What it is
The big toe's main joint, where the toe meets the foot (the first metatarsophalangeal joint), gets most of its stability from the soft tissue under and beside it: a thick pad of joint capsule called the plantar plate, ligaments on each side, and the short muscle that bends the big toe, with two small sesamoid bones inside its tendons. The joint takes 40% to 60% of body weight when you walk, 2 to 3 times body weight in sport and up to 8 times in a running jump.
Turf toe is an injury to that tissue when the toe is driven upwards beyond its range, usually with the front of the foot fixed on the ground and the heel raised. If the force also pushes the toe sideways, the inner side takes more damage and the toe can drift into what surgeons call a traumatic bunion.
The same pad under the smaller toes can tear too, usually at the second toe and usually gradually; our plantar plate tear guide covers it.
Sources 1, 2, 3, 22
The three gradesStrong evidence
Doctors grade turf toe from 1 to 3, and the grade guides the treatment:
- Grade 1: the tissue is stretched. There's tenderness in one spot and slight swelling, with little bruising.
- Grade 2: a partial tear. The tenderness is wider, with moderate swelling and bruising, and moving the toe is painful and limited.
- Grade 3: a complete tear. Swelling and bruising are severe, push-off is weak, and the joint can be unstable or even dislocated, sometimes with a broken sesamoid bone or damage to the joint surface.
Sources 1, 2, 3
Who gets it, and the artificial turf questionMixed evidence
In five seasons of US college American football, there were 0.062 turf toe injuries per 1,000 athlete-exposures (one player at one practice or game). They were about 14 times likelier in games than in practice, cost 10.1 days on average, and fewer than 2% needed an operation. In a survey of 80 professional players, 83% said their first turf toe happened on artificial turf. In a study of rugby players over four seasons, reported in a 2018 review, turf toe made up 11% of foot injuries and took 22 days on average to recover from. It also happens in football (soccer), basketball, tennis, volleyball, wrestling and dance.
The name comes from early artificial pitches: the first report saw it in players wearing flexible soccer-style boots on AstroTurf, not in stiffer boots or on grass. In US college football it was about twice as common on newer artificial turf as on natural grass (0.087 against 0.047 per 1,000 athlete-exposures), and in the National Football League (NFL), lower-limb injuries were 16% higher per play on synthetic turf.
But the picture isn't simple. A review of 53 studies found foot and ankle injuries more often higher on artificial turf, while overall injury rates on newer turf were usually similar. A review of football (soccer) studies found slightly fewer injuries overall on modern turf. And of 71 NFL turf toe injuries in one series, 29 happened on grass and 29 on turf.
Sources 4, 5, 3, 6, 7, 8, 9, 10, 11
How it's recognised, and what X-rays and scans showEmerging evidence
A clinician asks how the toe was bent, then checks the swelling, the exact tender spot and how stable the joint is, comparing it with the other foot. Pain further back, behind the sesamoid bones, points to a strained muscle rather than an unstable joint.
X-rays are taken standing and are often normal. They matter when they show a small piece of bone pulled off, or sesamoid bones sitting 3 mm or more further back than on the other foot, which suggests a significant tear. An MRI (magnetic resonance imaging) scan helps with grade 2 and 3 injuries.
A sesamoid bone in two pieces is a normal variant: one study found it in 1.9% of 1,651 foot X-rays. It can be mistaken for a fracture, which is why the other foot is often X-rayed for comparison.
Sources 2, 3, 1, 12
What else it could be
A broken big toe: the NHS sends suspected big toe fractures to A&E. Gout: sudden severe pain with hot, red, swollen skin over the joint, usually without an injury. A joint infection: severe pain, difficulty moving the joint or putting weight on it, and often a high temperature, which is urgent.
Stiffness and pain pushing off that build up slowly, without an injury, are covered in the big toe arthritis guide, and a bony lump on the side of the joint in the bunions guide.
Sources 13, 14, 15
How it usually goesEmerging evidence
A grade 1 sprain usually settles in days, a grade 2 in weeks and a grade 3 in months. Leftover problems are common: in a series of 20 people followed for 5 years, reported in two reviews, half still had pain and stiffness in the joint, and professional players who had had turf toe had less movement in it. A missed or poorly managed injury can lead to a stiff, arthritic big toe, a toe that drifts sideways or cocks up, or a damaged tendon.
Performance can recover. In 71 NFL turf toe injuries, players' performance ratings afterwards were no different from before or from players without the injury.
Sources 2, 3, 5, 11