Turf toe

What it is

How papers and reviews define it

The name comes from a 1976 paper⁶. It described a sprain of the capsule and ligaments on the sole side of the big-toe joint⁶. A capsule is the sleeve of tough tissue that encloses a joint, and a ligament is a tough band that holds bones together.

A 2014 study of college football used turf toe as an umbrella name for a sprained first metatarsophalangeal joint¹. That is the joint where the first metatarsal meets the big toe. The study counted damage to the joint’s connective tissue or plantar plate, or a break in a sesamoid¹. A 2018 review described injury to the sole-side tissues and sesamoids of the big-toe joint⁷. It called the condition fairly rare, seen particularly in American football after harder artificial surfaces came in⁷.

The joint involved

Four bones make up the first metatarsophalangeal joint⁸. They are the first metatarsal (the long bone behind the big toe), the first bone of the big toe, and two sesamoids⁸. Sesamoids are small bones partly or wholly embedded in a tendon⁹. The big-toe sesamoids sit on the sole side of the first metatarsal’s head, and the inner one is commonly in two parts⁹.

A review describes the joint as shallow, with little stability from its bones⁸. It relies on soft tissues such as the plantar plate, ligaments and muscles, as the metatarsals page describes⁸. One of the foot muscles is the flexor hallucis brevis, a short sole muscle that bends the big toe. It has a sesamoid in each of its two tendons¹⁰. The tendon of the flexor hallucis longus, a deep calf muscle that bends the big toe, runs between the two sesamoids¹⁰.

How it happens

A 2010 review says that typically, load is driven down through a foot with the heel raised and the big toe bent upward³. That forces the joint past its limit and stretches or tears its capsule and ligaments³. In football, this most often happens when a player lands on the back of a planted foot³. In 20 cadaver limbs (bodies donated for study), the estimated risk of injury reached 50% at 78 degrees of upward bending¹¹.

How it is graded

A 2010 review describes three grades³:

Grade	What the 2010 review describes
I	A sprain or stretching of the capsule and ligaments on the sole side3
II	A partial rupture of the soft tissues on the sole side3
III	A complete rupture of the structures on the sole side3

A 2018 review adds that a grade 3 injury may come with damage to the joint surface⁷. It may also come with a dislocation toward the top of the foot⁷. The 2010 review states that when the plantar plate ruptures, one or both sesamoids shift back toward the heel³.

The 2018 review says the sesamoids may also break alongside turf toe⁷. In a two-part sesamoid, the joint between the parts may be hurt instead⁷. A case series of 19 football players describes traumatic hallux valgus as a distinct variant of turf toe¹².

Who it affects

Sports and settings

A 2023 review calls turf toe common among athletes². It names football, soccer, basketball, dancing and wrestling². A study of 12 non-athletes notes that it also occurs outside sport, though it is most common in athletes¹³.

How often it is seen

Studies in several sports have counted it^1,7. An athlete-exposure is one athlete taking part in one practice or game.

Group studied	What was found
College football, five seasons, 2004–05 to 2008–09	0.062 injuries per 1,000 athlete-exposures1
3,607 foot injuries in 25 college sports over 10 years	The most common named foot injury, ahead of fifth metatarsal fractures14
320 college players examined at the 2006 NFL Combine	36 cases of toe joint (metatarsophalangeal) dislocation or turf toe, counted together: the third most common foot or ankle injury in their histories15
80 active professional football players, surveyed in 1990	45% had had it during their professional careers, as reported in a 2010 review3
Rugby players over four seasons	11% of all foot injuries, with about 0.4% of players affected per season, as reported in a 2018 review7

In the 2004 to 2009 college football data, players were nearly 14 times more likely to get turf toe in games than in practice¹. Most cases came from hitting the playing surface (35.4%) or another player (32.7%)¹. Running backs and quarterbacks were hurt most often¹. Mean time lost was 10.1 days, and fewer than 2% of cases needed an operation¹.

In 25 college sports, turf toe had the second-highest rate of career-ending injury among severe foot injuries¹⁴. Severe tendon injuries ranked first¹⁴.

Playing surfaces

The 1976 paper discussed surface hardness and shoe stiffness as two factors that seemed to make it more likely⁶. On natural grass it saw no cases, in stiff or flexible shoes⁶. It found turf toe “not uncommon” in players wearing soccer-style shoes on AstroTurf⁶. In the 1990 survey of 80 professional players, 83% reported their first turf toe on artificial turf¹⁶. Player age, years in professional football and the ankle’s range of upward bending were also significantly related to it¹⁶.

