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Athletes prone to big toe injury

Conway McLean, DPM

The Green Bay Packers are going to have a tough time without the services of their star receiver, Davante Adams, who has been an integral part of their offense. Wait, you thought this was the health section? Well, it is, but Mr. Adams’ injury is an interesting one, common in certain sports, and renowned for being quite debilitating. What body part has been damaged sufficiently to prevent him from participating? It’s just a toe! At least the name of the condition is called a turf toe injury.

But, technically speaking (which I must), this is not actually a toe injury. Anatomically, this injury involves a part of the foot, specifically, the ball of the foot, termed the first metarso-phalangeal joint (the MTP joint for short). But how important can it be if it’s just a foot? Think about what your foot does for you. I do. It transports us through space, carrying us across this concrete jungle.

The big news is the Packers’ excellent wide receiver has suffered a turf toe. Sounds quite innocuous, almost cute. But this vital joint allows us to pivot forcibly in one direction to the next. For a professional athlete, especially a wide receiver, executing a sudden change of direction while sprinting down the field is a critical action to their performance, and thus their livelihood.

The first MTP joint provides a powerful lever arm for push-off, propelling the body forward. I hope this sounds important: proper mechanical function of this joint is critical to anyone who walks, or at least anyone who has a propulsive gait. When a person is unable to stride forward, and instead walks flat-footed, they are said to have an apropulsive gait. For them, big toe joint mechanics is not nearly so important. That would not be the case for a professional athlete.

The anatomy of this body part is quite complex, as are the mechanics of how the joint moves. The first MTP joint is more than just a hinge joint and its motion involves a “sliding and gliding” movement. It even has two “kneecaps” of a sort. The two sesamoid bones lie underneath the first metatarsal bone and keep the tendon that lies there from rubbing against the head of the metatarsal bone. Just like the kneecap. And a total of nine ligaments span this joint, along with the joint capsule.

Turf toe is classified as a first metatarsophalangeal joint sprain, whereby the joint is pushed past its healthy range of motion. It’s the mechanism of injury that makes this interesting, and involves a common scenario in many sports. Somebody lands on the back of a player’s heel, while their foot is trapped against the ground. Tremendous forces are generated on the many soft tissue and bony structures. When the big toe joint is hyperextended, damage will occur. This means the top of the foot gets too close to the fixed big toe. This injury occurs when the heel is off the ground and power is applied to the big toe. Turf toe can occur suddenly, but may also develop gradually, from repeated push-off movements to the ball of the foot.

Interestingly, the composition of the new playing surfaces are a big part of this discussion. This injury was unheard of until the advent of artificial surfaces. Studies have revealed a much greater incidence when football players, both American and international (ie soccer), compete on artificial surfaces. The synthetic, astro-turf type materials do not “give” like natural terrain. This locks the big toe to the ground, while kinetic forces drive the first metatarsal out of an allowable position. All manner of structures can be stretched out of shape or even torn. And that is the definition of a sprain.

Turf toe is a common sports injury for football players, but is not exclusive to soccer or football. It also impacts basketball, field hockey, dance and lacrosse participants. In the end, any activity where the front of the foot is planted on the ground and the heel is lifted off can give rise to turf toe injury.

Another factor are the shoes that became available in the 60s, when softer-soled shoes were first developed. Shoes have become increasingly flexible and lightweight over the years, and provide little support at the front of the foot. This lack of stability allows greater forces to be exerted on this structure, and thus a greater likelihood of injury.

Davante Adams has been unable to play for weeks, with his return uncertain. This is a testament to both the severity of his particular injury and the importance of this critical joint. Although this author has not had the opportunity to examine Mr. Adams, I am confident his is a grade 2 or 3 injury. (It’s modern medicine; there has to be a classification system. We have classification systems for every condition imaginable!)

A grade 2 or 3 turf toe injury requires the individual abstain from demanding or physical activities. A grade 1 means some of the structures involved have been stretched but not torn, producing some tenderness and swelling. Minimal time off is required. A grade 2 will entail some structural damage. On the other hand, a grade 3 may require months off of activities to allow healing. Packer fans are hoping this is not the case, and Davante’s injury will heal in a few more weeks.

When turf toe develops gradually, symptoms may be mild at first. If engaging in some relevant activity, you should be watchful of pain or swelling in this region, which can result in the diagnosis of turf toe. (You read it here first: pain from the big toe joint may not be gout!)

If you are having some of these symptoms, get evaluated by a physician knowledgeable of the anatomy, as well as the problems experienced. A good history and detailed exam are often sufficient to make the diagnosis, but imaging may be used to verify it, and to specify which structures are damaged. Diagnostic musculoskeletal ultrasound is handy, safe, and very accessible, unlike an MRI, which requires insurance verification. A magnetic resonance imaging test (an MRI scan) provides detailed images of soft tissue structures, so is an excellent means of determining what is damaged.

Numerous modalities and techniques can help with the pain, swelling and stiffness. An “everyday Joe” will likely have rest, home therapies, and some type of immobilization prescribed. In contrast, the professional athlete has only the limits of modern science to aid the healing process. Regenerative medicine techniques are finding their way into the armamentarium of most sports teams, including shockwave therapy. This device, increasingly utilized over the last two decades, stimulates healing of the injured parts without the use of drugs or surgery. Many other therapeutic methods exist. A type of electric stimulation (of which there are many) is especially good for healing of acute injuries.

The take home message? Despair ye not, followers of the men in green and gold; Mr. Adams will return to the battlefield some day soon. Recovery from the debilitating turf toe injury is possible with appropriate and effective treatments. Surgery is not typically necessary. Your team will once again rise from the ashes of the NFC North division. As to the Detroit fans, well, I’ve got nothing. Good luck!

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.