The Small Injury That Is Sidelining Big Time Athletes…

sports, performance, injury

CEU Article Title: Metatarsophalangeal MTP Joint Sprain (Turf Toe)

You’ll hear a lot about this type of injuries with athletes and unless you know something about it,
you may find yourself wondering why these big strong athletes are letting a little toe injury get in their
way of playing in the big game. Well, this injury has so many consequences and is no small pain in the
butt for many athletes who suffer from it.
Basically, turf toe is considered a sprained big toe. If the
big toe is forcibly hyperextended, this can create a sprain in the
collateral ligaments (ligaments which run on each side of the big
toe), stretching of soft tissue, tearing, or worse, dislocation of the
1st MTP joint (Figure 1) (Hoffman & Daniels, 2010). The higher
the degree of injury to the plantar complex (plantar plate, collateral
ligaments, flexor hallucis brevis, sesamoids), the more debilitating it
becomes, frustrating athletes and coaches alike. You might also find
that your everyday clients can suffer from this injury and you may
have experienced a low grade MTP joint sprain if you have ever
stubbed your toe!
Since the push-off phase of gait requires your full weight
to be placed on the plantar complex and you inevitably toe off from your big toe, this injury adversely
affects your ability to walk, forcing you to either alter your gait patterns or stay off the injury until it heals
(Neumann, 2009).

What can a Fitness Professional Do?

Depending on the severity will determine the level of care required. If a client comes to you in
the early stages of this condition, refer them to their doctor right away. Generally, ice, anti-inflammatory
care, and compression are advised to help alleviate pain and reduce swelling (Hertling & Kessler, 1996).
A low grade 1st MTP sprain might require the client to stay off their feet for a day or two, and taping of
the injured area to help stabilize and support the joint may also be required. Higher-grade injury could require a boot and immobilizing the foot and toe for upwards of several weeks (Hertling & Kessler, 1996).
It’s important that you explain the potential injury to your clients, refer them out, and help communicate
the need to provide the proper amount of care to the injury. If they choose not to, they’ll find this injury
can re-occur, reducing their chances of reaching their goals in the future.

Exercise Recommendations

If your client insists on wanting to continue exercising throughout the injury, what you can do
is exercise their upper body and core without creating a strain on the injured area. Seated, stabilized or
machine-based exercises are recommended (Kisner & Colby, 2002). Floor crunches, reverse crunches,
bridges (toes up), and any supine exercise that does not require pressure on the foot/toe or toe flexion or
extension should be fine.

Cardiorespiratory Recommendations

Cardiorespiratory exercise, such as ellipticals, treadmills, and stair stepping should be avoided
until the injury has been reduced and then slow progression with these forms of cardio would be recommended (Kisner & Colby, 2002). If your client insists on getting in their cardiorespiratory exercises,
introduce them to the upper body ergometer, recumbent bike, or rowing machine. Or, you can even have
them perform seated battle rope exercises or seated boxing activity. Upper body and core-related exercises
performed in a circuit fashion to help emphasize cardiorespiratory demands, assuming one can easily
and comfortable transfer from one exercise to the next.

Future Recommendations

Once a client is released from the doctor or physical therapist and is ready to begin their usual
exercise regimen, be sure to do a movement assessment (such as an overhead squat). With injury comes
compensation and to help avoid further pain, you’ll want to see how the foot, ankle, knees, and hips are
moving prior to getting them back into the swing of things.
Look for tightness in the calves and hips, especially as reduced ankle flexion (if immobilized in a
boot) can increase hip flexion (Hertling & Kessler, 1996). You might also see asymmetrical weight shifting
as the client tries to move away from the source of pain or limitation as they squat. If you see altered
motion, begin with foam rolling and stretching of key areas that show tightness and implement low-level
strengthening exercises for muscles that show weakness (or inability to control unwanted movement, for
example at the knee or hip).

Recommendation Overview

Help your client bounce-back from injury by incorporating a slow and progressive protocol back  into full movement and programming. Start by performing an assessment. There are several ranging from the overhead squat, single-leg squat, Functional Movement Screen, or simple gait analysis. Whatever
one you choose, be sure to focus on any local and global inhibitions you might see – anything limiting
their movement ability.
Next, help them increase their mobility using a combination of myofascial release (foam rollers,
balls, vibration tools) and static stretching protocols, including partner-assisted stretching if you are qualified to perform these techniques (Clark & Lucett, 2011). Helping a client gain range of motion in areas
affected by the injury is key to them regaining function and strength.
Follow with isolated strengthening of areas shown to be inhibited during the assessment you performed.
Activating muscles that aren’t “turning on” appropriately can help guard your client from movement
imbalances and compensations moving forward (Clark & Lucett, 2011).
Lastly, integrate, integrate, integrate! Integrate complex, multi-joint movement (squatting, stepups,
lunging) back into your client’s program. Slowly implementing complex movements that require total
body control will help your client overcome any movement compensations that may have occurred as
a result of the injury (Clark & Lucett, 2011). Begin slowly and allow your client to adjust gradually rather
than throwing them back into too aggressive exercise right away. This can aggravate the injury or cause
a re-injury, which neither you nor your client want! Table 1 provides a synopsis of these general recommendations.

Table 1: General Recommendations for Turf Toe Exercises


Overall, this injury is hard to overcome and takes time for the injured to regain normal movement
without pain or compensation. Such a seemingly little injury can create large complications so
beware of exercise that can exacerbate the pain and injury. Reintroduce exercise slowly and adjust for
compensations once the client is ready to get back into exercise. Chances are they will be suffering from
tightness and inhibition in other areas like the hips and ankles.

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Clark, M.A., & Lucett, S.C. (2011). NASM’s Essentials of Corrective Exercise. Baltimore, MD:
Lippincott, Williams & Wilkins.
Hertling, D., & Kessler, R.M. (1996). Management of Common Musculoskeletal Disorders.
Physical Therapy Principles and Methods (3rd Ed.). Philadelphia, PA: Lippincott-Raven
Hoffman, R.M., & Daniels, J.M. (2010). Common Musculoskeletal Problems: A Handbook. New
York, NY: Springer.
Kisner, C., & Colby, L.A. (2002). Therapeutic Exercise Foundations and Techniques (4th Ed.).
Philadelphia, PA: FA Davis Company.
Neumann, D.A. (2009). Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation
(2nd Ed.). Philadelphia, PA: Elsevier Health Sciences.