Later studies point in more than one direction^1,17,18:

• College football, 2004 to 2009: the rate was significantly higher on third-generation artificial surfaces than on grass. It was 0.087 against 0.047 per 1,000 athlete-exposures¹.
• NFL players, 2011 to 2014, found through online reports: of 71 cases, 29 were on grass and 29 on turf. The surface of 13 was not known¹⁷.
• 39 college football programmes, 2006 to 2020: imaging and surgical procedures for foot injuries were less frequent on heavyweight-infill turf than on grass. The rates were 0.6 against 1.1 per 10-game season¹⁸. One author declared research support from FieldTurf, a maker of artificial turf¹⁸.

A 2023 systematic review of 53 studies concluded that the evidence suggests more foot and ankle injuries on artificial turf than on grass¹⁹. That applied to older and newer types of turf, though the studies varied too much to pool¹⁹. The few studies finding more injuries overall on natural grass all had financial support from the artificial turf industry¹⁹.

The few studies finding more injuries overall on natural grass all had financial support from the artificial turf industry.

Shoes

A 2017 review of football shoes reasons that a stiffer sole plate might lower the risk, since risk rises with upward toe bending²⁰. It adds that extra stiffness may limit the toe bending that football play needs²⁰. In a lab study of 10 college football players, shoes of three forefoot stiffnesses did not significantly change peak toe bending²¹.

What studies found

How much evidence there is

A 2020 systematic review found only 8 eligible studies: 5 case reports and 3 case series, covering 16 injured toes⁴. All were at the lowest level of evidence and rated poor quality, and it found no evidence-based guideline⁴. A 2018 review states that little research compares surgery with non-surgical approaches⁷. It reports that a 2017 review of 7 studies, presented at a conference, judged the evidence insufficient to say whether surgery is better⁷.

Time away from sport

The two reviews that give times by grade do not agree on grade III^2,3:

Grade	2010 review	2023 review
I	Typically, return to play as tolerated3	May return once there is little or no pain with normal weight-bearing, traditionally after 3 to 5 days2
II	Typically about 2 weeks3	Typically 2 to 4 weeks2
III	At least 10 to 16 weeks3	4 to 6 weeks or more, depending on the approach taken2

A 2019 systematic review and meta-analysis pooled 12 studies of 112 athletes²². Median return was 5.85 weeks without surgery and 14.70 weeks with it²². But the two groups had different injury grades²². The authors said very few studies report return to sport, and the low level of evidence carried a high risk of bias²².

In a study of 24 NFL players, 19 returned within the same regular season, after a mean of 36.7 days²³. Three needed season-ending surgery²³. Their performance over the next one and two years was similar to that of 436 comparison players²³. A 2023 review states that athletes with low-grade turf toe typically reach their previous level². Of those with higher-grade injuries, managed with or without surgery, about 70% are expected to keep their level².

Case series

Case series follow a group of patients with no comparison group^12,24,25,26:

• 15 football players, grade 3, after surgery: they missed an average of 16.5 weeks of play. Their mean AOFAS big-toe score, a foot and ankle score, was 91.3 at about 27.5 months²⁴.
• 21 athletes surveyed after plantar plate repair for grade 3: 19 (90.5%) returned to their previous level, at a mean of 20.4 weeks²⁵.
• 24 patients followed for an average 4.5 years: grades I and II were managed without surgery and grade III with surgery. Scores improved in both groups. Still, 29% of grade III and 20% of grade II patients did not resume previous activities²⁶.
• 19 football players with traumatic hallux valgus, after surgery: 74% returned to their previous level, at an average of 3.4 months¹².

A taping trial

A 2024 randomised trial split 60 people aged 25 to 30 with grade II turf toe into three groups of 20⁵. One had kinesiology tape plus a 12-week exercise programme, one had dummy taping plus exercise, and one had exercise alone⁵. After 12 weeks, the real-tape group had a larger drop in pain and walked farther in six minutes⁵. It also gained more in step length, stride length, cadence (steps per minute) and walking speed⁵. The dummy-tape and exercise-only groups did not differ in walking measures⁵.

Over the longer term

In the 1990 study of 80 professional players, turf toe was followed by a significantly smaller range of motion at the big-toe joint¹⁶. Among 44 players from one NFL team, toes with past turf toe bent upward less, about 41 against 48 degrees²⁷. They also had higher peak pressure under the big toe, an association, not a cause²⁷. A 2010 review reports an earlier series of 20 people in which half had lasting pain and stiffness five years on³.

