Wednesday, September 1

Turf toe

It was two months after the end of football season and Deion Sanders was still in pain. The Dallas Cowboys' All-Pro cornerback had limped through most of the 1998 campaign, his brilliant ability hampered by an injury that limited his mobility. In April, Sanders elected to undergo surgery to address the problem and he'll most likely return to action this fall. But it's not a knee ligament or herniated disc that has plagued Sanders -- it's his left big toe, which was afflicted by a condition familiarly known as turf toe.

 Dr. Warren King
Dr. Warren King

Turf toe is fairly common among athletes, particularly football players. In this week's feature on sports injuries, Dr. Warren King, a member of the Association of Professional Team Physicians (PTP) and team physician for the Oakland Raiders, talks about turf toe -- what it is, how it's caused and, most importantly, how it can be prevented.

What exactly is turf toe?

Dr. King: Turf toe is really a bruise that occurs at the base of the big toe at the joint called the metatarsal phalangeal joint. It usually occurs when the toe is jammed forcibly into the ground or, more commonly, when the toe is bent backward too far and it goes beyond where it should go. It causes significant pain and swelling at the base of the big toe. It can be a significant problem because players use the toe when they run and plant and push off. It can be so painful that they can't play at all, as in the case of Deion Sanders.

Once it happens the first time, the joint becomes a little bit stiffer and can get a little arthritic, which means your motion and mobility is less. It will take less of a force or bending of the toe next time to produce the pain. As the condition worsens, mobility is even further limited so that any bending of the big toe can cause a great deal of pain. This is one of the main reasons why turf toe can knock you out for a long period of time.

How is it treated?

Dr. King: Generally, the toe is iced and elevated and the patient is started on anti-inflammatory medication, and then usually devices are used to stiffen the shoe or to prevent the toe from being bent back further. Steel plates are put inside the shoes and trainers will tape the toe in a position that will keep it from bending too far backward. Much of the taping that keeps the toes stable is pretty elaborate and quite common, especially among veteran linemen in football. They are always pushing off their toes when they come out of the three-point stance and are also involved in pile-ups where their toes can get jammed.

When turf toe flares up, the RICE treatment is effective -- rest, ice, compression and elevation -- and sometimes a cortisone shot will help, but the main thing is to prevent the injury from happening again through the taping or with steel-plate shoe inserts.

Is artificial turf responsible for the majority of turf toe injuries?

Dr. King: The original artificial turf was a little higher risk than natural grass because of its hardness, but turf toe can occur on any surface. But because modern artificial turf has such a strong grip, many players use tennis shoes on it and these have particularly soft soles, especially in the forefoot. These don't protect your toe at all. So it's not the artificial turf per se, but rather the footwear that makes you more susceptible to turf toe on the artificial surface. But it's really not "artificial-turf toe"; it can be "grass-turf toe" as well.

Q: I am 19 years old and in the past three months I've grown about an inch from 6'2" to 6'3". While I am playing basketball and often afterwards, my lower back gets sore and I have also been having pains in my knees. Could this be a result of "growing pains?" What exactly are "growing pains?"
-- Ian Scale, Boston, Mass.

A: Dr. Robert Luberto, team physician for the Phoenix Coyotes:
"This may be a result of traction across a growth plate that may be like 'growing pains.' Growing pains suggest a muscle/tendon imbalance during a growth spurt. They should be self-limiting pain. If the pain persists beyond a couple of months, an evaluation would be warranted."

Do you have a question for a team physician? Click here to ask. And check out more "Ask the Pro Doc" answers to users' questions.

Can it be prevented?

Dr. King: The important thing is to get a stiff-soled shoe. In athletics, cleated shoes seem to work better at prevention because they usually have a built-in plastic sole that has more rigidity that a tennis shoe.

Is surgery necessary for turf toe?

Dr. King: Sometimes you'll develop a large bone spur around the toe joint that needs to be taken out. The joint becomes arthritic and the cartilage gets thin and the bone spurs start to form around it. Removing the spurs can bring relief, but many times you still haven't addressed the thing that caused the bone spurs in the first place and you still have arthritis. Just because you remove the bone spur, the joint can remain abnormal.

What is the prognosis?

Dr. King: The prognosis is generally pretty good as far as the ability to return to action, but it's relatively poor in the sense that you never really cure the condition. Essentially this becomes an arthritic condition. The longer you are in the league, the greater the chances are that you will get turf toe, which can lead to arthritis, which means you're more susceptible to repeat injury and so on. Most lineman that retire after 10 years or so will have very stiff big toes.

You can calm the symptoms down and you can play relatively symptom-free with proper protection, but the condition is hard to cure and much easier to accommodate. But the ability to accommodate it is pretty good. We can get almost every one of these guys playing -- comfortably and at close to 100 percent -- even though they have an arthritic toe.

Dr. Warren King, a member of the Association of Professional Team Physicians (PTP), who has been working with the Raiders since 1996, is an orthopedic surgeon at the Palo Alto Medical Foundation in Palo Alto, Calif. He received his medical degree from the University of Southern California and completed a sports-medicine fellowship at the Kerlan-Jobe Orthopaedic Clinic in Inglewood, Calif. In addition to his work with the Raiders, he also serves as team physician for the San Francisco Giants, the San Jose Sharks and the U.S. national rugby team.

The information, including opinions and recommendations, contained in this website is for educational purposes only. Such information is not intended to be a substitute for professional medical advice, diagnosis or treatment. No one should act upon any information provided in this website without first seeking medical advice from a qualified medical physician.

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