificial surfaces.

However ‘severe’ injuries seem to occur as frequently on natural grass as on artificial turf. They speculated that it was the shoe-surface combination which determined the frictional forces connected to injury frequency, i.e. the higher the frictional resistance, the higher the injury frequency.

Not only has turf toe been linked to artificial grass but it is believed to be linked to athletes wearing more flexible shoes.


Who gets turf toe?

Research suggests that turf-toe injuries are more commonly seen among offensive lineman. Here the toe can be injured when pushing out from a two or three point stance which forces the metatarsophalangeal joint (MTP) into hyper-extension.

Other positions where this injury could commonly occur are running backs, quarterbacks and receivers should they be tackled to the floor from behind, or when making sharp cuts to change direction.

Additionally, older players and those who have had a longer football career have reported a higher incidence rate of turf toe injury. This suggests that the injury of turf toe is exposure related.

A recent study suggested turf toe incident rates occurs significantly more during games than training.


Causes of turf toe

  • Extension of the big toe with a raised heel
  • Contact with the playing surface or with another player
  • An increase in ankle dorsiflexion has been found to be linked to a higher incidence of turf toe injury.
    When in the position of the mechanism of injury the ankle is usually slightly dorsiflexed. Therefore, an increase in ankle dorsiflexion at the time of injury will allow the foot to assume the position where greater stress can be placed on the first metatarsalphalangeal joint.
  • Individuals with pronated feet may also predispose them to turf-toe – This means that when weight bearing the foot/ankle rolls inwards into a valgus position.
  • It has been argued that shoe flexibility can be a contributing factor. Yet there is no conclusive research to back this up.
  • Shoe type – the rubber-soled multi cleat shoe has been linked to turf-tie injury. This shoe is more flexible at the end of the forefoot, unlike other more rigid soled shoes. It is believed that this increased sole flexibility does not protect the big toe from excessive hyper-extension. Yet there is no definitive research to back up this claim
  • Incorrectly sized shoes i.e. shoes that are too small can cause the big toe to curl up.


Symptoms of turf toe

  • Symptoms can be subtle therefore proper diagnosis is important.
  • Pain, tenderness and swelling around the metatarsal phalangeal joint of the big toe.
  • Pain with extension of the big toe.
  • Long term decreases in extension of the big toe.


Symptoms are likely to persist for a few weeks – months.


Treatment for turf toe

  • Take care of your feet. Ensure you do not allow for ingrowing toe nails and get rid of corns and verrucae’s. These only change the weight shift through the foot, thus affecting everything else higher up the chain.
  • Early acute care is the same as with any other injuries i.e. rest, ice, compression and elevation. (For more on acute injury care see my most recent e-book).
  • Anti-inflammatory medication can be used to help relieve acute symptoms.
  • Players might initially benefit from wearing a walking boot with a toe splint in flexion. This splinting position will protect the big toe metatarsal phalangeal joint from hyperextension, allowing for correct healing of the soft tissue structures. With this protection, the athlete can comfortably weight bear.
  • It is not advised to tape the toe in the acute phase to avoid compromising circulation of the toe

Grades 1 – 3

  • As with other injuries, turf toe can be graded from 1-3.
    • Grade 1 injury – the stretching of the plantar structures of the big toe MTP joint.
      • Return to play is normally fairly quick
      • Following the acute phase, the big toe can benefit from taping in a slightly plantarflexed position to limit hyperextension.
      • The football player can use a stiff-soled shoe with an orthotic insole (e.g. turf toe plate) to limit big toe movement.
      • Gradual return to play should include light low-impact exercise e.g. cycling, hydrotherapy and walking.
    • Grade 2 injury – the partial rupture of the plantar capsular ligamentous complex.
      • Time to return to play can take longer.
      • Should symptoms allow, early gentle passive motion can be allowed (you gently flex and extend your big toe) along with low impact exercises. During these exercises, you can use toe taping (as above) to protect the toe. Once the athlete can tolerate this exercise with no pain, higher impact exercise can be started e.g. running or jogging. This can then be followed by sport specific exercises such as cutting and jumping.
      • Again, orthotic insoles can be used to limit big toe extension.
    • Grade 3 injury – the complete rupture of the plantar capsular ligamentous complex.
      • The severity of this injury is the greatest, thus return to play takes longer. It could take up to 6 months for symptoms to resolve.
      • Immobilization of the joint may be required.
      • It has been suggested that the big toe MTP joint have 50 to 60 degrees of painless passive dorsiflexion before partaking in running or jumping activities.
    • In some cases, surgical intervention might be necessary. The goal of surgery is to restrore the normal and stable anatomy of the big toe.


Toe turf, although not a serious injury, is a significantly disabling injury, and therefore should be cared for as you would any other injury.



Bowers, K.D and Martin, R.B., 1976. Turf-toe: a shoe-surface related football injury. Medicine & Science in Sports & Exercise, 8(2), pp.81-83.

Nigg, B.M. and Segesser, B., 1988. The influence of playing surfaces on the load on the locomotor system and on football and tennis injuries. Sports medicine5(6), pp.375-385.

Rodeo, S.A., O’Brien, S., Warren, R.F., Barnes, R., Wickiewicz, T.L. and Dillingham, M.F., 1990. Turf-toe: an analysis of metatarsophalangeal joint sprains in professional football players. The American Journal of Sports Medicine18(3), pp.280-285.

McCormick, J.J. and Anderson, R.B., 2010. Turf toe: anatomy, diagnosis, and treatment. Sports Health2(6), pp.487-494.

George, E., Harris, A.H., Dragoo, J.L. and Hunt, K.J., 2014. Incidence and risk factors for turf toe injuries in intercollegiate football: data from the national collegiate athletic association injury surveillance system. Foot & ankle international35(2), pp.108-115.

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