A 2018 review states that unrecognised turf toe can lead to long-term problems⁷. It lists weaker push-off, ongoing pain, worsening deformity and eventual joint wear⁷. It also names hallux rigidus, a stiff, arthritic big-toe joint, among possible results of a missed injury⁷.

One study found that big-toe motion differed by about 21 degrees between 123 college basketball players and 123 non-competitive people²⁸. Its author concluded that subacute turf toe injuries likely occur in the players, leading to joint wear that limits big-toe motion²⁸.

Connections

The injury centres on the joint where the first of the metatarsals meets the big toe, which relies on soft tissues for stability⁸. The foot muscles page covers the flexor hallucis brevis, whose two tendons each hold a sesamoid¹⁰. A 2000 review lists the big-toe sesamoids among high-risk sites for a stress fracture²⁹. At the 2006 NFL Combine, toe joint (metatarsophalangeal) dislocation or turf toe, counted together, ranked third, after outer ankle sprains and high ankle sprains¹⁵.

Sources

1. George E, Harris AH, Dragoo JL, Hunt KJ (2014). Incidence and risk factors for turf toe injuries in intercollegiate football: data from the national collegiate athletic association injury surveillance system. Foot & ankle international. doi:10.1177/1071100713514038 PMID 24334272
2. Gupta A, Singh PK, Xu AL, Bronheim RS, McDaniel CM, Aiyer AA (2023). Turf Toe Injuries in the Athlete: an Updated Review of Treatment Options, Rehabilitation Protocols, and Return-to-Play Outcomes. Current reviews in musculoskeletal medicine. doi:10.1007/s12178-023-09870-y PMID 37789169
3. McCormick JJ, Anderson RB (2010). Turf toe: anatomy, diagnosis, and treatment. Sports health. doi:10.1177/1941738110386681 PMID 23015979
4. Seow D, Tengku Yusof TNB, Yasui Y, Shimozono Y, Kennedy JG (2020). Treatment Options for Turf Toe: A Systematic Review. The Journal of foot and ankle surgery. doi:10.1053/j.jfas.2018.12.041 PMID 31882133
5. Azab AR, Elnaggar RK, Aly SM, Basalem N, Alamri AM, Saleh AK, Ibrahim MN, Basha MA, Abdelbasset WK (2024). From injury to rehabilitation: How kinesiology taping helps patients with first metatarsophalangeal joint sprain (turf toe) in pain reduction, gait parameters and functional ability improvement. A randomized clinical trial. Heliyon. doi:10.1016/j.heliyon.2024.e29746 PMID 38681645
6. Bowers KD Jr, Martin RB (1976). Turf-toe: a shoe-surface related football injury. Medicine and science in sports. PMID 957935
7. Najefi AA, Jeyaseelan L, Welck M (2018). Turf toe: A clinical update. EFORT open reviews. doi:10.1302/2058-5241.3.180012 PMID 30305934
8. Embaby OM, Elalfy MM (2025). First metatarsophalangeal joint: Embryology, anatomy and biomechanics. World journal of orthopedics. doi:10.5312/wjo.v16.i4.102506 PMID 40290610
9. Nwawka OK, Hayashi D, Diaz LE, Goud AR, Arndt WF, Roemer FW, Malguria N, Guermazi A (2013). Sesamoids and accessory ossicles of the foot: anatomical variability and related pathology. Insights into imaging. doi:10.1007/s13244-013-0277-1 PMID 24006205
10. Zaottini F, Picasso R, Pistoia F, Perez MM, Möller I, Rossi F, Bruns A, Tagliafico AS, Martinoli C (2023). Ultrasound of the plantar foot: a guide for the assessment of plantar intrinsic muscles.. Journal of Ultrasonography. doi:10.15557/jou.2023.0024 PMID 37732108
11. Frimenko RE, Lievers WB, Riley PO, Park JS, Hogan MV, Crandall JR, Kent RW (2013). Development of an injury risk function for first metatarsophalangeal joint sprains. Medicine and science in sports and exercise. doi:10.1249/MSS.0b013e3182994a10 PMID 23657164
12. Covell DJ, Lareau CR, Anderson RB (2017). Operative Treatment of Traumatic Hallux Valgus in Elite Athletes. Foot & ankle international. doi:10.1177/1071100717697961 PMID 28335617
13. Pinter ZW, Farnell CG, Huntley S, Patel HA, Peng J, McMurtrie J, Ray JL, Naranje S, Shah AB (2020). Outcomes of Chronic Turf Toe Repair in Non-athlete Population: A Retrospective Study. Indian journal of orthopaedics. doi:10.1007/s43465-019-00010-8 PMID 32211128
14. Chan JJ, Geller JS, Chen KK, Huang HH, Huntley SR, Vulcano E, Aiyer A (2021). Epidemiology of Severe Foot Injuries in US Collegiate Athletes. Orthopaedic journal of sports medicine. doi:10.1177/23259671211001131 PMID 33997068
15. Kaplan LD, Jost PW, Honkamp N, Norwig J, West R, Bradley JP (2011). Incidence and variance of foot and ankle injuries in elite college football players. American journal of orthopedics (Belle Mead, N.J.). PMID 21720586
16. Rodeo SA, O'Brien S, Warren RF, Barnes R, Wickiewicz TL, Dillingham MF (1990). Turf-toe: an analysis of metatarsophalangeal joint sprains in professional football players. The American journal of sports medicine. doi:10.1177/036354659001800311 PMID 2372079
17. Madi NS, Parekh TJ, Parekh SG (2023). Outcome of Turf Toe Injuries in NFL Players. The Journal of foot and ankle surgery. doi:10.1053/j.jfas.2022.05.008 PMID 35697653
18. Meyers MC, Sterling JC, Robinson SK (2024). Imaging and Surgical Procedures After Surface-Related Collegiate Football Injuries on Artificial Turf Versus Natural Grass: Prevalence and Trends Over 15 Seasons. Orthopaedic journal of sports medicine. doi:10.1177/23259671241274144 PMID 39345932
19. Gould HP, Lostetter SJ, Samuelson ER, Guyton GP (2023). Lower Extremity Injury Rates on Artificial Turf Versus Natural Grass Playing Surfaces: A Systematic Review. The American journal of sports medicine. doi:10.1177/03635465211069562 PMID 35593739
20. Jastifer J, Kent R, Crandall J, Sherwood C, Lessley D, McCullough KA, Coughlin MJ, Anderson RB (2017). The Athletic Shoe in Football. Sports health. doi:10.1177/1941738117690717 PMID 28151702
21. Wannop JW, Schrier N, Worobets J, Stefanyshyn D (2020). Influence of forefoot bending stiffness on American football performance and metatarsophalangeal joint bending angle. Sports biomechanics. doi:10.1080/14763141.2020.1750682 PMID 32468921
22. Vopat ML, Hassan M, Poppe T, Tarakemeh A, Zackula R, Mulcahey MK, Mullen S, Burkholder R, Schroeppel JP, Vopat BG (2019). Return to Sport After Turf Toe Injuries: A Systematic Review and Meta-analysis. Orthopaedic journal of sports medicine. doi:10.1177/2325967119875133 PMID 31663005
23. Tran A, Kappa J, Smith E, Hoy M, Farrar J, Chandran A, Pandarinath R (2019). The Effect of Turf Toe Injuries on Player Performance in the National Football League. The Iowa orthopaedic journal. PMID 32577105
24. Smith K, Waldrop N (2018). Operative Outcomes of Grade 3 Turf Toe Injuries in Competitive Football Players. Foot & ankle international. doi:10.1177/1071100718775967 PMID 29909648
25. Cho D, Kukadia S, Josephson B, Stern J, Shamrock A, Johnson AH, O'Malley M, Drakos MC (2025). Return to Sport and Radiographic Postoperative Outcomes After Grade 3 Turf Toe Surgical Repair. The American journal of sports medicine. doi:10.1177/03635465251344313 PMID 40474355
26. Nery C, Fonseca LF, Gonçalves JP, Mansur N, Lemos A, Maringolo L, Fonseca LF (2020). First MTP joint instability - Expanding the concept of "Turf-toe" injuries. Foot and ankle surgery. doi:10.1016/j.fas.2018.11.009 PMID 30509556
27. Brophy RH, Gamradt SC, Ellis SJ, Barnes RP, Rodeo SA, Warren RF, Hillstrom H (2009). Effect of turf toe on foot contact pressures in professional American football players. Foot & ankle international. doi:10.3113/FAI-2009-0405 PMID 19439139
28. Trégouët P (2014). An assessment of hallux limitus in university basketball players compared with noncompetitive individuals. Journal of the American Podiatric Medical Association. doi:10.7547/0003-0538-104.5.468 PMID 25275734
29. Boden BP, Osbahr DC (2000). High-risk stress fractures: evaluation and treatment. The Journal of the American Academy of Orthopaedic Surgeons. doi:10.5435/00124635-200011000-00002 PMID 11104398

Every source the library cites

Changes

• October 22, 2026 First published.